1. SPLINTS and casting techniques

2. What is a splint? • A splint is a rigid support with padding made from
metal, plaster or plastic.
It is used to support, protect, or immobilize an injured or inflamed part of the body.
The splint is secured in place with an elastic bandage or an ACE wrap .
The purpose of the splint is to prevent movement of the injured extremity which helps prevent further injury, and to minimize pain

3. Indications for Splinting
Fractures
Sprains
Joint infections
Tenosynovitis
Acute arthritis / gout
Lacerations over joints
Puncture wounds and animal bites of the hands or feet

4. To reduce/prevent contracture
To increase grip strength
To stabilize and rest joint in ligamentous injury
To correct deformity
To support and immobilize joints and limbs postoperatively until healing has occured

5. Need for open reduction Skin at high risk for infection
Contraindications of Splinting
Compartment syndrome
Need for open reduction
Skin at high risk for infection

6. Plaster of Paris Splinting Material
Made from gypsum - calcium sulfate dehydrate
Exothermic reaction when wet - recrystallizes (can burn patient)
Average setting time – 3-9 min
Average drying time – hours

7. Factors decreasing setting time :- Hot water, Salt, Borax, Resins
Factors increasing setting time :- Cold water, sugar
Upper extremities :– use 8-10 layers
Lower extremities : layers up to 20 if big person (increased risk of burn!)

8. • Less expensive More difficult to apply Gets soggy when getting wet
Advantage
• Easier to mold
• Less expensive
Disadvantage
More difficult to apply
Gets soggy when getting wet

9. Splinting Material Ready Made Splinting Material (1) Plaster (OCL)
sheets of plaster with padding and cloth cover
(2) Fiberglass (Orthoglass)
Cure rapidly (20 minutes)
Less messy
Stronger, lighter, wicks moisture better
Less moldable
Disadvantage
• More expensive
• More difficult to mold

10. (3) Prefabricated splints
• Plastic shells lined with air cells, foam or gel components
• Same advantages and disadvantages as fiberglass splints

11. Pre / Post - Splint Checks
F – Function
A – Arterial Pulse
C – Capillary Refill
T – Temperature (Skin)
S - Sensation

12. Choose your splints Upper Extremity Hand/Fingers Shoulder And Arm
- Figure of eight
- Sling and Swathe
- Aeroplane splint
Elbow/Forearm
Long Arm Posterior
Double Sugar - Tong
Forearm/Wrist
Volar Forearm / Cockup
Sugar - Tong
Hand/Fingers
Ulnar Gutter
Radial Gutter
Thumb Spica
Finger Splints
Knuckle-bender splint

13. Spine Lower Extremity Hip and Thigh - Von Rosen’s Splint
- Thomas Splint
- Bohler-Braun Splint
Knee
- Knee Immobilizer / Bledsoe
- Bulky Jones
- Posterior Knee Splint
Ankle
- Posterior Ankle
- Stirrup
Foot
- Denis-Brown splint
- Buddy taping
- Cervical Collar
Four-post Collar
SOMI (Sternal Occipital Mandibular Immobilizer)
- Scoliosis
- Milwaukee Brace
- Boston Brace
- Taylor’s Brace

14. Upper Extremity

15. Shoulder and Arm • Indications: – Clavicle fractures
• Most figure of eight splints are prefabricated and Application is
simple.
• Read the product information insert
before applying the splint about the
correct application process.
• Apply with patient standing and hands on iliac crest Shoulders should be abducted
(1) Figure of eight

16. Figure of eight

17. (2) Sling and Swathe
Indication:
– Shoulder and humeral injuries
• Slings supports weight of shoulder
• Swathe holds arm against chest to
prevent shoulder rotation
• Apply the sling and swath with the
patient standing.
• Place the injured arm in the sling
with the elbow at 90 degrees of flexion.
• Next place the strap that is attached to
the sling over the patient head so that
the weight of the arm is supported

18. Sling and Swathe • Apply the swath. – This can be anything from
an ACE wrap to a prefabricated swath. This is designed to hold
the patients affected arm that
is in the sling against the body.
• The swath should wrap around the front and back of the sling
keeping the affected extremity against the mid-abdomen

19. (3) Aeroplane Splint
Indication- Brachial plexus injury

20. Elbow/Forearm (1) Long Arm Posterior
• Indications:
- Forearm and elbow injuries
- Olecranon and radial head fractures
- Distal humeral fracture
• Not recommended for unstable fractures
• Applied from palmer crease, wrapping around
lateral metacarpals, extending up to posterior arm
with elbow flexed at 90 degrees
NOTE - Doesn’t completely eliminate supination / pronation –either add an anterior splint or use a double sugar-tong if complex or unstable distal forearm fx.

21. Long Arm Posterior

22. (2) Double Sugar - Tong

23. Forearm/Wrist (1) Volar Forearm / Cockup • Indications:
- Distal forearm and wrist fractures
Soft tissue hand / wrist injuries - sprain, carpal tunnel night splints, etc
2nd -5th metacarpal fx.
Radial Nerve palsy
• Applied from volar
palmer crease to 2/3
forearm
• Allows elbow and
finger ROM
NOTE - Not used for distal radius or ulnar fx - can still supinate
and pronate.

24. Volar Forearm / Cockup

25. (2) Forearm Sugar - Tong
Indications –
Wrist and distal forearm fractures
Extends from MCP joints on dorsum of hand, tracks along the forearm, wraps around back of elbow to volar surface of the arm and extends down to mid-palmer crease
Immobilises wrist, forearm, and elbow

26. Forearm Sugar - Tong

27. Hand/Fingers (1) Ulnar Gutter Splint (2) Radial Gutter Splint
• Indications:
– Phalangeal and metacarpal
fractures
• Most common use-Boxer
• 5th MCP fracture Soft tissue injury to little and ring finger.
Indications
- Fractures, phalangeal and metacarpal and soft tissue injuries of the index and middle fingers.

28. Ulnar Gutter Splint
• Extends from DIP joint to the proximal 2/3 of the forearm
• Should immobilize the ring and little finger
• MCP should be in 70 degrees of flexion, PIP should be in 30 degrees of flexion and DIP in no more than 10 degrees of
flexion

29. Ulnar Gutter Splint

30. Ulnar Gutter Splint

31. Radial Gutter Splint

32. (3) Thumb Spica Indications: – Scaphoid fractures , thumb
phalanx fractures or dislocations
• Most Common use:
Gamekeepers thumb or skiers
thumb
2) Dequiervans tenosynovitis
Extends from DIP joint of thumb,
incorporates the thumb and extends
up 2/3 of the proximal lateral forearm

33. Thumb Spica

34. (4) Finger Splints Sprains - dynamic splinting (buddy strapping).
Dorsal/Volar finger splints - phalangeal fx, though gutter splints probably better for proximal fxs.

35. Finger Splints
(a) Stack Splint
Use – management of mallet finger

36. (b) Aluminium Splint
Uses - phalangeal fracture, mallet finger

37. Lower
Extremity

38. (1) Von Rosen’s Splint ‘H’ shaped malleable splint
Indication – Congenital dislocation of the Hip
‘H’ shaped malleable splint
Hip should be properly reduced before it is splinted
Object is to held hip somewhat flexed and abducted
Extreme positions are avoided and Joint should allowed some movement in the splint

39. (2) Hip Spica Cast
Uses- Fracture shaft of femur in children and in young adults once the fracture becomes ‘sticky’
encircles one or both arms or legs and the chest or trunk.
It generally is strengthened with a reinforcement bar.

40. Hip Spica Cast
When applied to a lower extremity , the cast is trimmed in the anal and genital areas to allow elimination of urine and stool.

41. Hip Spica Cast

42. Thomas Splint
- used as traction splint

43. Knee (1) Knee Splint Indications: - knee injuries
- proximal Tib/fib fractures
• Place knee in full extension
• The plaster is placed from the posterior buttocks to 3 inches
above level of bilateral malleoli

44. Knee Splint
Fixed
Hinged

45. Ankle Indications (1) Posterior Ankle Splint - Distal tibia/fibula fx.
- Reduced dislocations
- Severe sprains
- Tarsal / metatarsal fx
Use at least layers of plaster.
Placed from metatarsal heads on plantar surface foot, extends up back of leg to level of fibular neck
NOTE - Adding a coaptation splint (stirrup) to the posterior splint eliminates inversion / eversion - especially useful for unstable fx and sprains.

46. Stirrup Ankle Splint

47. Foot (1) Denis-Brown splint
Indication – Congenital Talipes Equino Varus (C.T.E.V.)
Used after successful correction of deformity ,to prevent relapse.
used throughout the day before child starts walking.
Once child starts walking ,a DB splints is used at night and CTEV shoes during the day.

48. (2) Buddy strapping Indications: – Phalangeal fractures of the toes
• Small piece of
wadding placed
between toes to
prevent maceration
• Fractured toe secured
to adjacent toe with
tape

49. Spine

50. (1) Cervical Collar
Flexible foam/Rigid/Adjustable
collar
Encircles the neck to support the skull against the thorax inferiorly
Motion control and keeping warm at cervical level
Soft tissue injury, minor sprains for first few days after injury
Post operative immobilisation
Note :- They are not useful for very unstable injury pattern

51. Cervical Collar Soft Cervical Collar
Commonly used for mild soft tissue strains and sprains

52. Cervical Collar Semi-Rigid (Philadelphia) Cervical Collar
Can provide access to the trachea
Moderate Control of ROM

53. (2) Four-post Collar
Indication – Neck immobilisation in cervical spine injury
More stable than cervical collar
Applying pressure to mandible , occiput , sternum and upper thoracic spine
They can be uncomfortable

54. (3) SOMI (Sternal Occipital Mandibular Immobilizer)
Uses – cervical spine injury
Rigid Frame Design
Commonly used in stable fractures and Moderate to Severe soft tissue damage
Limits Flexion and Extension
Extends Inferior into the Thoracic Region for greater control of all cervical levels

55. (4) Milwaukee Brace Indication- Scoliosis and kyphosis
Named after the city of Milwaukee where it was designed.
It fits snugly over the pelvis below; chin and head pads promote active postural correction and thoracic pad presses on the ribs at the apex of the curves

56. (5) Boston Brace Indication-Scoliosis Used for low curves
Worn 23 Hours / Day
Made of semi-rigid plastic and foam

57. How do I take care of the splint?
• Do not get the splint wet. Use plastic bags to cover the splint while bathing.
• Do not walk on the splint.
• Do not stick anything down the splint Such as a coat hanger to scratch or itch. This may lead to injury and infection.

58. What danger signs should to look for?
• Numbness, tingling, increased pain,
change in coloration of fingers or toes, or
swelling in fingers or toes.
• If these symptoms occur, you should call
your doctor immediately

59. Complications Burns - Thermal injury as plaster dries
- Hot water, Increased number of layers, extra fast-drying , poor padding all increase risk
- If significant pain - remove splint to cool
Ischemia
- Reduced risk compared to casting but still a possibility
- Do not apply Webril tightly
- Instruct to ice and elevate extremity
- Close follow up if high risk for swelling, ischemia.
- When in doubt, cut it off and look
Remember - pulses lost late.

60. Complications Pressure sores Smooth Webril and plaster well Infection
- Clean, debride and dress all wounds before splint application
- Recheck if significant wound or increasing pain

65. Future of orthopedic cast

66. VOLUME 1: Short Arm Cast Application Considerations
Dangers & Complications
Step-by-Step Application Instructions
Cast Removal
Summary
Disclaimer

67. Dangers & Complications
The unyielding nature of rigid casting materials leads to two potential serious dangers:
Pressure
Constriction

72. Dangers & Complications
Pressure
Special attention must be paid to bony prominences and superficial peripheral nerves by applying extra padding to these areas.
Care must be taken when molding the cast to prevent the indention of the material and the creation of a pressure point.

73. Dangers & Complications
Constriction
From Without – resulting from the improper application of the casting material (wrapping too tight).
From Within – resulting from excessive swelling that occurs after cast application.

74. Dangers & Complications
Prevention – “RICE” R – Rest I – Ice C – Compression E – Elevation
Rest to the injured part is accomplished by the splint or cast and reduced patient activity level.
Ice can be applied directly on the splint or cast and is the responsibility of the patient or caregiver.
Compression is accomplished by the splint or cast.
Elevation is when the injured body part is higher than the heart and is the responsibility of patient or caregiver.

75. Dangers & Complications
Warning Signs – 4 P’s
Pain
Pallor (pulseless)
Poikilothermia (cool)
Paresthesia / Paralysis
It is critical to listen to your patient.
If you are not confident interpreting a complaint, ask someone who is.
When treating a fresh injury where swelling is anticipated, it is good practice to have the patient come back the next day for a circulation check.

76. Step-by-Step Application Instructions (Short Arm Cast)

77. Gather your supplies. Stockinet Casting Tape Padding Gloves
Always gather all of your supplies before you begin the procedure.
The water temperature should be cool or standing room temperature.
You should also have bandage scissors, which are not shown in this slide.
Stockinet
Casting Tape
Padding
Gloves

78. Cut stockinet to assure “fit” and “dimensions.”
Functional End
(Single Layer)
Comfort End
(Double Layer)
When selecting the stockinet, you begin to impact the “fit” and “dimensions” of the cast.
The distal end of the cast is usually designed for function while the proximal end is designed for comfort. The functional requirements dictate the design.
You want the stockinet to fit snugly around the wrist without restricting venous return at the proximal end.
Two-inch stockinet is the appropriate size for most of the population.
The stockinet must be cut long enough to accommodate shortening that takes place when the stockinet is stretched widthwise.
You also need to have extra stockinet at the proximal end so you can create a double layer for comfort when the stockinet is rolled back over the casting material before the final wrap.
The hole for the thumb should be cut approximately four finger breadths from the distal end of the stockinet and just large enough to comfortably fit the thumb through.
Rolling up the stockinet into a donut starting, at the proximal end and continuing to the thumb hole, will help facilitate application.

79. Apply a double layer of stockinet to the thumb
to fold back over the fiberglass before the final wrap.
Cut a piece of one-inch stockinet approximately twice the length of the thumb.
Make a lengthwise cut about one third the length of the stockinet at one end.
Slip the stockinet onto the thumb with slit at the web-space.
Roll back the stockinet to create a double layer.

80. Apply the padding so that the “dimensions” are established and the “fit” is retained.
Two Fingers from the
Crease of the Elbow
Distal Palmar Crease
The padding becomes singularly the most important part of the cast application because it will establish both the dimensions and the fit.
With properly applied padding, you simply have to stay within the margins that have been established when applying the casting material and just lay the casting tape on the padding to retain the fit. There is no need to apply tension when applying the casting tape.
Two layers of padding is sufficient except over bony prominences, where more will be needed, or, more, if an excessive amount of swelling is anticipated.

81. Begin wrapping spirally without exposing the roll to water.
Put on your gloves.
Remove the casting tape from the foil pouch and place the empty pouch on the counter with your supplies. This will provide a place to set the roll when you are ready to turn back the stockinet.
Begin wrapping at the wrist, moving immediately to the ulnar border of the distal palmar crease.
Remember the dimensions have been created with the padding.
Continue around the back of the hand and stop when you get to the web-space.

82. Before passing through the web-space, cut the casting tape to avoid material build-up.
With the tips of your scissors pointing distally, cut at a 45-degree angle across the casting tape with the tips aiming down to the point between the thumb and index finger.
The cut should extend to within ½-inch of the edge of the casting tape.
The cut edges can then be folded under to bury the cut edge.
Lay the material down along the margin of the distal palmar crease that has been established with the cast padding.

83. Wrap a second time around the hand and through the web-space, cutting as before.
Repeat this cutting technique when you arrive back at the web-space, folding the edges under as before.

84. Proceed wrapping up the arm, overlapping by one-half.
After your second pass through the web-space, start wrapping up the arm spirally, overlapping by one-half until you reach the proximal border of the cast padding.

85. When you reach the proximal end
Because the roll has not been dipped in water, there will be enough time to let it sit on the foil pouch while you roll back the stockinet.
When you reach the proximal end
of the cast, cut off the remaining roll
and place it on the foil pouch.

86. Roll back the stockinet
distally, proximally,
and around the thumb.
Take care when you are rolling back the stockinet to eliminate all wrinkles and establish your margin distally just behind the distal palmar crease.

87. Complete one final pass through the web-space
Dip the remaining roll in water and begin wrapping from the proximal end covering the edge of the
rolled back stockinet.
Complete one final pass through the web-space
using the cut technique and covering all edges of the rolled back stockinet.
After completing the final pass through the web-space, cut off any extra casting tape just proximal to the thumb in the middle of the volar side of the wrist.
Wet your gloves and smooth the entire cast. This will give the finished cast a smoother surface.
Begin molding with your flattened palms and extended fingers.
Care should be taken NOT to cause indentions in the cast by squeezing with your fingers.
The cast should be molded to accurately replicate the hand and wrist in a neutral and functional position.
The wrist should look flat as you view it laterally and the casting tape should be molded into the palm.
Smooth and mold
to finish the cast.