How to Apply the Perfect Splint
Splinting and casting as a means of treating musculoskeletal injuries has been used for thousands of years. Hippocrates first described splinting in 350 BC when he wrote about wrapping injured limbs in bandages soaked in wax and resins. While we have come a long way since that time, the use of modern splints and casts are still used today. However, this is becoming a dying art. While used every day in the ED, operating room, and orthopedic clinics around the world, the functional and aesthetic art of splinting and casting is not taught as much as it should be.
Let’s first think about it from a patient’s perspective…the splint is the only thing they see of your surgery postoperatively. Whether it’s true or not, which surgeon do you think did a better job? The one who placed their patient in splint on the left or the right? Their ultimate outcome and satisfaction with surgery starts as soon as they wake up, and your splint is the first judgement they’ll make.
"Which surgeon do you think did a better job?"
Next, let’s turn to the resident and attending relationship. Often times, orthopedic attendings don’t see the patients in the ED. Reduction, splinting and/or casting are all managed by the orthopedic resident, midlevels or ED staff. When these patients first show up in the office, you want the cast or splint you applied to look good and be functioning well. If your attending is constantly hearing patient complaints about cast rubbing or pain, or is having to always cut off and replace your work, it’s not going to bode well for you. Alternatively, if your casts or splints all look and function great, then it will likely translate into more respect for your as a resident. Take pride in your work.
Lastly, placing a cast or splint is not always a benign procedure. Many complications can occur if it is done incorrectly including skin break down, wound complications and cast saw burns. Too often splints and casts are “slapped on” without attention to detail. While simple, it’s important to remember this is a procedure and should be done correctly.
Now we’ll review the proper technique for placing a splint and a cast in very broad steps. The videos walk you through, step by step, how to apply an AO splint, sugar tong splint and short arm cast.
Applying a Cast
Step 1. Supplies
Stockinette
Webril
Anti-cut tape (if used)
Fiberglass cast material
Step 2. Position the extremity
It’s vital to place the extremity in the final position that it will be casted before you begin. If you work part way through your cast, and then decide to flex the elbow or dorsiflex the ankle, your casting supplies will bunch up and cause skin problems – don’t do this. More importantly, you need to be monitoring your “holder” to ensure they do not do this!
Step 3. Apply the stockinette
This is done in one of two ways – either covering the whole extremity where the cast will be placed or just at the proximal and distal ends. It’s important to keep this longer than your expected cast, as its this material that is folded over to give you nice looking cuffs.
Step 4. Padding
You want there to be enough padding to prevent skin breakdown, but not so much that it will give your fracture “wiggle room” and you’ll lose reduction. We follow the 50% overlap rule. As you’re applying webril each pass around the extremity should overlap your previous pass by 50%. It’s also important to remember to pad all bony prominences – this means the elbow, ulnar styloid, fibular head, heel, etc… Basically, anywhere skin breakdown could occur secondary to pressure. Finally, it’s important to place nice cuffs around the proximal and distal ends of the cast. This not only prevents the cast from rubbing the skin here, but it makes it look a lot nicer! When applying your cast padding it’s also important to make sure that it’s smooth and without wrinkles - this is certainly part of the application art. Webril is made in such a way that it tears easily. Roll it close to the skin, and partially tear it to help it lay down nice and flat. Wrinkles in this layer can lead to pressure on the skin. Once the webril has been placed, you may place your anti-cut (aka Deflex) tape. This is placed on both sides of the extremity, either volar/dorsal for upper extremity casts or medial/lateral for lower extremity casts. Anti-cut tape, if used, should span the entire cast.
Step 5. Casting
Now it’s finally time to apply your cast material. We wrap distal to proximal, again following the 50% overlap rule. Several passes are applied to the proximal and distal aspects of the cast to make it stronger in these areas. Additionally, areas of thin cast, such as between the index finger and thumb, should also be reinforced with more than one pass to prevent cast breakdown. Never wrap beyond the webril padding. In fact, it’s important to leave a cm or so of padding past the ends of your cast tape. Once the first layer of cast is applied, a mold is placed (as indicated by the fracture). Once the cast material has dried in a satisfactory molded position, the stockinette is folded over, creating a nice cuff and protecting the skin from the edges of the cast. Finally, the last roll of cast tape is applied in what we call the “Cadillac Roll”. This simply makes the cast look nice and reinforces it. Be sure that your cast material is lying flat. When I was an intern my chief told me, “let the cast go where it wants to go.” You can always double back if needed, but it’s important to make sure the cast tape lays down flat, don’t force it go where it doesn’t want to. Additionally, you may cut the cast material partially as needed to help makes some turns and ensure the material is lying flat and without wrinkles. Lastly, take soap and rub it over the cast, this helps consolidate the material and smooth out any rough edges.
Step 6. X-rays
ALWAYS, ALWAYS, ALWAYS get x-rays after placing a patient in a cast. In my mind, this serves three purposes. First, you can see your reduction, and know that the bone is in the correct and appropriate alignment. Second, it gives you a radiograph to compare to when following the patient in the office. Finally, its documented proof that you adequately saw and treated the patient.
Step 7. Educate
Once a cast has been placed, it is imperative to discuss the “do’s and don’ts” of having a cast. First, it should be stressed that webril is not waterproof and the cast cannot get wet at all (unless applying a waterproof cast obviously). To shower, the extremity must be placed in a waterproof cast bag or covered with a trash bag, duck taped proximally, and kept out of the water. Secondly, review weightbearing restrictions with the patient. The patient in the image below told us he wasn’t walking on his cast, he was walking on his shoe – so be specific! Next, they need to know that they should not try to remove the cast (this seems obvious but with enough time you’ll understand that patients and their family don’t always understand this concept). Give the patient information about compartment syndrome and concerning symptoms – we cannot always anticipate how much swelling will occur after casting. While this is a very rare complication, it must be discussed with every patient placed in a splint or cast. If you are concerned about swelling, we recommend splinting or bi-valving the cast. Finally, stress the importance of follow up. Radiographs need to be obtained at regular intervals to assess for overall alignment of the fracture. If loss of reduction does occur casting wedging or other intervention can be performed and prevent the patient from having a malunion.
Applying a Splint
Step 1. Supplies
Webril
Splint material (plaster or orthoglass)
Water bucket
ACE wrap
Step 2. Set Up
Prior to starting your splint, you will need to measure out the appropriate materials. We always measure the patient’s “good extremity” with webril to create a template for how long your splint material should be. When choosing between orthoglass and plaster, we prefer plater for any splint that needs to hold a reduction. It just molds better and more easily, and thus is better at holding reductions in our opinion. We use 10-12 layers of plaster, and never end a layer short -if it does not make it all the way across, tear it and start a new roll. Positioning works the same as it does for casting, pick the position you want the extremity to be in, and leave it there.
Step 3. Padding
For splints, the padding goes directly on the skin, so there is no need for a stockinette – you can use it if you choose, but we do not. We wrap the same way we do for a cast – distal to proximal. Again, we can’t stress enough to pad all bony prominences!
Step 4. Splint
Wet your splint and wring it out. For those of you using orthoglass please do not soak it! All you have to do is get a small amount of water in both ends and use your thumb and index finger to squeegee it throughout the fiberglass. If you get these soaking wet, it just makes the skin breakdown and turns your webril to mush. Alternatively, with orthoglass, you can take the fiberglass out of the padding and wet it. Next, squeeze it dry and place it back into the padding (often you will have to trim an end off to make it fit) – this prevents the wet padding from sitting on the skin and macerating it. Hot water makes the splint materials set up faster so choose your water temp wisely. Finally, when using plaster, make sure to cover the entire surface of the wet plaster with webril so it doesn’t stick to your ACE wrap – whoever has to take it off will thank you.
Step 5. ACE wrap
The ACE wrap is applied loosely, but without wrinkles. Ultimately, this is the only thing the patient will see, so make it look nice!
Step 6. X-rays
If your placing a splint to hold a reduction. ALWAYS get x-rays post reduction to see how you did. If the reduction isn’t adequate, re-do it! Additionally, if treating nonoperatively, this gives you a baseline radiograph to compare films with in the office.
Demonstration Videos
Hopefully you have learned something from this post, and will now apply better looking and functioning splints and casts. Complications from improper technique can be devastating and are easily preventable, so always do your part.
Most importantly, take pride in your work. Best of luck!
--Pocket Pimped: Orthopedic Surgery