SplintER Series: Splint Application Principles 102

The SplintER Series is back with its second installment! In the first post, Splint 101, we discussed the indications and relative contraindications to splinting. In this post, we focus on the materials used in splinting and some key steps in splint application.

Learning Objectives

  1. List the materials that are required to place a splint.
  2. Be able to discuss some basic principles about the application of a splint.

The Bottom Line

A splint consists of 3 layers:1

  1. Deep layer = padding
  2. Middle layer = splint material
  3. Outer layer = compressive dressing

There are 2 types of traditional splinting material – plaster and fiberglass. Plaster allows for more malleability, whereas fiberglass is more lightweight and easier to apply. There are also prefabricated splints such as Ortho-Glass®.

To apply a splint:

  1. Place your stockinette (optional) and padding loosely.
  2. Submerge your material in water to generate an exothermic reaction that will harden your splint.
  3. Use your palm to conform the material to the extremity.
  4. Wrap the elastic bandage from distal to proximal and form the desired shape of your splint.

Although it is important that a splint fits to the extremity, it is equally important that it is not so tight that it obstructs venous outflow. Recall that a splinted limb is at risk for compartment syndrome. Be sure to perform a neurovascular exam before and after placing a splint.

For a concise instructional summary, the EMRA Splint Guide is extremely useful.

More Detailed, Step-Wise Instruction on Splint Application

Splinting Materials

  • Splint material: plaster or fiberglass
  • Stockinette and/or splint padding
  • Bucket of water
    • If plaster: Tepid water
    • If fiberglass: Cool water
  • Elastic bandage (eg Ace wrap, Kerlix)
  • Trauma shears
  • Tape

Splint Material:

First published in 1852 by a military surgeon named Antonius Mathijsen,2 plaster (of-Paris) has been used for over a century in order to immobilize fractures. It was the only true rigid splinting material available until the advent of fiberglass in 1987. More recently, prefabricated splints such as Ortho-Glass are available. This post focuses on the traditional method to forming a splint from plaster or fiberglass.

Given the layering and formed paste, plaster can be more difficult to apply. However, it is more malleable. Fiberglass, while less flexible, hardens quickly, is easier to apply, and is lightweight.3 The newer prefabricated splints such as Ortho-Glass contain fiberglass and are pre-padded. Unlike traditional plaster and fiberglass, these pre-padded fiberglass splints require only a minimal amount of cool water to activate. The selection of splint material will depend on provider preference and institutional availability.

Ortho-Glass® splint material (Photo Credit: William Denq)

Stockinette (optional):

The use of a stockinette can be useful in protecting the skin from the sharp edges of splinting material. It prevents chafing and helps to maintain the shape of the splint. However, if the stockinette is too loose or the wrong size, the material can collect together and create pressure points, which increase the risk of skin ulceration. If the stockinette gets wet, it can cause skin maceration. Typically, a stockinette is not required for a simple splint – padding is enough to protect the skin.

Stockinette (Photo Credit: William Denq)

Padding:

Padding is required for both plaster and fiberglass media. It provides a comfortable medium between the skin and rigid splint, while also preventing skin maceration.3 Padding, like the rigid splinting material, is categorized by its width, usually 3, 4, 5, or 6 inches.

Soft padding (Photo Credit: William Denq)

Evaluate for bony prominences, and adequately pad these areas, which are prone to forming pressure sores. Examples include the olecranon, malleoli, and calcaneus.2 Applying additional strips of padding to these areas avert the need to place an additional circumferential wrap.

Water Temperature:

Water temperature affects how fast the splinting material hardens.4 If the water is warmer, the material will harden faster. However, the quicker the material hardens, the greater potential for a serious burn. Never use warm or hot water for plaster. Utilize cool water with fiberglass as it inherently hardens faster than plaster. Tepid water should be be used to activate plaster. Be sure to change the water you use after each splint application because the residual splint material can accelerate the activating and hardening process.2

Use tepid or cold water for plaster or fiberglass, respectively. (Photo Credit: William Denq)

Before You Splint

Neurovascular Exam:

Before applying a splint, perform a neurovascular exam; findings should be the same before and after splint application.

 

Expert: Dr. Elizabeth Delasobera Tips on the Neurovascular Exam


Sports Medicine Fellowship Director, Georgetown University

  1. Check and document all pulses in the region
  2. Check and document capillary refill on the affected and contralateral side
  3. Check and document sensation on the affected and contralateral side

Stockinette, Padding, and Splint Material:

The patient’s stockinette, padding, and splint material all need to be measured out and cut to the appropriate length.

  1. Stockinette: Using your shears, cut the length to be 2-3 cm longer than the expected splint length.
  2. Padding: Using your shears, cut the length to be the same as your expected splint length.
  3. Splint material: Prepare 6-10 layers for the upper extremities and 12-15 layers for lower extremities. These layers will vary depending on the size of the affected limb. Your splint material length should be 1-2 cm longer than the length of your projected splint as splinting material shrinks when it hardens.5

Wounds:

Any wounds that are on the affected limb need to be thoroughly assessed, cleaned, and appropriately dressed prior to splint application. Avoid using tape with the dressing; instead secure it with a rolled gauze being careful to avoid excessive compression.

Splinting Application Instructions

Stockinette and Padding:

Apply the stockinette and then add 1-3 layers of padding. These should be placed circumferentially and loosely around the extremity beyond where the rigid splint is expected to be. When you run out of padding roll, half of the previous width should be covered by the subsequent, neighboring layer.5

Special Considerations:

If splinting fingers or toes, ensure padding is placed between fingers/toes to prevent maceration. If splinting the forearm and the padding needs to traverse the thumb, create a defect in the padding to stick the thumb through.

Application of stockinette and overlying padding (Photo Credit: Caleb Sunde)

Activating Your Splinting Material:

If using plaster, submerge the layers in tepid water until the bubbling stops. This signals the complete saturation of the material.3 If using fiberglass, submerge the layers in cool water until the bubbling stops. Prefabricated splints such as Ortho-Glass should not be submerged as it only requires a minimal amount of cool water to activate the material.

The purpose of applying water to a splint material is to activate it. Doing so will cause an exothermic reaction while the material hardens. Because burns have been reported, use cooler water (as opposed to hot water), and apply generous padding. Wring out as much water as possible while still maintaining the plate-like integrity of the splint material. Place the splint on a hard surface or several layers of your pre-cut padding to smooth out any formed wrinkles.

Activating the splint by submerging in tepid water (Photo Credit: William Denq)

Application of Rigid Splinting Material:

While keeping the extremity in its desired position, conform the material to the extremity with the palm. Fingers can create indentations and unintentional pressure points that may result in skin breakdown.4 An assistant may be used to help stabilize the splint material onto the affected limb. To avoid accidental soft tissue damage or discomfort from the sharp ends of plaster and fiberglass, fold the edge over on itself. In general, plaster hardens in 5-10 minutes and fiberglass in 3-4 minutes.

Do NOT rest the affected extremity with a forming splint on a surface such as a pillow or table as it could trap the exothermic reaction generated and result in a burn.2

Application of the splint over stockinette and padding (Photo Credit: Caleb Sunde)

Application of Elastic Bandage:

The elastic bandage should be wrapped onto the affected extremity in a distal to proximal direction. This theoretically helps with venous return and reduces subsequent swelling from an acute injury.5 Although the bandage application helps to conform the hardening splint material to its desired position, excessively tight application (in an effort to reduce swelling and mold the splint) may instead result in compartment syndrome.

Application of the elastic bandage should be in a distal to proximal fashion. (Photo Credit: Caleb Sunde)

After Splinting

After the splint application, the procedure is not yet complete.

  1. Check and document all the pulses in the region. If the occlusive dressing prevents you from being able to document these pulses. The next best assessment is to check and document the distal capillary refill and sensation exam.
  2. Check the range of motion of the unaffected joints to ensure that the splint does not interfere with their movement.1
1.
Brown S, Radja F, eds. Orthopaedic Immobilization Techniques. Urbana, IL: Sagamore Publishing; 2015.
2.
Browner B, Jupiter J, Krettek C, Anderson P. Skeletal Trauma: Basic Science, Management, and Reconstruction. 5th ed. Philadelphia: Elsevier Saunders; 2015.
3.
Tintinalli J, Stapczynski J, Ma J, Yealy D, Meckler G, Cline D. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th Edition. 8th ed. McGraw-Hill Education / Medical; 2015.
4.
Boyd A, Benjamin H, Asplund C. Principles of casting and splinting. Am Fam Physician. 2009;79(1):16-22. [PubMed]
5.
Roberts J R, Custalow C B, Hedges J R, Thomsen T W, eds. Roberts and Hedges’ Clinical Procedures in Emergency Medicine. 6th ed. Saunders; 2014.

Author information

Max Hockstein, MD

Max Hockstein, MD

Chief Resident
Department of Emergency Medicine
Parkland/University of Texas Southwestern

The post SplintER Series: Splint Application Principles 102 appeared first on ALiEM.

Trick of the Trade: Topical Treatment of Cannabinoid Hyperemesis Syndrome

A 23-year-old female with no past medical history presents to the ED for the 4th time this month complaining of severe “10-out-of-10” abdominal pain, nausea, and intractable vomiting. She denies alcohol use, but reports she has smoked at least 1 marijuana “bud” daily for the last 3 years. In an attempt to relieve her symptoms, she has increased her marijuana use, however she has found that her pain is actually increasing, and the only thing that appears to help is taking a hot shower or bath. With this statement, the provider immediately considers cannabinoid hyperemesis syndrome (CHS).

Cannabinoid Hyperemesis Syndrome

Cannabinoid hyperemesis syndrome (CHS) was first described in Australia in 2004 and is characterized by years of cannabis abuse, cyclic episodes of nausea and vomiting, and a learned behavior of hot bathing or showering.1

Δ9 -tetrahydrocannabinol (THC) is the principle active compound of cannabis, and acts similarly as an endogenous cannabinoid on cannabinoid receptors.2 The human body has 2 distinct cannabinoid receptors, CB1 and CB2. The CB1 receptors have been identified in multiple organ systems, including the brain, spleen, liver, heart, uterus, bladder, and gastrointestinal system. Less is known about CB2 receptor effects; they are likely involved in the inhibition of inflammation, visceral pain, and intestinal motility. It has been hypothesized that THC is the causative agent of CHS by chronic stimulation of CB1 and CB2 receptors, resulting in gastrointestinal disturbances.2

Diagnostic Criteria

CHS is often under-recognized and diagnosed only after multiple visits to the ED and extensive workups.

Proposed clinical criteria for CHS include:

  1. Long-term weekly cannabis use
  2. Abdominal pain
  3. Severe cyclic nausea and vomiting
  4. Relief of symptoms with hot showers3

Treatment

The most effective long-term treatment is the cessation of cannabis use. In the ED, treatment is directed towards symptom management. Intravenous hydration, electrolyte replacement, and pharmacologic alleviation of nausea, vomiting, and abdominal pain are the mainstays of therapy. Opioids for relief of abdominal pain should be avoided, as they may exacerbate nausea and vomiting.4 Typical antiemetics such as ondansetron, promethazine, prochlorperazine, and metoclopramide are infrequently effective as monotherapy. Treatment with haloperidol or droperidol should be considered, as they provide antiemetic effects likely due to D2 dopamine receptor antagonism in the central nervous system.4 A case report found that patients had resolution of their symptoms within 2 hours of receiving haloperidol, and were able to discharge from the ED within 8 hours.5 Benzodiazepines, such as lorazepam, should also be considered as a treatment option, especially for associated anticipatory nausea.4

There are various pharmacologic interventions to treat the symptoms of CHS, but what else can be done? As mentioned, patients with CHS compulsively take hot showers and report relief of symptoms during the shower. Hot water activates transient receptor potential vanilloid 1 (TRPV1) receptors, resulting in impaired substance P signaling in the area postrema and nucleus tractus solitarius.6 It is unlikely feasible to have patients shower in the ED for symptom relief; however, there is a pharmacologic trick to get the same effect.

Trick of the Trade – Apply Capsaicin Cream to the Abdomen

Topical capsaicin cream binds to TRPV1 receptors with high specificity, impairing substance P signaling, much like a hot shower. In multiple case series and reports, capsaicin cream used in the ED was found to provide adequate relief of symptoms:

  • Case series of 13 patients in 2 academic medical centers diagnosed with CHS were treated with capsaicin cream and had improvement in symptoms after other treatments failed7
  • Case series of 5 patients with chronic cannabis use diagnosed with CHS and treated successfully with 0.075% capsaicin cream8
  • Case report of 1 patient with CHS, treatment failed with metoclopramide and granisetron, but had successful treatment with 0.075% capsaicin cream9
  • Case report of 1 patient with CHS, no relief of symptoms with zofran, treated successfully with 0.025% capsaicin cream10

Bonus Trick of the Trade

If topical capsaicin irritates any sensitive areas outside the abdomen, rinse the area with milk to alleviate quickly! The milk protein, casein, acts as a natural detergent and breaks up the capsaicin.11

1.
Allen J, de M, Heddle R, Twartz J. Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuse. Gut. 2004;53(11):1566-1570. [PubMed]
2.
Galli J, Sawaya R, Friedenberg F. Cannabinoid hyperemesis syndrome. Curr Drug Abuse Rev. 2011;4(4):241-249. [PubMed]
3.
Simonetto D, Oxentenko A, Herman M, Szostek J. Cannabinoid hyperemesis: a case series of 98 patients. Mayo Clin Proc. 2012;87(2):114-119. [PubMed]
4.
Khattar N, Routsolias J. Emergency Department Treatment of Cannabinoid Hyperemesis Syndrome: A Review. Am J Ther. September 2017. [PubMed]
5.
Witsil J, Mycyk M. Haloperidol, a Novel Treatment for Cannabinoid Hyperemesis Syndrome. Am J Ther. 2017;24(1):e64-e67. [PubMed]
6.
Richards J, Gordon B, Danielson A, Moulin A. Pharmacologic Treatment of Cannabinoid Hyperemesis Syndrome: A Systematic Review. Pharmacotherapy. 2017;37(6):725-734. [PubMed]
7.
Dezieck L, Hafez Z, Conicella A, et al. Resolution of cannabis hyperemesis syndrome with topical capsaicin in the emergency department: a case series. Clin Toxicol (Phila). 2017;55(8):908-913. [PubMed]
8.
Lapoint J. Case series of patients treated for cannabinoid hyperemesis syndrome with capsaicin cream. Clin Tox. 2014;52:707.
9.
Román F, Llorens P, Burillo-Putze G. [Topical capsaicin cream in the treatment for cannabinoid hyperemesis syndrome]. Med Clin (Barc). 2016;147(11):517-518. [PubMed]
10.
Biary R, Oh A, Lapoint J, Nelson L, Hoffman R, Howland M. Topical capsaicin cream used as a therapy for cannabinoid hyperemesis syndrome. Clin Tox. 2014;52:787.
11.
Rohrig B. Hot peppers: muy caliente. Chem Matters. 2014.

Author information

Neda Krunic, PharmD

Neda Krunic, PharmD

Pharmacy Practice Resident
Banner - University Medical Center Phoenix

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Pediatric Trick of the Trade: Finger Immobilization Technique

A 3 year-old boy presents with a deep laceration of the distal phalanx, through the nail bed, after slamming his fingers in a car door. He is crying, anxious, and uncooperative. How do you make this situation easier to evaluate and repair?

Nail bed and finger laceration repairs can be challenging, and even more challenging in young patients. Preparation is key to getting a good outcome. Here we present a pediatric trick of the trade on immobilizing a finger for digit or nail bed procedures.

Pediatric Trick of the Trade: Finger Immobilization Technique

  • Distract child by utilizing parents, TV, cell phone, and/or child life specialists.
  • Use a large chuck or sheet to block the patient’s view of yourself and his/her hand.
  • Attach an adult size IV arm board (approximately the length of the patient’s forearm) with tape around the wrist and forearm. Be careful not to restrict blood flow.
  • Leave some extra distal arm board length to use as a handle.
  • Tape all finger joints (except those requiring evaluation or repair) to the arm board.
  • Administer a digital block for anesthesia.
  • Apply a tourniquet for hemostasis, as needed.

This technique allows for isolation of the area of interest, reduces patient movement, and conceals the procedure from the child’s view.

finger immobilization 1

finger immobilization 2

For tips on how to repair nail bed lacerations, see Trick of the Trade: Finger nail bed laceration repair.

Author information

Josh Bukowski, MD

Josh Bukowski, MD

Resident
Department of Emergency Medicine

University of California, San Francisco

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