Splinting is a nonsurgical procedure that involves applying a rigid or semi-rigid device to an injured limb to immobilize and protect the fractured bone, reduce pain and swelling, and prevent further damage. Splinting is often used as a temporary measure until definitive treatment, such as casting or surgery, can be performed. Splinting can also be used as a definitive treatment for some stable and uncomplicated fractures.

Splints can be either prefabricated or custom-made, depending on the type, location, and severity of the fracture. Prefabricated splints are ready-made devices that come in various shapes and sizes, such as knee immobilizers, wrist braces, or cervical collars. Custom-made splints are fabricated at the bedside using materials such as plaster or fiberglass, which can be molded and shaped to fit the specific anatomy and injury of the patient.

In this post, we will review some of the common splinting techniques for fractures of the upper and lower extremities, as well as their indications, advantages, disadvantages, and complications. We will also provide some tips and tricks on how to apply splints properly and safely.

Splinting Materials and Equipment

The basic materials and equipment needed for splinting are:

• Stockinette: A tubular cotton fabric that covers the skin and provides a smooth surface for padding and splinting material. Stockinette should extend 2 inches beyond the splinting material at both ends.
• Padding: A soft material that cushions the limb and protects the skin from pressure sores, blisters, or abrasions. Padding should be applied in 2 to 3 layers over the area to be splinted and between digits being splinted. Extra padding should be added over bony prominences, such as the elbow, heel, or ankle.
• Splinting material: A rigid or semi-rigid material that immobilizes the fracture and maintains its alignment. Splinting material can be either plaster or fiberglass. Plaster is cheaper and easier to mold, but heavier and takes longer to dry. Fiberglass is lighter and stronger, but more expensive and harder to mold. The number of layers of splinting material depends on the size of the limb and the degree of stability needed. Generally, 8 to 10 layers are used for upper extremity splints, and 10 to 12 layers are used for lower extremity splints.
• Elastic bandage: A stretchable fabric that wraps around the splint to secure it in place and provide compression to reduce swelling. Elastic bandage should be applied evenly and firmly, but not too tightly to impair circulation or cause discomfort.
• Water: A liquid that moistens the splinting material and activates its hardening process. The temperature of the water affects the setting time of the splint. Warm water makes the splint set faster, while cold water makes it set slower. The optimal temperature is around 25 degrees Celsius (77 degrees Fahrenheit).
• Trauma shears: A pair of scissors that can cut through stockinette, padding, elastic bandage, and splinting material. Trauma shears are used to trim excess material or remove the splint if needed.

Splinting Procedure

The general steps of applying a splint are:

1. Prepare the patient: Explain the procedure to the patient and obtain informed consent. Provide adequate analgesia and sedation if needed. Clean and dress any wounds or lacerations on the limb. Reduce any displaced fractures or dislocations if indicated.
2. Prepare the materials: Measure and cut the stockinette, padding, and splinting material according to the size and shape of the limb and the type of splint. Use gloves to handle the materials and avoid skin contact with wet plaster or fiberglass.
3. Apply the stockinette: Slip the stockinette over the limb and make sure it covers the entire area to be splinted. Cut a hole in the stockinette for the thumb if applying a wrist or forearm splint.
4. Apply the padding: Wrap the padding around the limb over the stockinette in a spiral fashion, overlapping each layer by half its width. Make sure there are no wrinkles or gaps in the padding. Separate and pad each digit if applying a hand or foot splint.
5. Apply the splinting material: Dip each layer of splinting material in water for a few seconds until it is fully wetted but not dripping. Squeeze out any excess water gently. Apply each layer over the padding in a smooth and even manner, following the contour of the limb. Overlap each layer by half its width. Fold the ends of the stockinette over the splinting material to create a smooth edge.
6. Apply the elastic bandage: Wrap the elastic bandage around the splint in a spiral fashion, overlapping each layer by half its width. Make sure the bandage is snug but not too tight. Secure the end of the bandage with tape or clips.
7. Mold and shape the splint: While the splint is still wet, use your palms to mold and shape the splint to fit the limb and maintain the desired position. Avoid using your fingers or creating any indentations or pressure points on the splint. Check the alignment and stability of the fracture and adjust the splint as needed.
8. Check the neurovascular status: After the splint is applied, check the pulse, sensation, and motor function of the limb distal to the splint. Compare with the contralateral limb and document any abnormalities. If there is any sign of impaired circulation or nerve function, loosen or remove the splint immediately and seek medical attention.

Common Splinting Techniques for Upper Extremity Fractures

The following are some of the common splinting techniques for upper extremity fractures, along with their indications, advantages, disadvantages, and complications.

Posterior Long Arm Splint

A posterior long arm splint is a type of splint that immobilizes the elbow and forearm. It is indicated for fractures of the olecranon, humerus, radial head, and neck.

The advantages of a posterior long arm splint are:

• It provides good stability and alignment for elbow and forearm fractures.
• It prevents elbow flexion and extension, which can cause displacement or angulation of fractures.
• It allows some rotation of the forearm, which can prevent stiffness or contracture of the elbow.

The disadvantages of a posterior long arm splint are:

• It can be uncomfortable and cumbersome for the patient, especially if it extends to the hand or fingers.
• It can impair hand function and limit activities of daily living.
• It can cause pressure sores or nerve injury at the elbow or wrist if applied too tightly or poorly padded.

The complications of a posterior long arm splint are:

• Compartment syndrome: A condition where increased pressure within the muscle compartments of the arm compromises blood flow and oxygen delivery to the tissues, causing severe pain, swelling, and tissue necrosis. This is a medical emergency that requires immediate fasciotomy (surgical release of the pressure).
• Radial nerve palsy: A condition where damage to the radial nerve causes weakness or paralysis of the wrist and finger extensors, resulting in a characteristic wrist drop. This can be caused by direct trauma to the nerve, compression by a tight splint or bandage, or prolonged elbow flexion.
• Ulnar nerve palsy: A condition where damage to the ulnar nerve causes numbness, tingling, or pain in the ring and little fingers, as well as weakness or paralysis of some hand muscles, resulting in a claw-like deformity of the hand. This can be caused by direct trauma to the nerve, compression by a tight splint or bandage, or prolonged elbow flexion.

To apply a posterior long arm splint:

1. Cut a piece of stockinette that extends from the shoulder to the metacarpophalangeal (MCP) joints of the hand. Cut a hole in the stockinette for the thumb if applying a forearm splint only.

Cut a piece of padding that extends from 2 inches above to 2 inches below2 inches below the elbow joint and from the elbow joint to the MCP joints of the hand. Cut a hole in the padding for the thumb if applying a forearm splint only.

3. Cut a piece of splinting material that extends from 2 inches above to 2 inches below the elbow joint and from the elbow joint to the MCP joints of the hand. Cut a hole in the splinting material for the thumb if applying a forearm splint only.

4. Slip the stockinette over the arm and position it properly.

5. Wrap the padding around the arm over the stockinette, making sure to pad the elbow and wrist well.

 6. Dip each layer of splinting material in water and apply it over the padding, starting from the elbow and working your way down to the hand. Overlap each layer by half its width and smooth out any wrinkles or bubbles.

 7. Fold the ends of the stockinette over the splinting material and secure them with tape or clips.

8. Wrap an elastic bandage around the splint, starting from the hand and working your way up to the shoulder. Make sure the bandage is snug but not too tight.

 9. Mold and shape the splint to fit the arm and maintain the desired position. The elbow should be flexed at 90 degrees and the forearm should be in neutral rotation (thumb pointing up).

10. Check the neurovascular status of the arm distal to the splint and document any abnormalities.

Sugar-Tong Splint

A sugar-tong splint is a type of splint that immobilizes the wrist and forearm. It is indicated for fractures of the distal radius, ulna, or both.

The advantages of a sugar-tong splint are:

• It provides good stability and alignment for wrist and forearm fractures.
• It prevents wrist flexion and extension, which can cause displacement or angulation of fractures.
• It encircles the elbow, which prevents pronation and supination of the forearm, which can cause rotational malalignment of fractures.

The disadvantages of a sugar-tong splint are:

• It can be uncomfortable and cumbersome for the patient, especially if it extends to the fingers.
• It can impair hand function and limit activities of daily living.
• It can cause pressure sores or nerve injury at the elbow or wrist if applied too tightly or poorly padded.

The complications of a sugar-tong splint are:

• Compartment syndrome: A condition where increased pressure within the muscle compartments of the forearm compromises blood flow and oxygen delivery to the tissues, causing severe pain, swelling, and tissue necrosis. This is a medical emergency that requires immediate fasciotomy (surgical release of the pressure).

Median nerve palsy: A condition where damage to the median nerve causes numbness, tingling, or pain in the thumb, index, middle, and half of half of the ring finger, as well as weakness or paralysis of some hand muscles, resulting in a flattened palm and difficulty making a fist. This can be caused by direct trauma to the nerve, compression by a tight splint or bandage, or prolonged wrist flexion.

• Ulnar nerve palsy: A condition where damage to the ulnar nerve causes numbness, tingling, or pain in the ring and little fingers, as well as weakness or paralysis of some hand muscles, resulting in a claw-like deformity of the hand. This can be caused by direct trauma to the nerve, compression by a tight splint or bandage, or prolonged elbow flexion.

To apply a sugar-tong splint:

1. Cut a piece of stockinette that extends from the shoulder to the MCP joints of the hand. Cut a hole in the stockinette for the thumb.
2. Cut a piece of padding that extends from 2 inches above to 2 inches below the elbow joint and from the dorsal surface of the MCP joints to the volar surface of the fracture site. Cut a hole in the padding for the thumb.
3. Cut a piece of splinting material that extends from 2 inches above to 2 inches below the elbow joint and from the dorsal surface of the MCP joints to the volar surface of the fracture site. Cut a hole in the splinting material for the thumb.
4. Slip the stockinette over the arm and position it properly.
5. Wrap the padding around the arm over the stockinette, making sure to pad the elbow and wrist well.
6. Dip each layer of splinting material in water and apply it over the padding, starting from one side of the elbow and working your way around to the other side, then down to the hand and back up to the elbow. Overlap each layer by half its width and smooth out any wrinkles or bubbles.
7. Fold the ends of the stockinette over the splinting material and secure them with tape or clips.
8. Wrap an elastic bandage around the splint, starting from one side of the elbow and working your way around to the other side, then down to the hand and back up to the elbow. Make sure the bandage is snug but not too tight.

• Mold and shape the splint to fit the arm and maintain the desired position. The elbow should be flexed at 90 degrees and the forearm should be in neutral rotation (thumb pointing up).
• Check the neurovascular status of the arm distal to the splint and document any abnormalities

Thumb Spica Splint

•  
• A thumb spica splint is a type of splint that immobilizes the thumb and wrist. It is indicated for fractures of the thumb, scaphoid, or trapezium.
• The advantages of a thumb spica splint are:
• It provides good stability and alignment for thumb and wrist fractures.
• It prevents thumb abduction and extension, which can cause displacement or angulation of fractures.
• It allows some finger movement, which can prevent stiffness or contracture of the hand.
• The disadvantages of a thumb spica splint are:
• It can be uncomfortable and cumbersome for the patient, especially if it extends to the forearm or elbow.
• It can impair hand function and limit activities of daily living.
• It can cause pressure sores or nerve injury at the wrist or thumb if applied too tightly or poorly padded.
• The complications of a thumb spica splint are:
• Compartment syndrome: A condition where increased pressure within the muscle compartments of the forearm compromises blood flow and oxygen delivery to the tissues, causing severe pain, swelling, and tissue necrosis. This is a medical emergency that requires immediate fasciotomy (surgical release of the pressure).
• Median nerve palsy: A condition where damage to the median nerve causes numbness, tingling, or pain in the thumb, index, middle, and half of the ring finger, as well as weakness or paralysis of some hand muscles, resulting in a flattened palm and difficulty making a fist. This can be caused by direct trauma to the nerve, compression by a tight splint or bandage, or prolonged wrist flexion.
• Radial nerve palsy: A condition where damage to the radial nerve causes weakness or paralysis of the wrist and finger extensors, resulting in a characteristic wrist drop. This can be caused by direct trauma to the nerve, compression by a tight splint or bandage, or prolonged elbow flexion.
• To apply a thumb spica splint:
• Cut a piece of stockinette that extends from the elbow to the fingertips. Cut a hole in the stockinette for the thumb.
• Cut a piece of padding that extends from 2 inches above to 2 inches below

2 inches below the wrist joint and from the dorsal surface of the thumb to the volar surface of the fracture site. Cut a hole in the padding for the thumb.

3. Cut a piece of splinting material that extends from 2 inches above to 2 inches below the wrist joint and from the dorsal surface of the thumb to the volar surface of the fracture site. Cut a hole in the splinting material for the thumb.

4. Slip the stockinette over the arm and position it properly.

5. Wrap the padding around the arm over the stockinette, making sure to pad the wrist and thumb well.

6. Dip each layer of splinting material in water and apply it over the padding, starting from one side of the wrist and working your way around to the other side, then down to the thumb and back up to the wrist. Overlap each layer by half its width and smooth out any wrinkles or bubbles.

7. Fold the ends of the stockinette over the splinting material and secure them with tape or clips.

 8. Wrap an elastic bandage around the splint, starting from one side of the wrist and working your way around to the other side, then down to the thumb and back up to the wrist. Make sure the bandage is snug but not too tight.

9. Mold and shape the splint to fit the arm and maintain the desired position. The wrist should be in neutral position (neither flexed nor extended) and the thumb should be abducted (away from the palm) and slightly flexed at the interphalangeal joint.

10. Check the neurovascular status of the arm distal to the splint and document any abnormalities.

Common Splinting Techniques for Lower Extremity Fractures

The following are some of the common splinting techniques for lower extremity fractures, along with their indications, advantages, disadvantages, and complications.

Posterior Long Leg Splint

A posterior long leg splint is a type of splint that immobilizes the knee and ankle. It is indicated for fractures of the tibia, fibula, or both.

The advantages of a posterior long leg splint are:

• It provides good stability and alignment for knee and ankle fractures.
• It prevents knee flexion and extension, which can cause displacement or angulation of fractures.
• It allows some rotation of the foot, which can prevent stiffness or contracture of the ankle.

The disadvantages of a posterior long leg splint are:

• It can be uncomfortable and cumbersome for the patient, especially if it extends to the toes.
• It can impair foot function and limit activities of daily living.
• It can cause pressure sores or nerve injury at the knee or ankle if applied too tightly or poorly padded.

The complications of a posterior long leg splint are:

• Compartment syndrome: A condition where increased pressure within the muscle compartments of the leg compromises blood flow and oxygen delivery to the tissues, causing severe pain, swelling, and tissue necrosis. This is a medical emergency that requires immediate fasciotomy (surgical release of the pressure).
• Peroneal nerve palsy: A condition where damage to the peroneal nerve causes weakness or paralysis of the foot dorsiflexors and evertors, resulting in a characteristic foot drop. This can be caused by direct trauma to the nerve, compression by a tight splint or bandage, or prolonged knee flexion.
• Tibial nerve palsy: A condition where damage to the tibial nerve causes numbness, tingling, or pain in the sole of the foot, as well as weakness or paralysis of the foot plantarflexors and invertors, resulting in a flat foot deformity. This can be caused by direct trauma to the nerve, compression by a tight splint or bandage, or prolonged ankle dorsiflexion.

To apply a posterior long leg splint:

1. Cut a piece of stockinette that extends from the groin to the toes. Cut a hole in the stockinette for the heel.
2. Cut a piece of padding that extends from 2 inches above to 2 inches below the knee joint and from the knee joint to the heel. Cut a hole in the padding for the heel.

3. Cut a piece of splinting material that extends from 2 inches above to 2 inches below the knee joint and from the knee joint to the heel. Cut a hole in the splinting material for the heel.

4. Slip the stockinette over the leg and position it properly.

5. Wrap the padding around the leg over the stockinette, making sure to pad the knee and ankle well.

6. Dip each layer of splinting material in water and apply it over the padding, starting from the knee and working your way down to the ankle. Overlap each layer by half its width and smooth out any wrinkles or bubbles.

7. Fold the ends of the stockinette over the splinting material and secure them with tape or clips.

8. Wrap an elastic bandage around the splint, starting from the ankle and working your way up to the thigh. Make sure the bandage is snug but not too tight.

9. Mold and shape the splint to fit the leg and maintain the desired position. The knee should be slightly flexed (10 to 20 degrees) and the ankle should be in neutral position (90 degrees).

10. Check the neurovascular status of the leg distal to the splint and document any abnormalities.

Posterior Ankle Splint

![Posterior Ankle Splint]

A posterior ankle splint is a type of splint that immobilizes the ankle and foot. It is indicated for fractures of the ankle, calcaneus, or talus.

The advantages of a posterior ankle splint are:

• It provides good stability and alignment for ankle and foot fractures.
• It prevents ankle dorsiflexion and plantarflexion, which can cause displacement or angulation of fractures.
• It allows some inversion and eversion of the foot, which can prevent stiffness or contracture of the ankle.

The disadvantages of a posterior ankle splint are:

• It can be uncomfortable and cumbersome for the patient, especially if it extends to the toes.
• It can impair foot function and limit activities of daily living.
• It can cause pressure sores or nerve injury at the heel or foot if applied too tightly or poorly padded.

The complications of a posterior ankle splint are:

• Compartment syndrome: A condition where increased pressure within the muscle compartments of the leg compromises blood flow and oxygen delivery to the tissues, causing severe pain, swelling, and tissue necrosis. This is a medical emergency that requires immediate fasciotomy (surgical release of the pressure).
• Sural nerve palsy: A condition where damage to the sural nerve causes numbness, tingling, or pain in the lateral aspect of the foot and heel, as well as weakness or paralysis of some foot muscles, resulting in a difficulty walking on uneven surfaces. This can be caused by direct trauma to the nerve, compression by a tight splint or bandage, or prolonged ankle plantarflexion.
• Tibial nerve palsy: A condition where damage to the tibial nerve causes numbness, tingling, or pain in the sole of the foot, as well as weakness or paralysis of the foot plantarflexors and invertors, resulting in a flat foot deformity. This can be caused by direct trauma to the nerve, compression by a tight splint or bandage, or prolonged ankle dorsiflexion.

To apply a posterior ankle splint:

1. Cut a piece of stockinette that extends from the knee to the toes. Cut a hole in the stockinette for the heel.
2. Cut a piece of padding that extends from 2 inches above to 2 inches below the ankle joint and from the ankle joint to the heel. Cut a hole in the padding for the heel.

3. Cut a piece of splinting material that extends from 2 inches above to 2 inches below the ankle joint and from the ankle joint to the heel. Cut a hole in the splinting material for the heel.

4. Slip the stockinette over the leg and position it properly.

5. Wrap the padding around the leg over the stockinette, making sure to pad the ankle well.

 6. Dip each layer of splinting material in water and apply it over the padding, starting from the ankle and working your way up to the knee. Overlap each layer by half its width and smooth out any wrinkles or bubbles.

7. Fold the ends of the stockinette over the splinting material and secure them with tape or clips.

8. Wrap an elastic bandage around the splint, starting from the knee and working your way down to the ankle. Make sure the bandage is snug but not too tight.

 9. Mold and shape the splint to fit the leg and maintain the desired position. The ankle should be in neutral position (90 degrees).

 10. Check the neurovascular status of the leg distal to the splint and document any abnormalities.

Stirrup Splint

![Stirrup Splint]

A stirrup splint is a type of splint that immobilizes the ankle and foot. It is indicated for fractures of the lateral or medial malleolus, or both.

The advantages of a stirrup splint are:

• It provides good stability and alignment for ankle and foot fractures.
• It prevents ankle inversion and eversion, which can cause displacement or angulation of fractures.
• It allows some dorsiflexion and plantarflexion of the ankle, which can prevent stiffness or contracture of the ankle.

The disadvantages of a stirrup splint are:

• It can be uncomfortable and cumbersome for the patient, especially if it extends to the toes.
• It can impair foot function and limit activities of daily living.
• It can cause pressure sores or nerve injury at the heel or foot if applied too tightly or poorly padded.

The complications of a stirrup splint are:

• Compartment syndrome: A condition where increased pressure within the muscle compartments of the leg compromises blood flow and oxygen delivery to the tissues, causing severe pain, swelling, and tissue necrosis. This is a medical emergency that requires immediate fasciotomy (surgical release of the pressure).
• Sural nerve palsy: A condition where damage to the sural nerve causes numbness, tingling, or pain in the lateral aspect of the foot and heel, as well as weakness or paralysis of some foot muscles, resulting in a difficulty walking on uneven surfaces. This can be caused by direct trauma to the nerve, compression by a tight splint or bandage, or prolonged ankle plantarflexion.
• Tibial nerve palsy: A condition where damage to the tibial nerve causes numbness, tingling, or pain in the sole of the foot, as well as weakness or paralysis of the foot plantarflexors and invertors, resulting in a flat foot deformity. This can be caused by direct trauma to the nerve, compression by a tight splint or bandage, or prolonged ankle dorsiflexion.

To apply a stirrup splint:

1. Cut a piece of stockinette that extends from 2 inches above to 2 inches below
2. 2 inches below the ankle joint. Cut a hole in the stockinette for the heel. 2. Cut a piece of padding that extends from 2 inches above to 2 inches below the ankle joint and from the medial to the lateral malleolus. Cut a hole in the padding for the heel.
3.  3. Cut two pieces of splinting material that extend from 2 inches above to 2 inches below the ankle joint and from the medial to the lateral malleolus. Cut a hole in each piece of splinting material for the heel.
4. 4. Slip the stockinette over the leg and position it properly.
5. 5. Wrap the padding around the leg over the stockinette, making sure to pad the ankle well.
6. 6. Dip each piece of splinting material in water and apply one piece over the padding on the medial side of the leg, and the other piece on the lateral side of the leg. Overlap each piece by half its width and smooth out any wrinkles or bubbles.
7.  7. Fold the ends of the stockinette over the splinting material and secure them with tape or clips.
8. 8. Wrap an elastic bandage around the splint, starting from one side of the ankle and working your way around to the other side, then up to the knee and back down to the ankle. Make sure the bandage is snug but not too tight.
9.  9. Mold and shape the splint to fit the leg and maintain the desired position. The ankle should be in neutral position (90 degrees).
10.  10. Check the neurovascular status of the leg distal to the splint and document any abnormalities.