Splinting 101: An NP’s Guide to Immobilization

A few months ago, the medical director of the emergency department where I work made a request.  He asked that MD’s, NPs and PAs keep an eye on the nurse’s splinting techniques, checking all splints before patients leave the ED.  “No problem”, I thought.  Well, there was a little problem.  While I was quite confident I could spot a shoddy splint job, I had barely been taught splinting technique myself.

So, I hit the books to review the basics of splinting and casting.  While splinting is a basic procedure and not at all difficult to learn, getting the basics down is important.  Although splinting is easy, applying your splints correctly prevents complications and helps ensure fractures heal properly.  So, how do you apply a splint worthy of praise from top ortho experts?

Why do you need to splint, anyway?

Splints and casts are used to immobilize orthopedic injuries.  They not only maintain bone alignment but also help relieve pain.  They promote healing and protect the area from further injury.  While advantages of splinting far outweigh the risks, improper splint application can result in some serious complications.

Take Your Pick: Splinting vs. Casting

When I first started working in the ED, I was surprised that providers routinely ordered splints rather than casts.  In fact, we don’t even supply casting material in the emergency department where I work.  But, then I learned there are some distinct advantages to splinting over casting.  Sorry kids, there’s no leaving the ED with a purple cast ready for your friends to sign if you see me.

Splinting is the preferred method of immobilization in acute care settings like urgent care clinics and the emergency department.  Splints offer adequate protection for fractures and are faster and easier to apply than casts.  Because splints are non-circumferential, they allow for natural swelling to occur while reducing the risk of complications like compartment syndrome compared to casting.  Splints are more easily removed than casts making follow-up after the initial injury more convenient.

Although splinting is preferred in the acute care setting, some fractures may ultimately require casting.  Splints allow for more motion than casting so unstable fractures may be initially splinted but ultimately be casted.

Get Your Materials Ready: What You Will Need for Splint Application

Traditionally, splints are made of plaster but fiberglass material can be used as well.  Advantages of fiberglass are a faster setting time and less mess while advantages of plaster include increased pliability and a slower setting time.  This slower setting time produces less heat decreasing patient discomfort and risk of burns.

In addition to either plaster or fiberglass splinting materials, you will need the following supplies on hand for splint application: adhesive tape, bandage scissors, basin of water, casting gloves (if using fiberglass), elastic bandage, cotton padding, sheets (to protect patient clothing).

Water temperature is important in splint application.  Splinting materials harden faster with warm water.  The faster the splint sets, the greater the heat produced  increasing risk of skin burns.  Cool water should be used to allow for time if you suspect the splinting process will be lengthy.  Slightly warm water is best for a typical application time while still preventing excess heat.

I’m Ready: How to Apply a Splint

Once your splinting materials are set out, you are ready to begin the splinting process.  If the patient has an open wound, make sure to take the appropriate precautions to protect yourself from bodily fluids.  Check neurovascular status of the affected limb to be sure it is intact.  Assess the area for signs of compartment syndrome.  If all is well, you are ready to proceed.

Measure the area you wish to splint.  Cut a stockinette about 10 cm longer at each end than the area you wish to splint.  This allows you to fold the stockinette over the ends of the splint once application is completed.  Place the stockinette on the affected extremity.  Make sure to smooth the stockinette, eliminating wrinkles and that it is not too tight.  In some cases, a stockinette is not necessary- extra padding may be used in its place.

Next, place layers of cotton padding over the stockinette by wrapping them around the extremity.  Layers of padding should overlap one another by 50 percent as you roll the padding from one end of the extremity to the other.  Padding should extend 2 to 3 cm beyond the edge of the splint.  Extra padding must be used at the ends of the splint and over bony prominences.  Joints should be placed in their proper position before, during and after padding application to ensure proper alignment.

Finally, apply the splinting material.  Cut the splint material to a length 1 to 2 cm longer than needed as material shrinks during wetting and drying.  Submerge splint material in water until bubbling has stopped.  Remove material, squeezing out excess water.  With the extremity in its proper position, place the wet splinting material over the padding molding it to the extremity.  Fold back the stockinette and padding edges to cover the ends of the splint material.  Secure the splint by wrapping an elastic bandage around the extremity.

Viola!  You have successfully applied a splint.  Don’t forget to re-check and document neurovascular status of the affected extremity.

Don’t Miss ‘Em: Splinting Complications

The most serious complication of splinting is compartment syndrome.  Compartment syndrome occurs when there is insufficient blood flow to muscles and nerves after an injury as a result of increased pressure in one of the body’s compartments, usually an arm or leg.  If left untreated, compartment syndrome leads to permanent damage of the muscles and nerves and may even require amputation of the affected limb.  Signs of compartment syndrome include pain out of proportion to injury, severe swelling, delayed capillary refill, or tingling and numbness.

Skin breakdown as a result of pressure can also occur with splinting.  To prevent skin breakdown, pad bony prominences appropriately and avoid folds and wrinkles beneath splint material.  Joint stiffness can also occur in the splinted extremity.  Make sure to apply the splint appropriately to avoid affecting joints unnecessarily.

All Done: After-Care of the Splinted Extremity

Always assess the neurovascular status of the extremity after applying the splint.  Warn the patient of potential complications describing signs and symptoms which warrant follow-up.  Prescribe medications to address the patient’s pain appropriately.  Ice may be used for 15 to 30 minutes at a time over the splint to help relieve pain.  Avoid getting the splint wet as moisture compromises the splint’s integrity.  Give the patient follow-up instructions including orthopedic referral if necessary.  Most fractures require four to eight weeks for healing.

Stay tuned… a post on types of splints coming later this week.