The wrist placed slight extension and ulnar deviation

When considering whether to apply a splint or a cast, the physician must assess the stage and severity of the injury, the potential for instability, the risk of complications, and the patient's functional requirements. Splinting is more widely used in primary care for acute as well as definitive management (management following the acute phase of an injury) of orthopedic injuries. Splints are often used for simple or stable fractures, sprains, tendon injuries, and other soft-tissue injuries; casting is usually reserved for definitive and/or complex fracture
management.

ADVANTAGES OF SPLINTING
Splint use offers many advantages over casting. Splints are faster and easier to apply. They may be static (i.e., prevent motion) or dynamic (i.e., functional; assist with controlled motion).

Previous literature has demonstrated the benefits of using plaster rather than fiberglass following fracture reduction.6 Table 3 lists standard materials and equipment used in splint and cast application.2

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Table 3.

Cooler temperature of dipping water

Use of plaster

PREPARING THE INJURED AREA
To prepare the injured extremity for splinting, stockinette is measured and applied to cover the area and extend about 10 cm beyond each end of the intended splint site (Figures 1 through 3). Later, once the padding and splint material have been applied, the excess stockinette is folded back over the edges of the splint to form a smooth, padded edge. Care should be taken to ensure that the stockinette is not too tight, and that wrinkling over flexion points and bony prominences is minimized by smoothing or trimming the stockinette. Generally, a stockinette 2 to 3 inches wide is used for the upper extremities and 4 inches wide for the lower extremities.

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Figure 2.

Stockinette application. Stockinette should extend about 10 cm beyond each end of the intended splint site. Black lines beneath the stockinette indicate the ends of the intended splint.

Next, layers of padding are placed over the stockinette to prevent maceration of the underlying skin and to accommodate for swelling. Padding is wrapped circumferentially around the extremity, rolling the material from one end of the extremity to the other, each new layer overlapping the previous layer by 50 percent. This technique will automatically provide two layers of padding. Extra layers may be added over the initial layers, if necessary. The padding should be at least two to three layers thick without being constrictive, and should extend 2 to 3 cm beyond the intended edges of the splint (Figure 4). Extra padding is placed at each end of the intended splint border, between digits, and over areas of bony prominence. Prominences at highest risk are the ulnar styloid, heel, olecranon, and malleoli. If significant swelling is anticipated, more padding may be used; however, care must be taken not to compromise the support provided by the splint by using too many layers. Both too much and too little padding are associated with potential complications and poor fit of the splint or cast (Table 5).2,4

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Information from references 2 and 4.

Joints should be placed in their proper position of function before, during, and after padding is applied to avoid areas of excess wrinkling and subsequent pressure. In general, the wrist is placed in slight extension and ulnar deviation, and the ankle is placed at 90 degrees of flexion. Padding comes in several widths. In general, padding 2 inches wide is used for the hands, 2 to 4 inches for upper extremities, 3 inches for feet, and 4 to 6 inches for lower extremities.

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Figure 5.

Figure 6.

Ulnar gutter splint molded and padding and stockinette edges folded back.

The principles of casting are similar to those of splinting (Table 5).2,4 Once the extremity has been prepared with stockinette and padding and placed in the desired position, the plaster or fiberglass material is applied. The casting material is wrapped circumferentially, with each roll overlapping the previous layer by 50 percent. The physician should avoid placing excess tension on the plaster or fiberglass because it can create a tight, constrictive cast that may damage underlying skin through pressure, neurovascular compromise, or both. Conversely, a cast that is overly padded or loosely applied can allow for significant rubbing, friction, and skin injuries (e.g., abrasions, friction blisters). Just before the final layer of casting material is applied, the physician should fold back the stockinette and padding, and then apply the final layer (Figure 8), molding the cast while the materials are still malleable.

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Bacterial and fungal infections or a pruritic dermatitis can develop beneath a splint or cast. Infection is more common with an open wound, but the moist, warm environment of a splint or cast can be ideal for infection.9 Finally, some degree of joint stiffness is an inevitable complication of immobilization. With proper application technique and effective patient education, complications can be minimized.

Follow-up and Length of Immobilization
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