& Splinting Workshop
workshop is intended to demonstrate and then allow participants
to apply simple splints using casting materials to stabilize injuries.
is not intended to give any participant expertise in their skills.
Participants are encouraged to seek further education and accreditation
through professional training.
precept of "do no harm" and "splint them where they lie" can be
very beneficial to laypersons with no training if they simply understand
the potential for a significant injury existing and treating it
as such in a protective manner until the injury can be definitively
diagnosed and managed by a qualified professional.
do not accredit or acknowledge the individual practice of our participants.
Brief Explanation of Fractures and Limb Injuries
a significant injury is suspected on the ability of pain, swelling,
disability or deformation it should be treated with respect until
it can be definitely treated.
fractures can exist as many types. Some heal extremely well with
no treatment while others will require extensive casting, surgery
the same time soft tissue injuries involving ligaments and tendons
may be so disabling as to require splinting or casting to assist
avoid misdiagnosis it is important to be able to ensure that no
significant injury is missed. People who are not experienced in
orthopedics are always best to assume an injury may be fractured
and treat accordingly. It should also be emphasized that occasionally
even X-rays do not always show fractures and each individual must
always be reviewed by providers qualified to diagnose and treat
Splints or Casts?
immobilize injuries to allow for faster healing. Slight motion will
aggravate healing bones and delay in fracture healing. There is
some degree of movement even within casts but this is felt to be
negligent and acceptable.
body's response to an injury is usually swelling and tenderness
at the site of injury. In the first 24-48 hours this swelling is
on going and can increase even if casted. Swelling in an enclosed
limb may lead to pressure on nerves and blood vessels causing pain,
pallor and pulselessness in the limb the three
P's of compartment syndrome .
help avoid this complication large fractures are managed with "
back slabs" or splints manufactured to give support
to part of the limb and accommodate swelling.
a slab is applied the injured limb is reexamined after a number
swelling is unlikely to get worse a full circumferential cast is
made, making the person more comfortable. Some may use circumferential
casts from the very beginning if the injury is small and unlikely
to get worse, the patient is accessible for frequent cast changes
(and don't mind paying the cost), and is reliable to recognize compartment
syndrome symptoms in themselves and report to an emergency department
for cast revision if problems occur.
cast or splint is applied to facilitate that injury to heal, and
for no longer.
orthopedic literature helps give the best amounts of time for immobilizations
of each type of fractures.
of an injury healing in progress will allow a better assessment
of how long a cast is needed.
is never wrong to splint an injury suspected of being injured. A
very general estimate of 4-6 weeks is required for injuries to heal
but this widely varies and is additionally dependant on the health
of the patient, their occupation and stress.
it is often over looked good nutrition and enough
rest helps facilitate healing. The demands a professional
(or amateur) athlete and worker may put on their limbs also factors
in the manner in which the injury must be dealt with.
" playing casts " are used to get athletes back
into their sport and workers return to their duties earlier before
a injury has completely healed by giving extra stability and support
for certain injuries. There are still injuries that a playing cast
cannot be negotiated for since they require precision care.
helps immobilize the bone but as the expense of the joint. Often
once a cast is off significant stiffness is found in the adjacent
joints to the fracture as well as muscle atrophy of the muscles
controlling the joints.
joints of the body should not be splinted for too long, as their
stiffness may be very hard to treat. The hand for instance must
be splinted in a specific way to prevent adhesions in the normal
glide of the tendon. These soft tissue effects
can be worse than the original fracture. For the most part soft
tissue stiffness after appropriate casting is self limited or may
be reversed with a course of rehabilitative stretches and exercises.
is appropriate for each person to get the appropriate care for his
or her injury. For example if someone had a small undisplaced fracture
of their hand and decided they did well with only a splint and refused
casting they would require many more weeks of an inferior form of
immobilization to treat the same injury. These additive weeks of
immobilization would also lead to a more profound soft tissue stiffness
and possible malunion . It is therefore best to
get the best possible care for each injury as soon as possible to
eliminate these sad stories of malunions or early osteoarthritis.
purpose of this instructive workshop is to teach simple basics of
wound protection. For definite diagnosis of injury examination with
x-rays and review by a qualified physician is strongly advised.
It would be very wrong to treat complicated fractures that require
immediate surgery and reduction with simple splinting. These measures
are taught as simple maneuvers to 'do no harm'
while arranging transfer to a more advanced center, where the diagnosis
can be made definitely.
Fracture - a fracture in a bone with skin intact.
(or compound fracture) - this fracture has open communication
with the skin so bacteria have entered the wound. Their bacteria
will multiply and cause rapid infection. All open fractures must
be cleaned (by appropriate people) and referred to an orthopedic
Fracture - a fracture on X-ray running less than 90 to
the long axis of a bone.
Fracture - is caused by twisting (this is highly suggestive
of child abuse)
Fracture - is seen in children whose bones aren't as hard
as adults. The bone is bent and fractured on the side where it is
Fracture - caused by a compressive load on a bone (in
Fracture - a fracture with two or more boney pieces.
Fracture - a small chip of bone caused by excessive pull
where a muscle inserts onto the bone.
Fracture - when bone is forcibly compressed, usually very
Fracture - a boney overload where repetitive force has
gradually caused the bone to crack under pressure.
Fracture - a fracture of a site where bone is weakened
by some other disease. When suspected should suspect a tumor or
a Fracture (Usually with X-rays)
the status of a fracture and documenting changes is very helpful
to orthopedic doctors when they are called upon for help.
describes the relationship of the fragments along the long
axis of the bone, in degrees. It is not as accurate without X-rays
but this can be also used to describe the apparent position of a
deformity by a layperson.
of Fracture Surfaces
X-rays the displacement of the fracture surfaces
are described either as partial 25-50-75% or complete.
also be described in on.
using two view X-rays further counts on whether the displacement
is anterior/posterior or medial/lateral
- if the fragment appears rotated fracture healing is
- the healing of a fracture. When clinical union has occurred
there is a return to limb motion. X-ray changes may lag after clinical
- this is when there is residual deformity after fracture
healing - is when healing takes longer than usual.
- when the fracture ends to not unite and heal. A false
joint appears between the 2 ends ( pseudo arthrosis
) this is not the same as healing by boney fibrous
healing which is when boney fragments unite but are separated
by fibrous connective tissue between that shows up as a black line.
Complications include arterial damage, nerve damage
, compartment syndrome, infection, tenting of skin,
accompanying soft tissue damage (crash injury)
all orthopedic injuries with care and suspicion will help avoid
problems with the above. Suspicious injuries must be periodically
sympathetic dystrophy - a pain syndrome affecting the
limb where blood circulation and nerve sensations are impaired after
- a long-standing infection of bone.
used for contusions that are severe and accompanied by swelling
abrasions that cross-joints, tendon lacerations, and severe strains.
arm sugar Tong splint (Resembles the sugar tong used for
handling cubes of sugar)
Used for distal radius and ulna fractures or fractures of
This splint limits flexion and extension of elbow and supination/formation
at forearm yet still allowing for swelling (does not completely
immobilize these joints)
Is used with an arm sling or shoulder immobilizer
arm volar splint (volar refers to support from the same
side as the palm)
Used for wrist fracture or sprain
May be useful for severe tendonitis or carpal tunnel syndrome.
This is easy to apply. Patient can remove and reapply as
This doesn't control supination/promotion that well
Useful when scaphoid fracture suspected or severe tendonitis
of the thumb
Arm Ulna Gutter Splint
This is useful for boxers fractures of the 4 th or 5 th
The special cure on this cast helps maintain a boxers fracture
in reduction by 3 point contact
This cast should be applied by someone knowledgeable in
treating boxers fracture
Useful for stable distal femur fracture
Prevents flexion/extension of knee and ankle, and aversion/inversion
Very bulky and may break down and the splint may fracture
at the knee or ankle. Usually the knee is flexed at 30 °
and ankle at 90 °
. (For knee fracture turn Achilles tendon)
Patients must remain non-weight bearing with this cast.
Leg Sugar Tong Splint
For medical and lateral malleoli fractures of the ankle
Limits ankle inversion/aversion and flexion inversion but
not as well as a cast
Holds up reasonably on partial weight-bearing
Leg Posterior (Back slab) Splint
Is used for posterior lateral, on medial malleoli fractures
and fractures of the foot, and selected stable other fractures
Also very useful for plantar fasciitis (This allows a continuous
passive stretch of the plantar fascia and Achilles tendon
at night and improves the flexibility
Be careful not to allow early breakdown of ankle portion
Must be non-weight bearing as this is intended for nighttime
Useful for fractures of wrist and hand
When applied correctly allow extensive movement of elbows
and fingers while immobilizing wrist
Allow some supination/promotion of forearm
(To eliminate this more effectively an above elbow cast
is necessary to leave no supination/pronation freedom)
Indicated for either confirmed or suspected scaphoid (navicular)
Long arm version is often preferred for 1 st 2-8 weeks to
allow for greater healing
Note- any pain after trauma in the anatomical snuffbox area
of the wrist should be assumed to be a scophoid fracture
scaphoid fractures are difficult to diagnose and if treated incorrectly
can lead to malunion and arthritis. It is important to have all
suspicious 'wrist sprains' reviewed by an orthopedic specialists
to ensure this potential problem is never missed.
Leg Cast (non walking)
Indicated for malleoli fractures and non-displaced fibula
fractures, and mid-foot fractures
This allows flexion and extension of the knee
Disadvantage is that it allows some rotation of lower leg
Leg Walking Cast
Good for initial treatment and ankle sprains and hip fractures
May be used as a follow-up cast for other leg fractures
after several weeks in a new fit bearing cast
This allows easy mobilization after injury but patients
should be selected
Inappropriate haste to use a walking cast or approved from
a previous non-weight bearing situation may be detrimental
Disadvantages include heel breakdown since plaster cast
is not commonly used for walking casts, this is less of
a problem than previous
When the layers of the cast are applied cohesively (and
laminate together properly) there is also less likelihood
Arm Sugar Tong Splint
Elbow is position at 90 °
with neutral position of the wrist (no supination
or pronation at the forearm)
Wrist is positioned slightly Dorsiflexed t 10 °
to attain a position of proper function
Measure length of splint using padding
For forearm, splint should go from just before the MCP joint
on dorsal side, around the elbow and back to the distal
Next measure several strips of material (plaster or fiberglass)
equal to the length previously measured
One option is to place these measured strips inside a stockinet,
then wet them (the additional use of the stockinet prevents
Padding should be placed between the limb and the splint
(I usually apply this on the patients arm but others may
apply it to the cast)
Apply the splint
Have an assistant keep splint in place while you wrap roll
on tensor wrap over top
The wrap will mold it comfortably to the elbow and wrist
After splint hardened, re-evaluate if initial wrap is too
At this stage you may replace the wrap with an ACE bandage
patient is educated on proper cast care and maintaining of injury.
rolls have the padding integrated into the cast
material and the roll is simply measured out and applied. Which
makes this an easier one step procedure.
forearm in neutral (no supination or pronation) with wrist slightly
dorsiflexed (10-15 ° ) and
thumb relaxed and extended (not the thumbs up position of hitchhikers)
splint length. Should be two finger widths from anticubital fossa
to half way down thumbnail.
splint. Have assistant hold splint while you wrap with gauze roll
or ACE bandage. Mold carefully around hand, thumb, and wrist. Evaluate
fit of splint after hardened. Instruct patient on cast care and
follow-up of injury.
forearm is placed in neutral (no supination or pronation) and wrist
in 10-15 ° of dorsiflexion.
the splint from 2 nd palmar crease to finger widths from the anticubital
padding to arm or on splint itself.
splint and have assistant maintain position as you apply wrap. After
splint hardened, review position and comfort. Educate patient on
proper cast care.
hand MCP flexed and at the wrist at 15 °
from the tip of the finger to within 2 finger widths of the anticubital
fossa. Apply padding. Apply splint, using an assistant to maintain
position. Carefully review this splint as it is hardening since
it is easy to lose position as the splint hardens. Explain this
to the patient and it will help them maintain the position.
the hardened splint for position and comfort. Give each patient
instruction on cast care.
Splint (Sugar Tung) Of Lower Extremities
with ankle at 90 ° with
no inversion/aversion of the foot. Have the person also flex their
knee at 90 ° , as this will
allow them to maintain 90 ° at
the splint length two fingers below the fibula head laterally down
under the heel at up to the same height on the inside. Apply padding,
then splint. Use an assistant to maintain position while wrap applied.
Mold to splint with care about both malleoli and lower leg.
splint hardened check position and comfort. Then give patient cast
care instruction. Make sure they are proficient with crutches and
do not weight bear on that leg.
slab applied to leg with knee flexed at 90 °
and foot in maximal dorsiflexed position at the ankle, and
splint 3 finger lengths below fibular head to tip of big toe. Cut
away material from where toes 3,4,5 would be, as this would make
the splint more comfortable. Apply padding, then splint. Have assistant
maintain position during wrap making sure that both big toe and
ankle are maximally dorsiflexed. After wrap, mold splint around
malleoli. Patient may use ACE wrap to apply cast with at home.
Cut to exact length
Place in cool water and squeeze 3-4 times in water. Remove
and squeeze to remove excess water
Placing on top of an absorbent towel will also remove water.
if you are using plantar and making your own back slabs, do not
squeeze excessive water out too vigorously as this will lose some
of the impregnated gypsum in the roll. Instead gently twist or squeeze
the excess water out.
hand in neutral position with slight dorsiflexion at wrist.
from the metacarpal heads to the anticubital fossa and cut stockinet
to length, allowing for extra stockmitte to fold over at each end.
stockinet on and smooth any wrinkles.
padding; overlap approximately 50% of width.
should extend from palmar crease to just before the anticubital
enough padding around thumb without pressing on web space.
cast and apply in wrapping motion with moderate tension.
rolls by 50% of width.
cast to support hand and wrist with slight dorsiflexion.
stockmitte over cast ends to make a smooth edge.
hand in neutral position with moderate dorsiflexion of wrist, elbow
is flexed at 90 ° .
stockmitte from metacarpal head to shoulder allowing for extra length
to fold over cast edges later.
small notch in stockinet for thumb.
stockinet, smoothing out any wrinkles.
with cast padding overlapping 50%.
should extend from the palmar crease of the hand to mid deltoid.
and apply cast material to support hand and wrist, make sure wrist
is still in moderate dorsiflexion.
stockinet over edges to give smooth edges.
the hand in neutral position with moderate dorsiflexion of wrist
and thumb in dorsiflexion.
stockinet from metacarpal head to anticubital fossa allowing for
a little extra length to later fold over edges.
hole in stockinet for thumb.
small 1-inch stockinet can be used for the thumb.
padding over taping 50%.
care to the thumb should be made.
that there is adequate padding without pressing on web space.
cast material and apply over-lapping 50%.
the thumb smaller rolls can be used or you can pre-cut a regular
sized roll before you start to allow finer application.
cast to support hand and wrist with wrist still in moderate dorsiflexion.
over stockinet to cover ends.
final thin layer of casting material may be added to cast and reinforce
the ankle in neutral position (90 degrees)
stockmitte from metatarsal head to knees, adding a little extra
length to be folded over the cast later.
stockinet on, smoothing wrinkles.
a crease forms at the ankles, it can be trimmed away with scissors.
padding starting at foot overlapping 50%.
should extend from metatarsal heads to just distal to fibular head.
enough padding at heel, malleoli, metatarsal heads, and anterior
tibia, as these are all boney prominences, which require added protection.
and apply cast material.
cast and ensure ankle is still in its original neutral position.
(Often a patient will unconsciously shift during the wrapping stage)
stockmitte over edges and apply final layer of material.
walking cast apply overlapping, reinforcing strips at heel and foot
with a plastic cast heel, prior to final layer.
the ankle at neutral position (90 °
) and knee at 20-30 °
from metatarsal heads to groin.
stockinet with extra length to fold over on cast edges later.
and smooth over stockinet to eliminate creases.
padding starting at foot from the metatarsal heads and extending
to just below groin.
sufficient padding to boney prominences, heel, malleoli, metatarsals
heads, anterior tibia, and femoral condyles.
padding overlapping 50%.
cast material also overlapping 50%.
cast material to ensure neutral position of ankle then around the
femoral condyles of the knee.
over stockinet edges to make smooth edges.
walking casts use-overlapping reinforcing strips under the heel
and foot (or plastic heel) then apply reinforcing layer to edges
of stockinet exposed.