eMedicine Specialties > Clinical Procedures > Musculoskeletal Procedures

Splinting, Volar: Treatment & Medication

Author: Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Contributor Information and Disclosures

Updated: May 15, 2009

Anesthesia

Splinting is usually tolerated without the use of anesthesia. However, if significant manipulation or reduction of the injury is required during the splinting process, anesthetic techniques may be used. Acceptable techniques include the following:

• Administration of a hematoma block or nerve block
• Procedural sedation with appropriate monitoring²
• Administration of oral or intravenous pain medications, including nonsteroidal anti-inflammatory drugs (NSAIDS) or opioid analgesic agents

With the administration of any analgesic agent or the initiation of a formal sedation protocol, take care to avoid oversedation. A complete neurovascular examination should be performed after the splint has been applied.

Equipment

• Stockinette
• Padding (eg, Webril)
• Plaster
• Bandage or wrap (eg, Bias bandage or Ace bandage)
• Clean, room-temperature water in a basin
• Trauma shears or a pair of medical scissors without pointed ends
• Chucks pads and bed sheet
• Tape or bandage clips
• Alternatively, prefabricated fiberglass (eg, Orthoglass) can be used in place of stockinette, plaster, and padding.

Positioning

• Place the patient in a comfortable position (eg, seated or reclined).
• Cover the patient with a sheet to avoid splatter from the wet plaster.
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  Cover patient appropriately. Video courtesy of Kenneth R. Chuang, MD.

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  Cover patient appropriately. Video courtesy of Kenneth R. Chuang, MD.

• Completely expose the injured limb. Remove all jewelry. In particular, rings can cause constriction and ischemia of the fingers with delayed swelling of the soft tissues. If unable to remove a ring, try using soap as a lubricant or consider a ring cutter.
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  Remove jewelry and rings to avoid ischemia from swelling. Video courtesy of Kenneth R. Chuang, MD.

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  Remove jewelry and rings to avoid ischemia from swelling. Video courtesy of Kenneth R. Chuang, MD.

Technique

• Explain the procedure to the patient, including risks and benefits. Obtain informed consent.
• Position the patient as described above. See Positioning.
• Apply stockinette. Cut an adequate hole for the thumb, being careful to avoid constriction of the thumb. When measuring the stockinette, allow for extra length. The stockinette should extend 2-3 cm beyond the overlying padding on either end. In turn, the padding should extend 2-3 cm beyond the overlying wet plaster on either end. Together, the stockinette and padding should be pulled over the edges of the wet plaster to create smooth edges.
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  Stockinette application for volar splint. Video courtesy of Kenneth R. Chuang, MD.

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  Stockinette application for volar splint. Video courtesy of Kenneth R. Chuang, MD.

• Wrap the padding (eg, Webril) over the stockinette. Overlap each layer by half the width. Also allow for extra length. The padding should extend 2-3 cm beyond the overlying plaster on both ends. Smooth out creases, unwrapping and rewrapping as necessary. Apply extra padding to the bony prominences of the wrist and to the base of the thumb.
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  Cotton padding application for volar splint. Video courtesy of Kenneth R. Chuang, MD.

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  Cotton padding application for volar splint. Video courtesy of Kenneth R. Chuang, MD.

• Measure the plaster. For an adult of average size, plaster for the volar splint should be 8-10 layers thick. Use plaster that is 3-4 in wide. After counting out the layers, measure the plaster from the level of the metacarpal heads to the proximal third of the forearm. Allow for roughly 5 mm of extra length on either end, as the plaster shrinks when wet. Fold over excess wet plaster on the ends.
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  Measuring dry plaster for volar splint. Video courtesy of Kenneth R. Chuang, MD.

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  Measuring dry plaster for volar splint. Video courtesy of Kenneth R. Chuang, MD.

• If using prefabricated fiberglass, the stockinette and padding steps can usually be skipped. In this case, follow the manufacturer recommendations.
• Submerge the plaster in clean, room-temperature water. Allow all the bubbles to escape. This starts the lamination process of the plaster and allows for the layers to bond together. Squeeze out the excess water. With the fingers, pull out remaining water. Then, lay the plaster on a flat surface or dry towel and smooth out wrinkles and folds. This allows for further bonding of the plaster layers.
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  Wetting the plaster for volar splint. Video courtesy of Kenneth R. Chuang, MD.

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  Wetting the plaster for volar splint. Video courtesy of Kenneth R. Chuang, MD.

• Apply the wet plaster, over the padding, to the volar surface of the forearm. The plaster should extend from the metacarpal heads to the proximal third of the forearm. Fold outward excess plaster on the ends. The underlying stockinette and padding should then be folded outward on both ends, creating smooth edges.
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  Applying wet plaster for volar splint. Video courtesy of Kenneth R. Chuang, MD.

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  Applying wet plaster for volar splint. Video courtesy of Kenneth R. Chuang, MD.

• Apply the bandage wrap over the wet plaster. Start distally and wrap proximally. Cut an adequate hole for the thumb. Avoid wrapping too tightly.
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  Applying bandage wrap for volar splint. Video courtesy of Kenneth R. Chuang, MD.

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  Applying bandage wrap for volar splint. Video courtesy of Kenneth R. Chuang, MD.

• While the plaster is still wet, mold the splint into the desired shape. The wrist and hand should be in a neutral position. Extend the wrist to 20°, abduct the thumb, and flex the metacarpophalangeal joints to 70°. The hand, wrist, and forearm should remain immobile until the splint is dry. Advise the patient that he or she may feel some warmth released from the plaster as it dries. However, if the heat becomes too intense, unwrap the splint and remove the plaster immediately, since thermal burns can occur.
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  Molding the volar splint. Video courtesy of Kenneth R. Chuang, MD.

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  Molding the volar splint. Video courtesy of Kenneth R. Chuang, MD.

• Check for neurovascular function and capillary refill after the splint has dried. Recall that the median nerve provides sensory function to the palmar side of the thumb; the second, third, and lateral half of the fourth digits; and, dorsally, to the distal half of the second, third, and lateral half of the fourth digits. The ulnar nerve provides sensory function to the palmar and dorsal aspects of the fifth digit and the medial half of the fourth digit. The radial nerve provides sensory function to the dorsal surface of the hand and to the web space between the first and second digits.
• Remember to check motor function as well. Wipe away any plaster that may have dropped onto the patient's skin.
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  Test neurovascular function and capillary refill. Video courtesy of Kenneth R. Chuang, MD.

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  Test neurovascular function and capillary refill. Video courtesy of Kenneth R. Chuang, MD.

• Deliver appropriate aftercare instructions.
  • Instruct the patient to rest, elevate, and ice the injured limb.
  • Instruct the patient to remove the splint and return immediately, or go to an emergency department, if he or she experiences weakness or numbness, color change (pale or bluish), increasing pressure or pain, or spreading redness or streaking.
  • Keep the splint clean and dry.
  • Do not stick any items into the splint. Patients can be tempted to use sticks, pens, or hangers to scratch an itch. Advise the patient that sticking objects into the splint can wrinkle the padding and lead to pressure sores or cause a break in the skin and lead to an unattended infection.
  • Arrange for follow-up with a consultant, usually within 2-7 days, depending on the reason for the splint.
  • If the patient received any sedation or opioids, advise against driving and/or alcohol consumption.

Pearls

• To assist in achieving a neutral position of the hand and wrist, some clinicians advocate having the patient hold a can or a bandage wrap. Alternatively, the patient can imagine holding a wine glass. With either method, maintain the wrist at 20° extension.
• For injuries or reductions that require shorter drying times, faster-setting plaster is available (eg, Specialist Extra Fast Setting Plaster). However, as plaster dries faster, the risk of thermal injury increases. For most splints, regular plaster (eg, Specialist Fast Setting Plaster) is appropriate.
• Consider prescribing an antihistamine (eg, diphenhydramine) for itching. However, if the itching persists or worsens, evaluate the splint for complications.

Complications

• Thermal burn:³ Patients can expect some warmth as the plaster dries. However, if the patient experiences intense heat or any pain, remove the plaster immediately, as thermal burns can occur.
  • As more layers of plaster are used, more heat is produced.^4,5
  • Use clean, room-temperature water. Water that is dirty or too warm decreases drying time and increases the heat produced.⁴
  • Do not wrap towels or blankets around the splint to shorten drying time. This produces excess heat.
• Pressure sore: Provide extra padding to bony prominences. When wrapping the cotton padding, avoid creases. When creases occur, smooth them out or unwrap and rewrap, as needed. When molding the wet plaster, use broad-based pressure. In other words, do not use the fingertips; rather, use the entire palmar surface of the hands and fingers.
• Contact dermatitis: See eMedicine article Contact Dermatitis.
• Ischemia and neurovascular compromise: These conditions can be caused by increased pressure from swelling.
  • If moderate to significant swelling is anticipated, cut the cotton padding lengthwise, on the ventral side of the forearm, before application of the wet plaster to the volar side. This allows for expansion of the padding. If using tape to secure the outermost bandage wrap, do not tape circumferentially.
  • The median nerve runs in the carpal tunnel on the volar aspect of the wrist. Compression of the median nerve can lead to pain, numbness, paresthesias, and weakness in the median nerve distribution (sensory function to the palmar side of the thumb, second, third, and lateral half of the fourth digits and, dorsally, to the distal half of the second, third, and lateral half of the fourth digits). If compression of the nerve is suspected, immediately remove the splint and perform another neurovascular examination. Consider consultation if symptoms do not subside.
• Decreased range of motion from immobilization: Advise the patient that, depending on the extent and nature of the initial injury, he or she can often expect long-term pain, arthritis, stiffness, and decreased range of motion, despite best care practices. The aftercare of such injuries often requires physical therapy.

Special thanks to Mrs. Leni L. Chuang and Dr. Iris Gluzman.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Kenneth R Chuang, MD, to the development and writing of this article.

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