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Posterior Long Leg Splinting Periprocedural Care

  • Author: Suzanne Bentley, MD; Chief Editor: Erik D Schraga, MD  more...
 
Updated: Jul 29, 2015
 

Equipment

Materials employed in posterior long leg splinting include the following:

  • Bucket
  • Water source
  • Stockinette
  • Cast padding (eg, Webril; Covidien, Mansfield, MA]
  • Plaster or fiberglass casting material - Recommendation for long leg splints is to use 12-15 layers of 6-in. plaster
  • Elastic bandage (eg, Ace wrap; 3M, St Paul, MN) - Recommendation is to use 4- or 6-in. rolls
  • Crutches
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Patient Preparation

Anesthesia

It is important to ensure adequate analgesia of the patient during and after splinting because splint application may involve some painful movement of the injured limb. With the administration of any analgesic agent or the initiation of a formal sedation protocol, care should be taken to avoid oversedation. A complete neurovascular examination should be performed before and after the splint has been applied.

Acceptable techniques include the following:

  • Administration of a hematoma block or nerve block (see Nerve Block, Sural, and Nerve Block, Saphenous)
  • Procedural sedation, administered by an experienced practitioner with appropriate monitoring in place
  • Administration of oral or intravenous (IV) pain medications, including nonsteroidal anti-inflammatory drugs (NSAIDs) or opioid analgesic agents

Controversy exists regarding whether NSAIDs delay bone healing, and further investigation is warranted to determine which patients are at highest risk for delayed healing and complications produced by NSAIDs. Vuolteenaho et al note that “in the meantime, use of NSAIDs in fracture patients should be cautious, keeping in mind the benefits of pain relief and inhibition of ectopic bone formation on one hand, and the risks of non-union and retarded union on the other hand.”[4]

To date, studies have been inconclusive on this issue; however, most orthopedists and emergency medicine practitioners continue to use NSAIDs in the treatment of fractures. Because of the potential risk of delayed healing and other complications, the clinician may want to choose non-NSAID analgesics in cases of confirmed fractures.

Positioning

Remove all clothing from the affected limb upon initial presentation to the emergency department (ED). Ensure adequate analgesia. Remove all jewelry from the affected limb, including toe rings or ankle bracelets. Drape the patient with a sheet to ensure cleanliness, then completely expose the affected limb. Perform and document neurovascular and wound/skin examinations before and after splint application.

If an assistant is available, position the patient prone on the bed while the assistant elevates the leg for stockinette and padding placement. Then, as the assistant holds the splint in place, secures it with elastic wrap.

If no assistant is available, position the patient supine with the foot flexed. In this position, the patient’s toes elevate the injured limb off the bed to allow room for plaster and elastic bandages to be wrapped around it. The splint may then be laid on the posterior surface of the extremity, and the leg may be wrapped with no need for further support from applied plaster.

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Monitoring & Follow-up

Provide appropriate discharge and follow-up instructions. These should include pain control; instructions on resting, icing, and elevating the injured extremity; and advice on keeping the splint clean and dry. Provide properly adjusted crutches, and instruct the patient on how to use them safely. Arrange for orthopedic follow-up in 1-5 days.

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Contributor Information and Disclosures
Author

Suzanne Bentley, MD Assistant Professor, Departments of Emergency Medicine and Medical Education, Elmhurst Hospital, Mount Sinai School of Medicine

Suzanne Bentley, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Medical Womens Association, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Jessica Freedman, MD Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Consulting Staff, Department of Emergency Medicine, Mount Sinai Hospital

Jessica Freedman, MD is a member of the following medical societies: Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Vaishali Patel, MD Assistant Clinical Professor, Co-director of Quality Assurance/Continuing Quality Improvement, Department of Emergency Medicine, Mount Sinai School of Medicine; Consulting Staff, Department of Emergency Medicine, Mount Sinai Medical Center; Director of ED PAs, Department of Emergency Medicine, Mount Sinai Medical Center

Disclosure: Nothing to disclose.

Lisa Jacobson, MD Attending Physician, Department of Emergency Medicine, Washington Hospital Center

Lisa Jacobson, MD is a member of the following medical societies: American College of Emergency Physicians, Physicians for Social Responsibility, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Acknowledgements

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
  1. Chanmugam AS, Chudnofsky CR, Custalow CB, Dronen SC. Splinting techniques. Roberts JR, Hedges J. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, Pa: WB Saunders Company; 2003. chap 51.

  2. Arkader A, Warner WC Jr, Horn BD, Shaw RN, Wells L. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop. 2007 Sep. 27(6):703-8. [Medline].

  3. Gravlee JR, Van Durme DJ. Braces and splints for musculoskeletal conditions. Am Fam Physician. 2007 Feb 1. 75(3):342-8. [Medline].

  4. Vuolteenaho K, Moilanen T, Moilanen E. Non-steroidal anti-inflammatory drugs, cyclooxygenase-2 and the bone healing process. Basic Clin Pharmacol Toxicol. 2008 Jan. 102(1):10-4. [Medline].

  5. Tintinalli JE, Gabor D, Kelen J, Stapczynski S. Initial evaluation and management of orthopedic injuries. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York: McGraw Hill; 2003. 1657-63.

  6. Halanski MA, Halanski AD, Oza A, Vanderby R, Munoz A, Noonan KJ. Thermal injury with contemporary cast-application techniques and methods to circumvent morbidity. J Bone Joint Surg Am. 2007 Nov. 89(11):2369-77. [Medline].

  7. Halanski M, Noonan KJ. Cast and splint immobilization: complications. J Am Acad Orthop Surg. 2008 Jan. 16(1):30-40. [Medline].

 
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Measuring and applying stockinette.
Measuring padding and plaster.
Preparing and applying splint.
 
 
 
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