Posterior Long Leg Splinting Periprocedural Care

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. (15-cm) plaster
• Elastic bandage (eg, Ace wrap; 3M, St Paul, MN) - Recommendation is to use 4-in. (10-cm) or 6-in. (15-cm) rolls
• Crutches

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 noted 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.

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.