Posterior Long Leg Splinting

Posterior long leg splinting is used to stabilize injuries by decreasing movement and providing support, thus preventing further damage. Splinting also alleviates extremity pain, edema, and further soft-tissue injury and promotes wound and bone healing. Splints can be used for immobilization of an extremity before surgery or as a temporizing measure before orthopedic consultation.

Splints, rather than circumferential casts, are often the treatment of choice in the emergency department (ED) because they allow for continued swelling and thus are associated with a lower risk of compartment syndrome. Follow-up for definitive care with an orthopedist should occur 1-5 days after splint application.

In addition to immobilization, posterior long leg splinting may offer additional benefits specific to the particular injury or problem being treated. Examples include the following:

• Splinting deep lacerations that cross the knee joint reduces tension on the wound and helps prevent wound dehiscence
• Immobilizing tendon lacerations may facilitate the healing process by relieving stress on the repaired tendon
• The discomfort of inflammatory disorders such as tenosynovitis or acute gout is greatly reduced by immobilization
• Cellulitis over the joint should be immobilized for comfort
• Limiting early motion also may reduce edema and, theoretically, improve the immune system’s ability to combat the infection
• Patients with multiple traumatic injuries should have fractures and reduced dislocations adequately splinted while other diagnostic and therapeutic procedures (eg, focused assessment with sonography for trauma [FAST] examination or computed tomography [CT]) are completed; immobilization decreases blood loss, minimizes the potential for further neurovascular injury, decreases the need for opioid analgesia, and may decrease the risk of fat emboli from long-bone fractures ^[1]

Posterior long leg splinting is indicated for the immobilization and support of various knee injuries.[2] In many EDs, the use of prefabricated knee immobilizers has replaced traditional posterior long leg splinting[3] ; however, the plaster long leg splint remains particularly useful when knee immobilizers are unavailable and in the following situations[1] :

• Extremities that are too large for knee immobilizers
• Treatment of angulated fractures
• Temporarily immobilization of knee injuries that require immediate operative intervention or orthopedic referral

The use of long leg splinting in the treatment of pediatric femoral shaft fractures has been described.[8]

There are no absolute contraindications for posterior long leg splinting. However, there are some situations that, though not constituting contraindications, are likely indications for surgical intervention, in which case splinting is only a temporary treatment. Examples include the following:

• Multiple or complicated fractures
• Open fractures
• Injuries associated with neurovascular compromise

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.

With the patient in position, measure the proposed splint length, which should extend from the crease of the buttocks to approximately 5-8 cm above the malleoli.[1] Cut the stockinette to the appropriate length, and apply it to the dry, clean lower limb (see the video below).

Measure the padding and plaster (see the video below). Use padding that is wider and longer than the plaster. The padding should extend over the entire length of the leg (1-3 cm longer than the splint length). Wrap sufficient layers of padding around the stockinette in a distal-to-proximal direction. Apply minimal extra padding to bony prominences and pressure points.

The posterior long leg splint is made with 12-15 layers of plaster. Prepare 12-15 single layers of 6-in. (15-cm) plaster or fiberglass (a smaller width should be used in pediatric patients) of the appropriate length. The plaster strips should be slightly shorter than the template (see above). Submerge the plaster in warm water until no further bubbles appear. Squeeze the water out by running the fingers along the length of the plaster three times. To laminate the splint, run the palm of the hand over the plaster on a flat surface.

Lay the plaster onto the padding in such a way that at least a few centimeters of padding extends underneath the plaster and may be folded over the edges of the plaster. Direct contact between the plaster edge and unprotected skin may result in abrasion and pain. Apply the splint to the posterior leg (see the video below).

Once the splint is in position, secure it with elastic wrap in a distal-to-proximal direction. Reexamine the patient. Assess neurovascular status, evaluate patient comfort, and look for any areas of pressure that may require additional padding. Ensure that plaster edges are sufficiently covered with padding. Splints take approximately 10 minutes to set completely; the patient should be instructed not to move the limb during this time.

Complications of posterior long leg splinting include the following:

• Thermal burns ^{[5, 6]} - Splinting material hardens through an exothermic reaction, in which the amount of heat liberated is directly proportional to the setting process, which is based on the water temperature at which the splint is prepared; to prevent severe burns, use warm water rather than hot or boiling water to moisten the plaster, and be aware that splinting material becomes hotter once wet and during drying
• Pressure injuries ^{[5, 7]} - This complication can be minimized by applying extra (thin) layers of padding at bony prominences and pressure points
• Contact dermatitis ^[5] - This complication can be minimized by ensuring full coverage of a clean, dry extremity with the stockinette and providing adequate padding between the patient’s skin and the splinting material
• Neurovascular compromise ^[5] - This complication can be minimized by documenting neurovascular status both before and after splinting; the patient should be reminded to seek immediate medical attention if he or she notices any decline in function or sensation of the extremity
• Decreased range of motion - This complication can be minimized by encouraging timely orthopedic follow-up to prevent decreased function, improper healing, and joint fusion

The goals of pharmacotherapy are to reduce morbidity and prevent complications. Drugs used for injuries include various NSAIDs and analgesics. The strength of the analgesics depends on the type of pain resulting from the injury.

Class Summary

NSAIDs are the drugs of choice for the initial treatment of myofascial pain.

Ibuprofen (Motrin, Advil, Neoprofen, Ultraprin)

Ibuprofen inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. It is used to provide relief of cervical myofascial pain.

Indomethacin (Indocin)

Indomethacin is thought to be the most effective NSAID for the treatment of ankylosing spondylitis, although no scientific evidence supports this claim. It is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.

Naproxen (Naprosyn, Naprelan, Aleve, Anaprox)

Naproxen is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.

Diclofenac (Voltaren, Cataflam XR, Zipsor, Cambia)

Diclofenac inhibits prostaglandin synthesis by decreasing COX activity, which, in turn, decreases formation of prostaglandin precursors.

Ketoprofen

Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages are indicated initially in small patients, elderly patients, and patients with renal or liver disease. Doses higher than 75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe the patient's response.

Class Summary

These medications provide control of moderate to severe pain.

Hydrocodone and acetaminophen (Vicodin, Lorcet, Lortab, Norco, Zolvit)

This drug combination is indicated for moderate to severe pain.

Acetaminophen with codeine (Tylenol-3)

This drug combination is indicated for mild to moderate pain.

Oxycodone and acetaminophen (Percocet, Endocet, Tylox)

This drug combination is indicated for the relief of moderately severe to severe pain. It is the agent of choice for aspirin-hypersensitive patients. Different strengths are available

Oxycodone and aspirin (Percodan, Endodan)

This drug combination is indicated for the relief of moderately severe to severe pain.