Radial Gutter Splinting Technique

Updated: Jul 05, 2016
  • Author: Lynne McCullough, MD, FACEP; Chief Editor: Erik D Schraga, MD  more...
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Technique

Application of Radial Gutter Splint

Explain the procedure to the patient, including risks and benefits. Obtain informed consent. Position the patient as described previously (see Periprocedural Care, Positioning).

Apply the stockinette. Cut longitudinally at the distal end of the stockinette to allow covering for the second and third digits. Then, cut an adequate hole for the thumb, being careful to avoid constriction of the thumb. The stockinette should be cut so that it is longer than the splint. It 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 are pulled over the edges of the wet plaster to create smooth edges. (See the video below.)

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

Place a piece of padding (eg, Webril) between the second and third digits to help prevent skin maceration. Wrap the padding over the stockinette, overlapping each layer by half the width. Allow for extra length. The padding should extend 2-3 cm beyond the overlying plaster on both ends. Leave nails exposed to assess for perfusion. Smooth out creases and avoid wrinkles, unwrapping and rewrapping as necessary. Apply extra padding to the bony prominences of the wrist, the metacarpophalangeal (MCP) joints, and the interphalangeal (IP) joints. (See the video below.)

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

Measure the plaster of Paris. For an average-sized adult, a radial gutter splint should be eight to 10 layers thick. Use plaster that is 3-4 in. wide. After counting the layers, measure the plaster from the second distal IP (DIP) joint to the proximal third of the forearm. Allow roughly 5 mm of extra length on either end; the plaster shrinks when wet. The excess wet plaster on the ends will be folded over to create smooth edges. Measure and mark an opening on the plaster for placement of the thumb through the splint, and cut out the opening. (See the video below.)

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

If prefabricated fiberglass is used, the stockinette and padding steps can usually be skipped. In this case, follow the manufacturer's 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 the layers to bond together. Squeeze out the excess water. Use a milking action with the fingers to strip out the remaining water. Then, lay the plaster on a flat surface or dry towel, and smooth out wrinkles and folds. This allows further bonding of the plaster layers. (See the video below.)

Wetting plaster for radial gutter splint. Video courtesy of Kenneth R Chuang, MD.

Apply the wet plaster, over the padding, to the lateral or radial surface of the forearm. The plaster should extend from the second DIP joint to the proximal third of the forearm. Fold outward any excess plaster on the ends. The underlying stockinette and padding should then be folded outward on both ends, creating smooth edges. (See the video below.)

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

Apply the bandage wrap over the wet plaster. Start distally, at the DIP joints of the second and third digits, and wrap proximally. Cut an adequate hole for the thumb. The thumb and the fourth and fifth digits should be left free. Avoid wrapping too tightly. (See the video below.)

Applying bandage wrap for radial gutter 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 15-25°, abduct the thumb, and flex the MCP joints to 70°. When immobilizing metacarpal neck fractures, flex the MCP joints to 90°. 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. If the heat becomes too intense, unwrap the splint and remove the plaster immediately; thermal burns can occur. (See the video below.)

Molding radial gutter splint. Video courtesy of Kenneth R Chuang, MD.

Once the splint is dry, check for neurovascular function and capillary refill. The median nerve provides 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 and third digits and the lateral half of the fourth digit. 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. (See the video below.)

Test neurovascular function and capillary refill after radial gutter splinting. Video courtesy of Kenneth R Chuang, MD.

Remember to check motor function as well. Wipe away any plaster that may have dropped onto the patient's skin.

Next:

Postprocedural Care

Deliver appropriate aftercare instructions. Instruct the patient to rest, elevate, and ice the injured limb. Emphasize to the patient that if weakness or numbness, color change (pale or bluish), increasing pressure or pain, or spreading redness or streaking develops, he or she should remove the splint and return immediately, or else go to an emergency department.

Instruct the patient to keep the splint clean and dry and to refrain from sticking any items into it. 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.

Consider prescribing an antihistamine for itching. However, if the itching persists or worsens, the splint should be reevaluated for complications.

If the patient received any sedation or opioids, advise against driving or alcohol consumption.

Arrange for follow-up with a consultant, usually in 2-7 days, depending on the reason for the splint.

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Complications

Potential complications of radial gutter splinting include the following:

  • Thermal burns [4]
  • Pressure sores
  • Ischemia and neuovascular compromise
  • Decreased range of motion (ROM) due to immobilization

Patients can expect some warmth as the plaster dries. As more layers of plaster are used, more heat is produced. [5, 6]  If the patient experiences intense heat or any pain, remove the plaster immediately; thermal burns can occur. To minimize the risk, use clean room-temperature water; water that is dirty or too warm accelerates the setting time and increases the heat produced. [6]  Do not wrap towels or blankets around the splint to shorten the drying time; this produces excess heat.

To prevent pressure sores, provide extra padding to bony prominences. When wrapping the cotton padding, avoid creases; if creases do 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 to mold the plaster.

Ischemia and neurovascular compromise may be caused by increased pressure from swelling. If moderate-to-significant swelling is anticipated, cut the cotton padding lengthwise along the medial or ulnar side of the forearm before applying of the wet plaster to the radial side. This allows for expansion of the padding. If using tape to secure the outermost bandage wrap, do not tape circumferentially.

Application of a radial gutter splint can result in compression of the median nerve, which provides sensory function to the palmar side of the thumb and second and third digits and the lateral half of the fourth and, dorsally, to the distal half of the second and third digits and the lateral half of the fourth. Any numbness or weakness in this distribution suggests median nerve compression and should prompt splint removal with subsequent neurovascular examination. Immediate consultation (with orthopedics or hand surgery) should be considered if symptoms do not resolve.

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 ROM, despite best care practices. Aftercare of such injuries often requires physical therapy.

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