Sugar-Tong Forearm Splinting

Splints are used to prevent motion of injured body parts. Unlike casts, splints are not circumferential and are slightly flexible. This allows splints to expand and accommodate swelling. Splints are often used immediately after an injury and exchanged later for a more rigid cast.[1, 2, 3]

Sugar-tong splints are used to stabilize injuries of the forearm and wrist by preventing forearm rotation and wrist motion.[4, 5] These splints may be used to maintain alignment of broken bones or to protect a patient’s forearm or wrist after surgery. Sugar-tong splints are long and U-shaped, not unlike a utensil used to pick up sugar cubes.

Indications for sugar-tong splints are as follows[1, 2, 6, 7] :

• Initial treatment of distal radius fractures ^{[8, 9]}
• Initial treatment of isolated radius or ulna fractures
• Initial treatment of fractures of the shafts of both the radius and ulna (“both-bone” fractures)
• Postoperative protection of the forearm or wrist

The risks and limitations of sugar-tong splinting should be considered before the splint is applied. There are no specific contraindications for sugar-tong splinting. For some pediatric distal forearm fractures, a short arm cast may be more cost-effective than a sugar-tong splint, though it does not provide significantly better fracture alignment.[10]

The patient must be assessed before the splint is applied. Sugar-tong splints cover the elbow, forearm, and wrist and may cause certain injuries (particularly to the skin) to be missed. Before a sugar-tong splint is applied, the entire limb from the shoulder to the fingertips should be examined for tenderness, bruising, and skin injury. A complete neurovascular examination should be performed before and after application of the splint.

Ultimately, the person applying the splint should be sure of the diagnosis, aware of all injuries to the affected limb, and familiar with the risks and benefits of splinting.

The splint and the splinting procedure should be explained to the patient.

Equipment used in sugar-tong splinting is as follows (see the image below):

• Splint padding material in rolls (4-6)
• 10-cm (4-in.) plaster in rolls (3 or 4)
• Elastic roller bandages in rolls (2 or 3)
• 2.5-cm (1-in.) tape (most varieties are effective)
• Room-temperature water
• Hospital gown

Sugar-tong forearm splinting. Splinting materials.

Anesthesia

Sugar-tong splinting itself is generally well tolerated without anesthesia. Anesthesia, however, is sometimes administered to patients requiring sugar-tong splinting in order to facilitate manipulation of broken bones.

Positioning

The patient should be supine or sitting upright on a hospital bed or stretcher. If possible, the patient’s bed should be adjusted to a height comfortable for the person applying the splint. The patient should be covered with a hospital gown to protect his or her clothes from plaster dust and drips. The patient should be asked to flex the elbow of the injured limb to 90°.

Sugar-tong splints may be made from a variety of materials and in several different ways. A useful and common method is described below.

Find a flat work surface on which to prepare the splint; a table or countertop is ideal. Remove all circumferential materials from the patient’s injured limb, including clothing, bracelets, and watches. Rings, in particular, may cut off circulation to swollen fingers and should be removed. Lubrication with soapy water and gentle manipulation usually suffice. A ring cutter may be used if necessary.

Wrap one or two layers of splint padding material around the wrist and elbow. Extra protection is necessary at these sensitive areas. (For clarity, this step is omitted in the images below.)

Roll out a length of splint padding material sufficient to extend from the patient’s palm, around his or her flexed elbow, and onto the back of the hand to the base of the fingers. (See the image below.) Approximately 5 cm of extra length should be added.

Sugar-tong forearm splinting. Measuring splint.

Roll out three more sheets of splint padding material, all equal in length to the first. Arrange two sheets side to side on the work surface. Lay a third sheet on the seam between the first two sheets. Lay the fourth and final sheet directly on top of the third (see the image below).

Sugar-tong forearm splinting. Four sheets of splint padding have been correctly arranged.

Roll out 10 layers of 10-cm plaster roll to a length approximately 2 cm shorter than the splint padding material (see the image below). Once wet, the plaster will shrink about 3 cm further.

Sugar-tong forearm splinting. Ten layers of plaster roll.

Holding the plaster layers by both ends, submerge the plaster in room-temperature water (see the image below).

Sugar-tong forearm splinting. Soaking plaster layers.

Squeeze any excess water from the plaster before drawing it back out to length. Hold the wet plaster splint high with one hand, and use the other hand to strip excess water from the splint between the index and middle fingers. This laminates the layers of plaster (see the image below).

Sugar-tong forearm splinting. Laminating plaster layers.

Lay the wet plaster strip onto the stacked splint padding material. Fold the exposed portions of the splint padding material around the plaster strip (see the image below). A stack of split padding material and plaster is thus created, composed of three layers of splint padding material, covered by 10 layers of wet plaster, covered by a single layer of splint padding material folded over from the bottom. (The final, folded-over layer of splint padding material prevents the elastic roller bandage from sticking once it is applied).

Sugar-tong forearm splinting. Splint padding is folded up and around each side of plaster strip.

Bring the prepared splint material to the patient’s forearm. Position one end of the splint in the patient's palm at the midpalmar crease (see A in the image below), with the triple layer of splint padding material against the patient’s skin. Bring the splint material down around the elbow and then back up onto the back of the hand. The plaster should reach to the base of the fingers on the back of the hand but not beyond (A in the image below). A corner of the splint should be folded away from the base of the thumb in the palm to prevent the thumb from being immobilized (B in the image below). To ensure proper length, the splint may be folded back on itself slightly on the back of the hand.

Sugar-tong forearm splinting. Splint is applied in stages (A, B, C) and shown in its final form (D, E).

Make a perpendicular cut through three quarters of the width of the elastic roller bandage, and place the apex of this cut in the web space between the patient’s thumb and index finger (C in the image above). Wrap the elastic roller bandage around the palm and then toward the elbow, completely covering the underlying splint material with a single layer of elastic roller bandage (D in the image above). The elastic roller bandage should be stretched lightly—enough to engage the elastic in the material but not more. Secure the end of the elastic roller bandage with short strips of tape if necessary (not shown).

Gently mold the splint to the contour of the elbow, forearm, and wrist. Hold the splint in place with the elbow in 90°, the forearm in neutral rotation, and the wrist in neutral flexion/extension (D and E in the image above) until the plaster is hard.

The patient should now be able to make a full fist in the splint without difficulty (E in the image above). If the patient is unable to do so, it is likely that the splint extends beyond the midpalmar crease in the palm or has not been sufficiently folded away from the base of the thumb.

Pearls

Sugar-tong splints may be difficult for one person to apply. Seek out an assistant. If no assistant is available, it may be advantageous to position the patient prone with his or her shoulder abducted and the injured forearm hanging from the bed/stretcher with the elbow at 90° of flexion. This allows gravity to aid in positioning of the splint.

To avoid excessive manipulation of the patients injured forearm or wrist, measure the splint length on the patient’s uninjured limb. The splint applier’s own limb may be used as a guide.

Instead of sandwiching splint padding material and plaster before application of the splint, splint padding material may be wrapped directly around the patient’s limb. Three layers should be created, with an additional layer or two at the ulnar styloid, the olecranon, and the ulnar nerve on the medial side of the elbow. Extra care is required to do this without tensioning the splint padding material. Tight splint padding material may constrict the limb as the forearm and wrist swell.

Instead of a perpendicular cut made in the elastic roller bandage, a hole may be cut in one end of the bandage to accommodate the thumb. (See the video below.)

Sugar-tong splints may be made with prefabricated splinting material (eg, Orthoplast), which eliminates the need to layer plaster and splint padding material. Prefabricated splinting material is easy to use but does not mold to the limb as well as plaster does. Plaster is generally better at holding broken bones in place.

If the patient can comfortably make a fist, consider asking the patient to hold the palm end of the prepared splint material against his or her midpalmar crease with the tips of the fingers. The splint material may be then wrapped around the elbow and onto the back of the hand. This ensures proper splint length at the patient’s palm and aids in securing the splint.

Once splinting has been completed, the patient should be told to adhere to the following instructions:

• Keep the splint in place
• Keep the splint dry - A large plastic bag secured proximal to the splint with a rubber band may be used for bathing
• Use the fingers for light activities, such as holding reading material and fastening buttons
• Avoid trying to relieve itching under the splint with pencils, coat hangers, or other items - This risks injury to the skin, bunches up the splint padding material, and may cause discomfort necessitating splint replacement; low-dose, over-the-counter diphenhydramine is a safe alternative, provided that the patient is aware of the potential subsequent drowsiness
• Elevate the splint above the heart whenever possible, both when the patient is standing/sitting and when he or she is lying down - This is easily achieved when lying down by using pillows or resting in a semisitting position with the forearm overhead; when sitting and standing, the most favorable position is with the hand resting on the opposite shoulder or with the forearm resting on top of the head
• Do not use a sling continuously - A sling may provide a sense of security when walking but should be used only intermittently. Slings invite placement of the hand below the heart, which may worsen swelling. Constant use of a sling promotes neck pain, shoulder stiffness, and shoulder weakness.
• Seek immediate medical attention if pain worsens or if numbness, tingling, weakness, or discoloration of the fingers is experienced

Sugar-tong splints cover the forearm and may cause certain injuries (particularly to the skin) to be missed. Before a sugar-tong splint is applied, the entire limb from the shoulder to the fingertips should be examined for tenderness, bruising, and skin injury. A complete neurovascular examination should be performed before and after the splint is applied.

Unsafe splint temperature is a concern. Plaster emits heat once it has been soaked in water. If more than 10 layers of plaster are used or if the plaster is soaked in hot water, the patient may be burned.

Unsafe positioning may lead to additional injury. To avoid such injury, a sugar-tong splint should hold the patient’s elbow at 90° of flexion, the forearm in neutral rotation, and the wrist in neutral flexion/extension. The patient’s elbow, forearm, and wrist should be splinted in different positions only at the direction of an orthopedist.

Improper splint length may cause problems. Plaster material in rolls shrinks slightly when wet. This should be accounted for by rolling out an extra 3 cm or so of dry plaster roll. The splint should extend to the base of the fingers on the back of the hand so as to provide maximum stability. The splint should extend to, but not beyond, the midpalmar crease on the palm.

The patient should be able to fully flex his or her fingers with the splint in place. If he or she cannot, the splint is likely too long on the palmar side and will discourage finger motion. Muscle contraction and active finger motion promote circulation and relief of swelling.

Constriction of the forearm and wrist may occur. Well-made splints expand slightly. Avoid wrapping the elastic roller bandage tightly. Tape used to secure the elastic roller bandage should not be placed circumferentially around the patient’s forearm; however, short segments of tape placed over some of the elastic roller bandage’s exposed edges can help keep it in place.

Wrinkles in the splint padding material may cause pressure hot spots. Care should be taken to apply the padding smoothly. Indentations in the plaster material, particularly those created by the applier’s fingers, may cause uneven pressure and discomfort. To avoid creating such indentations, use the palms and move the hands back and forth as the splint is molded. Plaster may irritate the skin if not adequately padded, particularly at the ulnar styloid, the olecranon, and over the medial elbow where the ulnar nerve is superficial. Care should be taken to protect these areas.

Excess material can be problematic. Three layers of splint padding material (with slightly more at the ulnar styloid, the olecranon, and over the medial elbow where the ulnar nerve is superficial) are sufficient; more padding reduces the immobilizing effect of the plaster. Ten layers of 10-cm-wide plaster provide full rigidity. One layer of elastic roller bandage suffices to secure the plaster.

Materials in excess of these recommendations make the sugar-tong splint unnecessarily bulky, heavy, and expensive. Excess bulk limits the choice of clothing that the patient can wear, as well as the patient’s ability to dress and undress independently. Excess weight increases general discomfort and discourages elevation, shoulder motion, and light manual activities.