A–1 Distal Phalanx Splints
Dorsal Distal Phalanx Splints
Dorsal and volar splints are very useful in treating avulsion fractures of the distal phalanx as discussed in the text. Our preference is the dorsal splint, which provides more support because there is less “padding” on the dorsal aspect of the finger. The splint is in closer contact with the bone. When using these splints, do not hyperextend the distal interphalangeal joint as was previously recommended in older texts. Full extension is the position of choice when applying the splint.
This splint is made from a thin metal strip. It provides protection for distal phalangeal fractures resulting from external injury. This splint provides no structural support.
Dorsal and Volar Finger Splints
These splints are fashioned from commercially available metallic splints that have sponge rubber padding on one side. The splint is cut to the proper size and shaped as desired.
The splints should be applied with the metacarpophalangeal joint at 50 degrees of flexion and the interphalangeal joints flexed approximately 15 to 20 degrees.
The injured finger is splinted to the adjacent normal finger. This provides support of the injured digit while permitting motion of the metacarpophalangeal joint and some motion at the interphalangeal joint. This type of splinting is used commonly in sprains of the collateral ligaments of the interphalangeal joints and other injuries discussed in the text. A piece of cast padding cut to proper size is inserted between the fingers and the two digits taped together.
Gutter splints are used for the treatment of phalanx and metacarpal fractures. Fractures of the ring and little finger are immobilized in an ulnar gutter splint. The MCP joint should be flexed 50 to 90 degrees and the PIP and DIP joints are extended. Remember to place a piece of padding between the fourth and fifth digits.
Radial gutter splints are used to treat fractures of the index and long fingers. A hole is cut out so that the thumb is free to move normally. Padding is placed between the second and third digits. The position of immobilization of the digits is the same as the ulnar gutter splint (Video A–3A).
Gutter Splint Application
The splint is made by using plaster sheets cut to the proper size (Video A–3B). A. The measurement should be from the tip of the finger to a point two-thirds of the way down the forearm.
Video A-3B: Application of a plaster splint
B. When applying a radial gutter splint, cut out the hole for the thumb. C. Next, apply Webril to the fingers, hand, and forearm, making sure to pad between the fingers. D. The plaster is soaked in warm water and then the excess is squeezed out. E. The wet plaster is then smoothed out and placed on the patient’s extremity. F. A piece of cotton roll (Webril) can be placed on the wet plaster before wrapping the extremity with the elastic bandage. The proper final position for the plaster splint is 50 to 90 degrees of flexion at the metacarpophalangeal joint, 15 degrees of extension at the wrist, and full extension at the interphalangeal joints.
A–4 Dorsal Splint with Extension Hood (“Clam Digger”) Splint
This splint is placed over the dorsum of the forearm and includes the second, third, fourth, and fifth digits. It covers the DIP joint. To decrease swelling and stretch the collateral ligaments during healing, the MCP joint should be flexed 50 to 90 degrees, the PIP and DIP joint are fully extended, and the wrist is extended approximately 15 degrees.
A–5 Universal Hand Dressing
The universal hand dressing is used when treating inflammatory conditions that affect the hand. This is a soft dressing that places the hand in a position that allows for maximal drainage. A. In applying this dressing, the fingers are separated by gauze (4 × 4) that is unfolded and layered in between the digits. B. Once the gauze sufficiently pads between the fingers, an elastic bandage is applied around the forearm and onto the hand. C. When encircling the fingers, the elastic bandage is cut so as to allow the fingers to go through the bandage. D. In the final stages of encircling the digits, the elastic bandage courses along the palmar aspect of the hand and holes are cut to incorporate the fingers. E. The hand is pulled back so that the wrist is held in extension and the elastic bandage is secured. F. To assist in maintaining the wrist at 15 degrees of extension with the fingers separated, tape is used between the fingers, applied from the palmar aspect to the dorsum of the hand so as to pull the wrist back.
This cast is made by applying stockinette dressing to the arm extending from the hand to the midarm. A. This is followed by application of cotton bandage (Webril), which is then followed by plaster rolls. The method of applying the plaster rolls is discussed in Chapter 1. B. Before application of the final roll, the stockinette is folded back over the cast and the final plaster roll is applied.
C. Note the position of the thumb that must be maintained in applying this cast (abducted with the IP joint in extension as if holding a can of soda). The interphalangeal joint is incorporated in the cast in the figure below, although controversy exists whether this is necessary. The fingers are left free so there is full motion of the metacarpophalangeal joints. The position of the wrist shown here is the neutral position. In using this cast for fractures of the scaphoid, we advocate extending it to above the elbow, making it a long-arm cast.
A–7 Short- and Long-Arm Thumb Spica Splints
A. The short-arm thumb spica splint is made by applying a plaster slab from the tip of the thumb to approximately two-thirds of the way along the forearm. B. In applying the plaster, be certain that the width is enough so that the two ends overlap at the distal tip of the thumb. C. An elastic bandage is applied. D. To create a long-arm thumb spica splint, add a volar splint to include the wrist and the elbow. If fiberglass is used, a single slap extending beyond the elbow is acceptable. E. An elastic bandage is used over the plaster (Video A–7).
A short-arm cast is used for immobilizing a number of fractures of the forearm. A. The cast is made by applying a stockinette from the fingers to above the elbow. Cotton bandage (Webril) is then applied over the stockinette with the thumb remaining free at the metacarpophalangeal joint and the fingers free at the same level. B. Plaster rolls are used while the hand is maintained in position. C. The stockinette is then folded down over the cast and cut and the final roll of plaster bandage is applied. Note that the fingers and thumb are free and the patient is able to use the fingers without any impingement on normal motion.
A long-arm cast is produced in a similar fashion except that it is extended above the elbow to approximately the midarm.
A–9 Long-Arm Posterior Splint
A long-arm posterior splint is used to immobilize a number of injuries to the elbow and forearm. The splint is produced by wrapping a cotton bandage (Webril) around the forearm from the midpalmar region to the midarm. Next, a posterior plaster splint is applied to the arm held in a position of 90-degree flexion at the elbow and neutral position at the wrist. This is followed by an elastic bandage to hold the posterior slab in position. A sling should be applied after the splint is in position (Video A–9).
A–10 Long-Arm Anterior–Posterior Splint
This splint is used for fractures of the distal humerus, combined fractures of the radius and ulna, and an unstable distal radius or proximal ulna fracture. Generally speaking, the arm, forearm, and wrist are placed in a position most comfortable for the patient. This position usually conforms to the most relaxed placement of the muscles. A. Apply a plaster slab over the volar and dorsal portion of the arm and forearm. The plaster slab should extend from the midarm to the dorsum of the hand, incorporating both the elbow and wrist joints. It is important that the volar (anterior) and dorsal (posterior) slabs do not meet so as to form a circumferential “cast.” After measuring the slabs, place cotton roll on the undersurface and apply the plaster slab to the extremity. We use a small amount of gauze wrapping at the distal end of the splint as shown to keep the slab in place during application. An assistant can hold the upper end. B. Wrap the splint with an elastic bandage as shown.
This splint is used in distal forearm fractures, especially fractures of the distal radius (Colles fracture). The forearm can be supinated or pronated during the application of the splint. A cotton bandage is first applied to the injured limb. Next, a single long plaster splint is applied by encircling the elbow.
The splint should extend from the metacarpophalangeal joint palmarly around the elbow to the dorsal aspect of the hand just proximal to the metacarpophalangeal joint. The excess plaster, created by encircling the elbow, is tucked. An elastic bandage holds the splints in position. The advantage of this splint is that it permits immobilization in a position of pronation or supination without a circumferential cast being applied to the extremity. A sling should be used with the splint (Video A–11).
This splint is used for the acute management of humeral shaft fractures. Following the application of padding to protect the skin, the splint is applied to extend from the axilla, around the elbow, to above the shoulder. The arm is kept adducted and the elbow is flexed 90 degrees. Elastic bandage is wrapped around the splint. The weight of this splint will aid in keeping the fracture aligned. For this reason, a collar and cuff is recommended over a traditional sling.
A. A commercial sling is used to support the arm for a number of injuries as discussed in the text. B. A collar and cuff is an alternate method used to support the forearm in patients with a humeral fracture treated with a coaptation splint. C. A stockinette Valpeau and swathe (the component encircles the patient’s waist) is used in situations where there is an unstable fracture of the proximal humerus, which has a tendency to displace due to contraction of the pectoralis major muscle. This position relaxes the pectoralis major.