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AAOS Now

Published 11/1/2014
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Maureen Leahy

Improper Placement of Upper Extremity Splints Common in Children

Study finds poor splinting techniques often performed in EDs, urgent care centers

Initial evaluation and treatment of upper extremity injuries in children frequently occur in an emergency department (ED) or urgent care center. As a result, a variety of healthcare professionals—ED physicians, residents, nurse practitioners, and physician assistants—are involved in applying the splints necessary to immobilize the extremity and stabilize a potential fracture. According to study data presented at the American Society for Surgery of the Hand annual meeting, however, a significant number of these splints are placed incorrectly.

“Incorrect splint placement may lead to adverse consequences, such as rubbing or pressure ulcers, stiffness, or inadequate immobilization that can result in displacement or pain,” said Joshua M. Abzug, MD, of the University of Maryland School of Medicine. “The purpose of our study was to evaluate the appropriateness and adequacy of splints applied for pediatric upper extremity injuries in EDs and urgent care centers and to assess any complications from improper splint application.”

Study design
The researchers evaluated 205 children (122 males, 83 females; average age, 8.7 years) who had been treated with an upper extremity splint and were seen at a pediatric orthopaedic clinic for an initial evaluation. The most common injuries were distal radius buckle-type fractures, Salter-Harris I and II fractures of the distal radius, both-bone forearm fractures of the radial and ulnar shafts, and supracondylar humerus fractures.

The following demographic and clinical data were collected:

  • type of splint
  • type of facility where splint was applied
  • type of practitioner who placed the splint
  • time from splint application to orthopaedic evaluation

The splints were evaluated for appropriateness and adequacy based on the general principles shown in Table 1. After frontal and lateral photographs of each splint were taken, the splint was removed and the extremity was examined for any soft-tissue complications. (Splints were not removed in 31 patients who required a reduction of a displaced fracture on initial presentation.) An orthopaedic surgeon then performed a full musculoskeletal examination on each patient.

Most splints incorrectly applied
Overall, 93 percent of the splints were incorrectly applied, leading to complications in many cases. Specifically, the elastic bandage used to wrap the splint had been applied directly to the skin in 83 percent of the patients, resulting in excessive swelling in the digits. The researchers also found that 51 percent (104) of the splints did not allow for proper function. Of these, “excessive wrist flexion occurred in 63 percent (66/104); improper extension of the elbow or metacarpophalangeal (MCP) joints was also prevalent,” Dr. Abzug said.

In addition, 57 percent of the splints were the improper length. “The most common error was excessive distal length. We also saw many finger fractures that were immobilized too far proximally, preventing MCP flexion,” he noted.

Among the 174 patients whose splints had been removed during examination, the researchers observed skin and soft-tissue complications in 35 percent; 9 percent had two or more complications. “Complications included significant edema in distal extremities that led to decreased range of motion. This may have been related to the fracture itself; however, given that the edema was distal to the splint application, we felt it was due to the way the splint was applied,” Dr. Abzug explained.

The researchers also observed evidence of pressure on the skin beneath the splint, as well as bruising, abrasions, blistering, and ulcerations. “Although no patients needed invasive treatment as a result of inadequate splint placement, several patients did require local wound care,” Dr. Abzug said.

“The results of our study reveal that upper extremity splints are being placed improperly in children in ED and urgent care centers,” he concluded. “Our plan is to create educational materials that can be posted in these settings that demonstrate appropriate placement of splint applications and to then repeat the study to gauge the effectiveness of our intervention.”

Dr. Abzug’s coauthor of “Appropriateness and Adequacy of Splints Applied for Pediatric Upper Extremity Fractures in an Emergency Department/Urgent Care Environment,” is Brandon S. Schwartz, MPH.

Disclosures: Dr. Abzug—Checkpoint Surgical, Axogen, Springer. Mr. Schwartz—no conflicts.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

Bottom Line

  • A significant number of splints applied in EDs and urgent care centers for pediatric upper extremity injuries are placed improperly.
  • Inadequate splint placement may lead to adverse events such as edema and skin complications.
  • Healthcare professionals in EDs and urgent care settings may benefit from education in appropriate splint application.

Additional Information:
Clinical Paper Session 04: Pediatrics (Papers 24-28)
  (See paper 24)