Pediatric Orthopedic Basics
Between 8 and 10 layers of plaster (additional layers for lower extremity splints) should be wetted with room-temperature water. Hot water should never be used as this will intensify the exothermic reaction that occurs when curing and could cause burns.2 The limb should be kept in the anatomic position while the plaster is being molded to the shape of the extremity, allowing 15 to 20 minutes to dry.1 Once dry, an elastic bandage such as an Ace wrap may be placed over the entire cast to hold it secure in place. If fiberglass is used, it is helpful to squeeze out extra water before molding to the extremity. Again, an additional padding roll should be employed to avoid any discomfort or pressure beneath the splint.
In both fiberglass and plaster splinting, the edges of either type of material should not be abrasive to the skin; this can be avoided by rolling over excess padding and stockinette to create a round soft edge on either end.7 Finally, the patient should be fitted with a shoulder sling or crutches (if age appropriate) to further immobilize the injured extremity and avoid any movement or weight bearing.
Types of Splints
The type of splint depends of the location and characteristics of the fracture being immobilized. The following are a few examples of the more popular splinting techniques indicated for common pediatric fractures.
Long-Arm Posterior Splint. This splint is useful for most forearm and elbow fractures. The splint length should extend from midlength of the humerus to the palmar crease, and the width should be semicircular. In addition, an anatomic position of 90˚ flexion of the elbow should be maintained, with the hand in a neutral position and slight dorsiflexion. It is generally accepted to slightly pronate the forearm when splinting a supracondylar fracture. Orthopedics should always be consulted if the fracture involves the elbow.
Ulnar “Gutter” Splint. Useful for nondisplaced, minimally-angulated metacarpal “boxer’s fracture” or fourth and fifth phalangeal fractures, the length of the ulnar splint should extend from the distal phalanx to proximal forearm. Splint width should enclose both the volar and dorsum surfaces of the fourth and fifth metacarpals. In addition, padding should be placed between the digits for comfort. The metacarpophalangeal joints should be positioned at 70˚, and the proximal phalangeal angle at approximately 20˚ flexion2; this will help minimize the risk of contractures.
Forearm “Sugar-Tong” Splint. These splints are indicated for immobilization of a distal radius fracture or wrist injury. Distal radial fractures are by far the most common fractures encountered in the pediatric population,8 and splinting for angulation less than 15˚ is preferred.9,10 For proper stabilization, a long U-shaped splint should originate at the palmar crease, wrap around the elbow, and end at the metacarpophalangeal joint dorsally. Again, the hand should be dorsiflexed, and a soft rolled edge should be kept on the palmar crease to allow full finger flexion to near 90˚.
Thumb Spica Splint. A thumb spica splint is useful to immobilize uncomplicated fracture of the first metacarpal or proximal phalanx or when scaphoid (navicular) bone fracture is suspected. A semicircumferential molding of the radial forearm should be formed, extending to the thumbnail bed, and wrapping around the thumb. The proper hand positioning is slightly dorsiflexed, with thumb abducted slightly, as if holding a glass of water.2 If there is any doubt of a navicular fracture (rare in prepubescent children), the clinician should never hesitate to splint!
Long-Leg Posterior Splint. This type of splint is appropriate for immobilization of midshaft tibia/fibula fractures or most knee injuries. Full length of the splint should start beneath the inferior gluteal fold and extend to the ball of the foot, leaving the toes free. The ankle should be at 90˚ flexion and the knee should remain just slightly flexed, never locked straight. Orthopedics should always be consulted in cases of proximal tibia/fibula fractures or knee joint involvement.
Posterior Ankle Splint. Essentially a shorter version of a long-leg splint extending proximally to just below the knee, the posterior ankle splint is useful to immobilize ankle fractures, foot fractures, and severe ankle sprains. The distal fibula and occasional tibia physes are another common site of pediatric fractures, particularly in obese or more active children.11,12 When using either a long- or short-leg posterior ankle splint, it is helpful to hold the foot at 90˚ flexion until the material hardens or the proper angle may be lost. A recall that displaced or Salter-Harris type III or IV physeal fractures justify orthopedics consult. Nonweight-bearing, use of crutches, ice, and elevation are all important points for recovery in 3 to 6 weeks.
