Abstract
The purpose of this chapter is to provide a basic instructional reference for upper extremity splint application in the context of pediatric orthopaedic trauma. In addition to reviewing the steps necessary for successful splint application, this chapter will also discuss common pitfalls to avoid in order to optimize outcomes and prevent complications during and after splint immobilization for upper extremity injuries. Embedded throughout the chapter are figures and videos that highlight how to apply various splints to the upper extremity based on the injury location and the immobilization required for different clinical situations. Previous studies have indicated that many practitioners caring for pediatric trauma patients lack the proper training to apply splints safely and effectively. This chapter and its accompanying media should ideally serve as a primer for medical trainees, including orthopaedic residents, fellows, advanced practice providers, and other medical professionals learning to treat pediatric patients in clinical and emergency department settings. Generally, upper extremity splints are used as a method of temporary immobilization while awaiting definitive management, which may involve conversion to a cast once the swelling has resolved or following surgical intervention.
Key Concepts
-
(1)
Splints should be considered for pediatric patients with upper extremity injuries when associated soft tissue injuries or anticipated swelling prevent the use of a cast.
-
(2)
Similar to casting, upper extremity splints should immobilize the injured area while minimizing the immobilization of uninjured joints. This approach allows for a continued range of motion and helps prevent iatrogenic stiffness.
-
(3)
Successful splint application depends on the proper use of cast padding and plaster to effectively immobilize injuries and prevent iatrogenic soft tissue complications like wounds or skin ulceration.
Keywords: Short arm, Long arm, Sugar-tong, Coaptation, Volar resting splint for hand fractures
Introduction
When to choose a splint instead of a cast?
In general, fiberglass casting is the preferred method of immobilization for upper extremity injuries. Fiberglass casts are lightweight and durable, making this choice ideal for treating many pediatric orthopaedic upper extremity injuries. However, providers frequently encounter situations where a patient would be better served by a non-circumferential plaster splint. Examples of such clinical situations include (1) expected worsening of swelling soon after an injury or surgery, (2) the need for temporary immobilization while awaiting surgery, (3) concomitant soft tissue injuries such as a wound or laceration that requires reassessment in the near future, or (4) lack of access to casting materials or a cast saw based on the clinical working environment. In these circumstances, choosing a plaster splint for an upper extremity injury is the preferred method of immobilization. Although technically less demanding than fiberglass cast application, proper training is essential for the safe and effective application of plaster splints in a functional position for the extremity [1].
Tips for successful upper extremity splinting
Applying splints in the pediatric population can often be challenging, as it requires some level of cooperation or compliance from the patient. This issue can be particularly pronounced in young children or those with cognitive or behavioral disorders, such as autism spectrum disorder, who may not understand the rationale behind splint application. Additionally, patient anxiety can be heightened by the loud and chaotic hospital environment, the presence of strangers, and pain. Minimizing these factors and ensuring adequate pain control can enhance the likelihood of applying a comfortable and appropriately molded splint.
Ensuring adequate pain control and sedation is arguably the most important aspect when reducing fractures and applying splint or cast immobilization. Creating a calm environment to examine and perform splint application is crucial to the overall success of the experience. Speaking softly to the patient, positioning oneself at the patient's level, and starting the exam at a distance from the fracture while progressing slowly to the area of concern are all techniques that help maintain a relaxed patient interaction. Preparing splint materials outside the room or out of the child's direct line of sight helps sustain a calm atmosphere and facilitates smooth, efficient application when the time comes. Lastly, obtaining adequate assistance to hold the affected limb and taking time to review splint steps and techniques with your assistant before application is essential for success.
Complications from upper extremity splinting often involve iatrogenic skin ulceration or wounds due to inadequate padding at bony prominences, thermal injury, or increased swelling from circumferential elastic bandages that are applied too tightly [[1], [2], [3], [4], [5]]. Close attention to proper splinting technique is critical for preventing these complications. Adequate padding should be used over all bony prominences to prevent excessive pressure and skin irritation.
Master's Method.
Dr. Joshua Abzug: Padding should be applied in a deliberate manner, meticulously rolling the material onto the extremity to allow for even application without wrinkles.
Typically, there should be at least 3 to 4 layers of padding covering the part of the extremity that will be immobilized. This can be achieved by aiming for slightly more than a 50% overlap of cast padding material as the arm is wrapped from distal to proximal. Bony prominences included in the splint should be identified, with additional padding applied to address these areas (e.g., ulnar styloid, olecranon, medial and lateral epicondyles, etc.). To minimize the risk of thermal injury, care should be taken to avoid using more than 10 layers of plaster. Using more than 10 plaster layers or excessively long slab lengths that cause folding at the ends of the splint increases heat during curing, leading to potential burns. It is also important to prevent direct contact between the plaster and skin, as this can raise the likelihood of thermal burns. Water used for dipping plaster should be no warmer than room temperature to avoid elevated temperatures and reduce the risk of burns. If multiple slabs of plaster are being dipped before application, they should be laid on towels or blankets to allow for heat dissipation before use, thereby minimizing the risk of thermal injury.
Master's Method.
Dr. Suzanne Steinman and Dr. Joshua Abzug: To minimize the risk of thermal injury, care should be taken to: (1) Avoid using more than 10 layers of plaster, (2) Avoid using water warmer than room temperature, (3) Avoid allowing any plaster to come into direct contact with the skin at any time, (4) Avoid resting the extremity on a pillow which is plastic insulated and does not allow heat dissipation, instead rest the extremity on a stack of cloth blankets or towels. (5) Elastic bandages should be applied loosely. Any circumferential dressing that is wrapped too tightly may increase swelling, impede blood flow, or cause pressure sores, as seen on this ankle that was wrapped tightly with an ACE bandage.
As the primary purpose of the splint is to provide comfort and temporary immobilization until definitive treatment, it is essential to take precautions to prevent skin irritation or worsening of swelling to avoid delays in care. Transitioning the patient to a cast or definitive surgical treatment may need to be delayed if the skin or soft tissue is compromised.
Master's Method.
Dr. Hilton Gottschalk: Elastic bandages placed over plaster-based upper extremity splints should be applied loosely. If necessary, additional bandages can be used to cover and protect the splint instead of tightly stretching the elastic material around the extremity. If the goal of the splint is to temporarily immobilize the injured area (days, not weeks), then more padding is preferable to less. Avoiding irritation to soft tissue and skin is critically important to prevent unnecessary delays in definitive cast or surgical treatment.
Splint for hand fractures
Indications
There is a wide variety of hand injuries, such as fractures of the metacarpals or phalanges, that may be suited for initial treatment with splint immobilization. The “volar resting” splint is the workhorse of splints for hand injuries. When extended distally, this splint can be used for injuries to the index, long, ring, and/or small finger, as well as their associated metacarpals. Some soft tissue injuries, including extensor or flexor tendon injuries, along with fingertip injuries, may also be appropriate for temporary splint immobilization applied to the hand. Initial immobilization in a non-circumferential plaster splint may be preferred for hand injuries to facilitate quick application, allow for ongoing swelling after injury or surgery, or enable easy removal for repeat assessment of the soft tissues. The choice between splint or cast should be made on a case-by-case basis, depending on the clinical situation and the uniqueness of the patient's injury. In the case of an injury to a single finger or fingertip, consideration should be given to using a variation of the splint described below to avoid immobilizing as many of the uninjured digits as possible, thus allowing continued motion at these digits and maximizing the patient's function while the splint is in use.
Methods
After any wounds or lacerations have been cleansed and/or closed and dressed, and following any closed manipulation of the fracture or injured joint, cast padding is applied circumferentially around the digits, hand, and wrist/distal forearm to be included in the splint. Some practitioners prefer to place loosely fluffed gauze or padding between the digits in the web spaces (Fig. 1). Careful attention should be given to applying enough padding at the prominences to avoid skin ulceration or pressure injury (Fig. 2). Buddy tape is sometimes needed to help maintain alignment, such as after the reduction of a Salter Harris II fracture of the proximal phalanx. Whenever buddy tape is applied, care should be taken to ensure the tape is loose enough to accommodate swelling and not cause pressure sores.
Figure 1.
Placement of fluffed gauze or padding between digits is preferred by some practitioners.
Figure 2.
Padding being applied prior to plaster for hand-based volar resting splint.
Ideally, the hand is positioned in the intrinsic-plus position with the metacarpophalangeal joints at approximately 90 degrees of flexion to place the collateral ligaments of these joints on stretch and the interphalangeal joints in full extension, which minimizes the risk of soft tissue contracture and later stiffness after splint removal. The hand should be held in intrinsic-plus position during application of both padding and plaster.
Master's Method.
Dr. Joshua Abzug: As with all splints, ensure the extremity is placed in a functional position when applying the splint. For the hand-based volar-resting splint, most commonly, the hand should be positioned in intrinsic-plus position with the MP joints flexed and the IP joints extended.
Applying the splint with the wrist and fingers in a resting position, along with manipulation and molding to an intrinsic plus position after the plaster is applied, can create pressure points and increase the risk of skin irritation, so this should be avoided. The intrinsic-plus position cannot always be maintained while molding a splint to uphold a fracture reduction, which is often the case in metacarpal neck fractures. In these situations, maintaining fracture reduction should take precedence, and the splinting technique should be adjusted accordingly.
Master's Method.
Dr. Suzanne Steinman: Volar resting, ulnar gutter, or radial gutter splints for metacarpal neck fractures should be molded to hold the fracture reduction and need not necessarily be in the intrinsic-plus position.
Once adequately padded, approximately 10 layers of plaster of Paris are measured and cut to the appropriate shape (Fig. 3). If the contralateral extremity is uninjured, the plaster may be held up to the patient's other hand to estimate the desired length from fingertips to mid-forearm. Most often, this can simply be a single rectangular “slab” of plaster that is dipped in room temperature water, laminated together manually, and then applied and molded to the volar surface of the hand and distal forearm while maintaining the hand in an intrinsic-plus position. If desired, a small amount of plaster can be trimmed with scissors at the thenar eminence to avoid restricting thumb motion. While continuing to maintain the desired hand position, the plaster is then wrapped with an additional layer of cast padding and a loosely applied Ace-wrap or other self-adherent elastic tape (Fig. 4). The splint is then held in the intrinsic plus position until the plaster has hardened (Fig. 5). While some injuries may require placing a dressing that precludes direct visualization of the fingertips, when possible, every effort should be made to leave the fingertips exposed so that perfusion of each digit can be individually assessed.
Figure 3.
Measurement of plaster prior to application. A relief cut in the radial side avoids unnecessary immobilization of the thumb when warranted.
Figure 4.
Plaster is applied preferrably with the hand already positioned in intrinsic plus position and then wrapped with additional padding and elastic bandage.
Figure 5.
The splint is molded with the hand in intrinsic plus position.
In addition to the volar-resting splint, closely related ulnar gutter or radial gutter splints may be utilized for hand injuries. These variations involve similar positioning of the hand in an intrinsic-plus position, but with plaster wrapped non-circumferentially around the ulnar or radial border of the hand. Finally, a thumb spica splint is frequently used for injuries isolated to the thumb and can be extended distally to include the thumb interphalangeal (IP) joint or may also be left shorter to keep the IP joint free for motion.
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Pitfalls and complications
Like all types of splints and casts, the volar-resting splint for hand injuries can lead to iatrogenic skin ulceration or wounds that develop from inadequate padding on bony prominences. The ulnar side of the wrist and hand is one such prominence that is vulnerable to pressure injury when the patient rests the hand on a table or other flat surface, and it should be padded appropriately. When using circumferential buddy tape to help maintain fracture reduction, care should be taken to ensure the tape remains loose enough to accommodate swelling and avoid causing pressure sores.
Short arm splint
Indications
A short arm splint is another common tool for managing upper extremity injuries. Practitioners in emergency department settings may also refer to this splint as a “volar-resting” splint, similar to the previously described hand-based “volar-resting” splint; however, the short arm splint is primarily intended for injuries around the wrist. Examples of injuries that may be suitable for a short arm splint include fractures of the distal radius, distal ulna, and/or carpal bones. When planning for definitive non-operative management, strong consideration should be given to the use of a circumferential fiberglass cast for these wrist and/or distal forearm injuries, which can be either uni-valved or bi-valved to accommodate swelling. Nevertheless, certain situations still justify the use of a plaster short arm splint, even temporarily, such as when immobilization and comfort are needed for a patient with an injured wrist while awaiting surgery, or to provide support and protection to the wrist after surgery has been performed.
Methods
After appropriately managing the soft tissue and completing any necessary reduction maneuvers, the volar short arm splint is applied using cast padding and 10 layers of plaster of Paris. Stockinette may be utilized as desired for a protective “cuff” at the proximal and distal ends of the splint (Fig. 6). Cast padding is then applied with at least 3-4 layers throughout the portion of the extremity that will be immobilized. This can be achieved by aiming for slightly more than a 50% overlap of padding as the arm is wrapped distal to proximal. The plaster “slab” for the short arm splint may also be trimmed at the thenar eminence to improve the motion of the thumb if desired (Fig. 7). The wrist is held in the desired position, which is typically the resting posture of 20–30 degrees of extension, while the plaster hardens, and additional padding, along with a loose elastic bandage, is applied (Figure 8, Figure 9). A layer of cast padding rolled neatly over the plaster before applying the elastic bandage allows for easy removal of the elastic bandage (avoiding adherence to the plaster once hardened) and enables re-application in some situations, such as during compartment and neurovascular assessments, wound checks, or other serial examinations.
Figure 6.
Stockinette and padding are applied in a similar manner for the short arm splint.
Figure 7.
Plaster is measured for the short arm splint. A relief adjacent to the thumb may be cut in a similar manner to the hand-based volar resting splint.
Figure 8.
Plaster is applied to the volar side of the forearm and hand and then wrapped with additional padding to allow ease of removal and avoid adherence of the elastic bandage to the plaster.
Figure 9.
The stockinette border is rolled back and then the splint is wrapped with an elastic bandage.
Pitfalls and complications
A short arm splint is specifically designed for injuries around the wrist, not for those involving the digits. However, a common mistake with short arm splints is positioning the padding and plaster material distal to the distal palmar crease, which prevents full flexion and movement of the MCP joints, unnecessarily restricting the digits' full range of motion. Care should be taken to avoid this mistake to prevent iatrogenic hand stiffness when using splints on the hand and wrist, although stiffness is admittedly uncommon in pediatric patients. This principle can also be applied to other similar splints and casts, such as the sugar tong splint or short arm cast. Additionally, one should avoid using a short arm splint that extends too far proximally, as this could impede elbow range of motion due to padding or plaster material.
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Long arm splint
Indications
The long arm splint is used for various injuries, especially those related to the pediatric elbow. This includes the most common pediatric extremity fracture, which is an injury of the supracondylar humerus. Other elbow injuries that may benefit from immobilization in a long arm splint include lateral humeral condyle fractures, medial epicondyle fractures, as well as proximal forearm injuries such as radial neck fractures, olecranon fractures, elbow dislocations, or Monteggia fracture-dislocations. Typically, a long arm splint should be applied following closed manipulative reduction (often done under conscious sedation) of the injury, unless no manipulation is required or if reduction will be performed in the operating room. As mentioned elsewhere, the unique clinical situation should be considered when choosing between a long arm splint and a fiberglass cast. A common scenario that would warrant the use of a plaster splint for temporary immobilization of a patient with a displaced Gartland Type III supracondylar humerus fracture while awaiting surgical treatment. Many other situations may also favor a splint over a circumferential cast when managing pediatric elbow injuries in the clinic or emergency department setting.
Methods
Stockinette is applied to the hand and upper arm to create a cosmetic “cuff” as desired before beginning the application of cast padding (Fig. 10). The elbow is maintained in the desired position, which may be 90 degrees of flexion or relative extension, depending on the clinical situation's demands. For instance, a long arm splint for the previously mentioned patient with a supracondylar humerus fracture can be applied in a comfortable position to prevent unintended pain or neurovascular compromise that could result from forceful manipulation of the elbow in the emergency department. Cast padding is applied continuously using the previously discussed 50% overlap method, ensuring that the digits or MCPs distally remain immobilized. Additional padding is added to the medial, lateral, and posterior aspects of the elbow to provide extra protection at these bony prominences. Caution should be exercised when adding padding at the elbow to avoid creating additional layers in the antecubital fossa, as this could hypothetically impinge upon the anterior neurovascular structures. A posterior slab of approximately 10 layers of plaster is then measured from the contralateral uninjured extremity, cut, dipped in room temperature water, and laminated together to be applied along the posterior elbow. The authors' preferred method of long arm splint application is the A-frame structure, referring to adding a lateral and medial strut of plaster that connects the upper arm portion to the forearm for additional support (Fig. 11). Similar to the lamination of the individual plaster slabs, these lateral and medial struts should be laminated into the posterior slab while the plaster remains wet to form a singular solid structure. Finally, an extra layer of cast padding and an Ace wrap are loosely applied to secure the molded plaster to the arm while keeping the splint clean and protected (Fig. 12). A window can also be cut out of the plaster at the wrist to allow for serial radial pulse checks as needed.
Master's Method.
Dr. Suzanne Steinman: To protect the axilla from skin irritation, have an assistant hold the most proximal part of the upper arm with their thumb and index finger to prevent extending the splint materials, including plaster, too far up.
Figure 10.
Stockinette and padding are applied for the long arm splint.
Figure 11.
Posterior and ulnar-based plaster slab and A-frame side struts are applied for the long arm splint.
Figure 12.
The splint is completed similar to others with additional padding and an elastic bandage.
Pitfalls and complications
The long arm splint can cause skin and soft tissue issues, similar to the other splints described in this chapter. Adequate padding should be carefully applied along the entire length where plaster is to be used. Special attention must be given to padding the medial and lateral epicondyles, as well as the olecranon, while avoiding excessive padding in the antecubital fossa. Too much padding in the anterior elbow could potentially impinge upon the neurovascular structures. Additionally, special care should be taken to pad the upper arm toward the axilla to prevent the hard plaster from irritating the skin in and around the axilla. Furthermore, when adding the A-frame struts of plaster, it is important to ensure that the plaster does not connect to itself circumferentially, as this would create a cast effect at that level and hinder accommodation to swelling as intended.
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Sugar tong splint
Indications
The sugar tong splint is used for various injuries, but it primarily supports fractures of the wrist and forearm. Fractures involving the distal, midshaft, and proximal portions of the radius and ulna are all suitable for immobilization in sugar tong splints. Moreover, forearm and wrist fracture dislocation variants such as perilunate dislocations, Monteggia, and Galeazzi fractures are also appropriate for sugar tong splinting or combination splinting, depending on the specific clinical scenario. Sugar tong splinting offers effective support for forearm injuries, as it immobilizes both the wrist and elbow while preventing forearm rotation. Most sugar tong splints are applied following fracture reduction as temporary support until definitive casting or internal fixation can be performed. When applied correctly and comfortably, sugar tong splints may serve as definitive treatment since they can be retightened 3–5 days after application to accommodate soft tissue swelling. Retightening a splint typically involves removing and reapplying the elastic bandage or wrapping it with fiberglass when appropriate.
Methods
Before applying the splint, the uninjured limb can serve as a template to measure and prepare a suitable slab of splint material. The slab should be wide enough to fully support the dorsal and volar surfaces of the arm (without radial and ulnar overlap to prevent circumferential plaster) and long enough to extend from the volar MP flexion crease, around the elbow (held at 90°), to the dorsal metacarpal heads. It is essential that the plaster slabs are no thicker than 10 layers and are of appropriate length to prevent folding of the edges, which increases both thickness and heat during curing.
The injured extremity is manipulated under conscious sedation (as needed) and is then positioned with the patient lying supine, shoulder abducted 90°, elbow flexed 90°, and forearm held in a neutral position with the assistant holding the fingers. Forearm rotation can be adjusted in pronation or supination to accommodate the rotational positions necessary for maintaining fracture reduction. A stockinette is applied at the hand and upper arm for a cosmetic “cuff” if desired prior to the application of cast padding. In addition to cosmesis, a stockinette maintains the integrity and cleanliness of the splint during the immobilization period; however, the use of the stockinette is optional. Cotton cast padding is then wrapped in 3–4 layers from the hand and around the elbow with slightly more than 50% overlap (Fig. 13). The plaster slab is then dipped in room temperature water, laminated, and excess water is removed. The plaster slab can be trimmed around the thenar eminence, and relaxing cuts are made where the slab spans the elbow to allow for smooth application and to avoid bunching. The plaster is then applied to the arm and overwrapped with one layer of cotton roll (Figure 14, Figure 15). The stockinette is rolled down at both the wrist and elbow to cover the ends of the plaster and ensure adequate padding. An elastic bandage is then applied with minimal tension, and an appropriate mold is applied to the forearm while the plaster hardens (Fig. 16).
Figure 13.
Stockinette and padding being applied in preparation for a sugar tong plaster splint.
Figure 14.
The appropriate length and position of the plaster is measured for the sugar tong splint.
Figure 15.
The plaster slab for a sugar tong splint is dipped in water and laminated together and applied to the forearm. Additional assistants may be required for molding or holding the extremity during application.
Figure 16.
Example sugar tong splint after covering plaster with additional padding and elastic bandage.
Pitfalls and complications
Sugar tong splinting can cause skin and soft tissue issues, much like other splints described in this chapter. The sugar tong splint spans the elbow, which can create an area of bunched or folded plaster at the joint. Small relaxing cuts in the overlapping plaster material at the elbow, or using a pinch, fold, and smooth technique, enable the splint to conform to the shape of the elbow. Care should be taken to ensure proper padding just proximal to the elbow to prevent pressure wounds in patients (especially those who are obtunded or have altered mental status) since the weight of the forearm and splint tends to keep the elbow in a position of relative extension. This may lead to the plaster edge impinging at the posterior aspect of the elbow, just proximal to the olecranon. Additionally, care must be exercised to prevent extending the plaster beyond the volar or dorsal MP joints, as this would restrict full MP joint motion during the period of splint immobilization.
Master's Method.
Dr. Hilton Gottschalk: Avoid allowing the plaster on the volar and dorsal side of the hand to extend beyond the palmar crease, to allow full MP joint motion during the period of immobilization in the splint.
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Coaptation splint
Indications
The coaptation splint is mainly used for injuries involving the pediatric humeral shaft. Coaptation splints can be applied for proximal extra-physeal, midshaft, or distal third humeral shaft fractures to maintain fracture alignment and provide comfort after injury. Most coaptation splints are used as temporary immobilization until the patient can transition to functional bracing, a hanging arm cast, or internal fixation.
Methods
Before applying the splint, the uninjured limb can serve as a template to measure and prepare an appropriate slab of casting material. The slab should consist of 10 layers, be wide enough to fully support the medial and lateral aspects of the upper arm without circumferential overlap, and be long enough to extend from the axilla, around the elbow (held at 90°), to the lateral acromion. Both the axilla and lateral acromion portions of the splint require ample padding to prevent pressure wounds. Small pads made of 4–5 layers of cast padding can be prepared and attached to each end of the plaster before application.
The injured arm is reduced and positioned for ease of application, often with the patient supine, the shoulder abducted 45–90°, and the elbow flexed to 90°. Cosmetic stockinette “cuffs” can be applied at the upper arm in the axilla and around the elbow (Fig. 17). The arm is then wrapped with 3–4 layers of cotton padding from the shoulder to the elbow, and the length of plaster is measured (Fig. 18). The plaster slab is dipped in warm water, laminated, and any excess water is removed. Additional padding can be added to the plaster itself before laying it against the patient to prevent irritation, particularly in the axilla and near the acromioclavicular joint. The plaster is then applied to the arm and overwrapped with one layer of cotton padding to hold it in place (Fig. 19). An elastic bandage is applied from the shoulder to the elbow under minimal tension (Fig. 20). A mold (often valgus to oppose the typical varus deformity encountered in humeral shaft fractures) is then applied to the splint as it hardens. The authors prefer the use of a cuff and collar to assist the patient in supporting the weight of the splinted extremity during the immobilization period, which also helps prevent elbow extension and thus minimizes the risk of the splint falling off the extremity. If a cuff and collar are unavailable, an alternative means of support is a standard sling.
Figure 17.
Application of stockinette in preparation for the coaptation splint.
Figure 18.
The plaster is measured for the coaptation splint.
Figure 19.
The plaster slab is dipped in water, laminated together evenly, and then carefully applied to the extremity.
Figure 20.
Example coaptation splint after covering plaster with additional padding and elastic bandage.
Pitfalls and complications
The coaptation splint is prone to skin and soft tissue issues, similar to other splints described in this chapter. Small relaxing cuts in overlapping plaster at the elbow, or using a pinch, fold, and smooth technique at the elbow, can help the splint conform to the elbow's shape. Care must be taken to ensure adequate padding in the axilla and lateral shoulder, especially in those who are obtunded, to avoid pressure wounds. The proximal end of the splint should terminate at the level of the AC joint; failing to extend the splint proximally often results in the splint ending at the fracture site. As mentioned above, using either a cuff and collar or a standard sling is advisable to minimize the risk of elbow extension causing the splint to slide off the extremity, which may lead to patient discomfort, soft tissue irritation or injury, and possibly loss of reduction in cases of a humeral shaft fracture.
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Test your knowledge
Review questions and answers for the JPOSNA® Primer on Cast and Splint Application can be found through the links below.
Ethics approval and consent
The authors declare that no patient consent was necessary as no images or identifying information are included in the article.
Declaration of competing interests
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments
We thank our consultant splint/cast masters Drs. Joshua Abzug, Hilton Gottschalk, and Suzanne Steinmann.
Footnotes
This article is part of a special issue entitled: JPOSNA® Primer on Cast and Splint Application published in Journal of the Pediatric Orthopaedic Society of North America.
Supplementary video related to this article can be found at https://doi.org/10.1016/j.jposna.2025.100239.
Contributor Information
Jonathan D. Grabau, Email: jonathan.grabau@tsrh.org.
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Supplementary material
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