In this SplintER Series, we review splinting fundamentals, introduce advanced concepts, and highlight ways to implement these into your next shift. In SplintER 102, we reviewed the materials used in splinting and a general approach to applying a splint. Today’s post puts the spotlight on some of the potential complications of splinting, discharge care plans, and pharmacological adjuncts to aid in recovery.

Learning Objectives

1. List some of the potential complications of splinting.
2. Review key points to include in patient discharge instructions.
3. Name some of the pharmacological adjuncts to aid in recovery.

Splinting Complications

A number of complications can develop after placing a splint, some of which are limb-threatening. This highlights the importance of clear return instructions. We review 2 of these in detail below, but other potential complications to be familiar with include:¹

Most of these complications occur when a splint is placed without adequate room for post-traumatic swelling. However, immobilization alone can result in complications such as permanent joint stiffness and chronic pain. It is also important to recall that the hardening of splint material is an exothermic process. This can result in a serious burn.¹

If a patient returns to the ED with any concern, remove the splint and perform thorough neurovascular and skin exams. Subtle findings (e.g. mild paresthesias) may be your only clue to a more serious underlying pathology.

Complication: Compartment Syndrome

The “classic” 5 P’s of arterial insufficiency and compartment syndrome include:^2–5

1. Pain
2. Pallor
3. Pulselessness
4. Paresthesias
5. Paralysis

Although these findings are insensitive and fairly unreliable for identifying compartment syndrome, you should ask patients about each of these symptoms.^2–5 Pain out of proportion to the injury^2,4 and pain with passive stretching^2,4,5 can be early signs of vascular compromise and compartment syndrome, but are also not reliable findings. This underscores the importance of removing a splint whenever a patient returns to the ED with complaints of pain around or under the splint. If you suspect compartment syndrome, consult an orthopedic or general surgeon early in the patient’s course.

Complication: Skin Infections

A simple skin cellulitis can occur after splinting, but more severe infections have been documented, including necrotizing fasciitis and toxic shock.⁶ A high index of suspicion is warranted to prevent such complications, and it is imperative that you remove any cast or splint material when a patient presents with signs of a localized or systemic infection. Obvious signs may include increasing pain, warmth, or erythema. However, subtle signs of discomfort may signal the beginning of a cellulitis or a pressure ulcer.

Special Populations

Emergency physicians should be particularly careful when evaluating patients with increased risk for neurovascular compromise. Examples include patients with diabetes, peripheral arterial disease, or immunosuppression. Patients with these co-morbidities are at an increased risk for splint complications and may have a subtle or atypical presentation.

Provide the Patient with Clear Indications to Return to the ED

There are a variety of reasons why a patient should return to the ED after splint placement. These reasons should be made clear to the patient prior to discharge. Key indications include:⁷

• For the injured extremity
  • Increasing, intractable pain that does not improve with a short trial of elevation and ice
  • Burning or stinging pain
  • New numbness or tingling
  • Skin findings of any new warmth, redness, discoloration, breakdown, or discharge (clear or purulent) from under or near the splinted area
  • Increasing paralysis
  • Malodorous splint
• Fevers or chills
• Nausea or vomiting
• Persistent lightheadedness

Patient Education: Strategies for Reducing Pain and Swelling

Half of the RICE mnemonic of rest, ice, compress, and elevate has recently come under fire — specifically rest and ice. Rest is a misnomer and many experts are advocating for early mobilization of unaffected joints. Also despite icing being one of the oldest adages of sports medicine, there is surprisingly very little evidence supporting it changing clinical outcomes.⁸ Evidence suggests that there is a reflex vasodilation that occurs after icing that can subsequently worsen edema and inflammation.⁹

Medication (Controversial): NSAIDs

NSAIDs and acetaminophen are common first-line agents for pain after an extremity injury. However, NSAIDs remain controversial. There is conflicting evidence in animal trials and basic science studies related to the potential impact of NSAID use on bone healing.¹⁰ In general, however, a short period is thought to be safe. Although clinical trials are inconclusive, some experts recommend the use of modern selective COX-2 inhibitors to allow for more prostaglandin production.¹¹ A randomized trial is currently underway, and may shed more light on this issue.

Medication (Controversial): Vitamin C

Vitamin C is also another controversial treatment. The American Academy of Orthopedic Surgeons (AAOS) recommends Vitamin C to prevent complex regional pain syndrome (CRPS) after distal radius fractures. This recommendation is based on several randomized controlled trials, the relatively low cost of vitamin C, and its low side effect risk.¹² The recommended oral dose is 500 mg for 50 days.

Outpatient Follow-Up

A number of factors will influence the appropriate timing of ED follow-up. These include:

• Type and severity of fracture or sprain
• Mechanism of injury
• Co-morbidities
• Initial neurovascular exam

Sometimes the initial splint is the definitive treatment. Other times, it is a temporizing measure until the patient can be seen in an orthopedic or sports medicine clinic. Approximately 7 days is a reasonable follow-up period for most injuries. It is long enough to allow for bone healing and reduced swelling, and short enough to minimize the risk for muscle atrophy and joint stiffness from prolonged immobilization.