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
- List some of the potential complications of splinting.
- Review key points to include in patient discharge instructions.
- Name some of the pharmacological adjuncts to aid in recovery.
| SplintER 103: The Bottom Line |
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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
| Dermatological Complication | Neurovascular Complication |
| Pressure ulcers | Compartment syndrome |
| Plaster burns | Vascular compromise |
| Splint dermatitis | Nerve palsies |
| Skin infection | Complex regional pain syndrome (CRPS) |
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.
A lower extremity fasciotomy performed in order to manage compartment syndrome (Credit: Wikimedia)
Complication: Compartment Syndrome
The “classic” 5 P’s of arterial insufficiency and compartment syndrome include:2–5
- Pain
- Pallor
- Pulselessness
- Paresthesias
- 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 injury2,4 and pain with passive stretching2,4,5 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.
Cellulitis with skin breakdown after placement of a left upper extremity splint. (Credit: Wikimedia)
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
| At-Home Treatments to Reduce Pain & Swelling 7 | |
| Elevation | Elevating the extremity is particularly important in the first 24-72 hours, when swelling is at its peak and can limit venous return. |
| Exercise | Mobilizing and ranging the unaffected extremities are important to prevent atrophy and joint stiffness. |
| Ice | For the first 24 hours, apply ice 2-4 times for a maximum 15-20 minutes each time. Ice should be in a plastic bag. Do not get the splint wet! |
| Medications | Consider NSAIDs and acetaminophen |
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.
| Expert Peer Review: Anna Waterbrook, MD, FACEP |
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Just like any other procedure that we perform in Emergency Medicine, it is important to understand the potential complications that may occur with splinting. Anytime a patient presents with increased pain, swelling, color change, or any other concerns, it important to do a thorough assessment for potential complications including a complete neurovascular exam on the affected extremity. While splints can protect joints and allow healing after acute injuries, EM providers must also ensure close outpatient follow-up. This helps to ensure that the splint is being used appropriately and not kept on longer than is indicated for a particular type of injury. A good general rule of thumb is to arrange follow-up with either an Orthopedics or Sports Medicine in approximately 7 days after placement of the splint. It is also important to educate patients on splint care and ED return precautions for potential |
References
- Ramirez MR, Souza K. Procedures Consult: ClinicalKey. (Thomsen T, ed.). Elsevier; 2007.
- Olson S, Glasgow R. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg. 2005;13(7):436-444. [PubMed]
- Shadgan B, Menon M, O’Brien P, Reid W. Diagnostic techniques in acute compartment syndrome of the leg. J Orthop Trauma. 2008;22(8):581-587. [PubMed]
- Mubarak S, Owen C, Hargens A, Garetto L, Akeson W. Acute compartment syndromes: diagnosis and treatment with the aid of the wick catheter. J Bone Joint Surg Am. 1978;60(8):1091-1095. [PubMed]
- Elliott K, Johnstone A. Diagnosing acute compartment syndrome. J Bone Joint Surg Br. 2003;85(5):625-632. [PubMed]
- Delasobera B, Place R, Howell J, Davis J. Serious infectious complications related to extremity cast/splint placement in children. J Emerg Med. 2011;41(1):47-50. [PubMed]
- Care of Casts and Splints – OrthoInfo – AAOS. Care of Casts and Splints. https://orthoinfo.aaos.org/en/recovery/care-of-casts-and-splints/. Published 2017. Accessed March 7, 2018.
- Collins N. Is ice right? Does cryotherapy improve outcome for acute soft tissue injury? Emerg Med J. 2008;25(2):65-68. [PubMed]
- Warren T, McCarty E, Richardson A, Michener T, Spindler K. Intra-articular knee temperature changes: ice versus cryotherapy device. Am J Sports Med. 2004;32(2):441-445. [PubMed]
- Pountos I, Georgouli T, Calori G, Giannoudis P. Do nonsteroidal anti-inflammatory drugs affect bone healing? A critical analysis. ScientificWorldJournal. 2012;2012:606404. [PubMed]
- Boursinos L, Karachalios T, Poultsides L, Malizos K. Do steroids, conventional non-steroidal anti-inflammatory drugs and selective Cox-2 inhibitors adversely affect fracture healing? J Musculoskelet Neuronal Interact. 2009;9(1):44-52. [PubMed]
- Malay S, Chung K. Testing the validity of preventing chronic regional pain syndrome with vitamin C after distal radius fracture. [Corrected]. J Hand Surg Am. 2014;39(11):2251-2257. [PubMed]
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