The Procedural Pause

Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, PNP, are teaming up to create a new EMN blog, The Procedural Pause.

The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.

Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

Monday, May 1, 2017

The Nitty-Gritty of Splinting

​One of the most important things you can do as a clinician is to fix a patient’s immediate problem. Mastering certain procedures like splinting allows us to provide immediate solutions to patient problems when they arise. We all want to be masters when it comes to splinting, and here is why.



EP splinting a complex distal radial fracture with the help of countertraction. stockinette, fiberglass splinting material, and ACE wrap are utilized.

One of the more common mistakes NPs, PAs, and even MDs make is avoiding splinting their own patients. This means they spend less time at the bedside. If you personally splint your patient, studies show that your added bedside experience may shorten your patient's length of stay and could produce higher patient satisfaction scores. (Am J Manag Care 2014;20[5]:393.) When you skip doing the splint, it can disrupt care and limit your interaction with the patient, which is disliked by patients. Splinting the patient yourself is a great way to expedite care, provide patient teaching, set the mold of the splint the way you want it, and connect with your patient. This is true in emergency care areas and primary care offices. Patients may expect similar interactions with caregivers in the ED as they do in the primary care environment, and the added time at the bedside increases their satisfaction. (Arch Intern Med 2001;161[11]:1437.)

Understandably, you may not always have time to splint a patient yourself. If this is the case, it's important to rely on a team member well-versed in splinting techniques. If the splinting is done incorrectly, it can decrease your satisfaction scores, increase wait time, and impair treatment. Many technicians and nurses are able to apply appropriate splinting, but you as the clinician must always go back into the room and check the splint for accuracy and neurovascular status. Documentation of neurovascular status and splint check is also a billable procedure and recommended by the American Academy of Emergency Medicine. (Acad Emerg Med 2009;16[5]:423.)

The Basics

When you find yourself saying, "Splinting takes too long," we encourage you to attempt a few before coming to that conclusion. The average splint, when done properly, should only take about five minutes. Before you splint, you must know what type of splint is best for the patient's injury or problem.

Casting is a way to immobilize an area circumferentially, and is often reserved for outpatient orthopedic settings. The goals of ED splinting are to protect the injured area, limit the range of motion, and decrease pain, all while providing support and comfort to the patient. Splinting also allows room for swelling, which will occur during the initial healing process of the injury. Surgery, casting or booting, rehabilitation, and reevaluation all come later and should be followed by appropriate orthopedic referral. (Roberts and Hedges' Clinical Procedures in Emergency medicine. Philadelphia, PA: Elsevier Saunders; 2014.)

Complications of Splinting

Be aware of the potential complications of splinting and how to best approach patient concerns. If a patient returns with a splint that is causing more pain or impairs neurovascular status, simply remove and reapply the splint. Potential splinting issues are listed in the table. Keep in mind, all minor problems can turn to severe problems if left untreated.

MinorModerateSevere

Infection (mild)

Dermatitis

Joint stiffness

Pain

Heat injury

Skin breakdown

Burns

Pressure sores

Muscle atrophy

Chronic pain

 

Ischemia

Gangrene

Neurologic injury

Compartment syndrome

Splinting requires an understanding of the materials used during application. The most common splinting material used in the ED is a fiberglass padding that is moistened, applied, and set to dry. Plaster can also be used, but it's more difficult to work with and can be a lot messier. Plaster and fiberglass splints will be very hard once dried. All splinted extremities should be in a position of function, and a stockinette (or protective covering against the skin) should be used prior to covering with fiberglass. (Am Fam Physician 2009;80[5]:491.) This can help prevent minor, moderate, or even severe complications. The splint should have a padding folded over molded contours to provide a smooth edge, and the final splint should be wrapped with an elastic bandage in a "distal to proximal" direction. (Am Fam Physician 2009;80[5]:491.)


Photo of a thumb spica splint after application of a plaster splint in the emergency department. Notice the ring on the patient's middle finger; all jewelry should be removed before splinting and remain off during the healing process because of associated distal joint swelling. Photo courtesy of Larry Mellick, MD.

Managing Splint Application

Maintaining good anatomic fracture alignment throughout the splinting process is important to prevent the injury from getting worse. Stable fractures should be seen one to two weeks after splint application, although hand and forearm fractures are often reevaluated within the first week of injury. (Am Fam Physician 2009;80[5]:491.) Displaced and unstable fractures should be followed more closely, and if proper reduction cannot be achieved, orthopedic surgery consult or surgery may be indicated. (Hand Clin 2000;16[3]:323.)

Why Your Splints Matter

Patients are more likely to follow up with appropriate referrals when they leave your department with a splint. The type of bracing or splinting applied influenced the "no-show" rates for orthopedic follow-up, according to a 2014 study in The Journal of Bone and Joint Surgery. (2014;96[19]:1650.) Patients with splints that were easier to remove or were poorly applied were less likely to follow up with the orthopedic clinic. The better you apply the splint and the more time you spend with your patient, the more likely they are to receive proper follow-up care. The study found that assault victims had the highest no-show rate, and by anatomic region, patients with spine or back complaints had the highest no-show rate. "The easier it was to remove the splint, the worse the follow-up," the authors wrote, noting that patients who were morbidly obese and who currently used tobacco were also less likely to follow up. These factors may influence your disposition and management decisions for these patients.

Pearls

-Splinting should be completed after all radiographs and reductions.

-All jewelry should be removed, especially rings, as soon as possible after injury.

-Keep all patients in the ED until the splint is fully hardened.

-Teach patients the signs of ischemia, i.e., coloring, pain, numbness.

-Complete neurovascular checks before and after splinting.

-Splint in position of function (unless otherwise indicated).

-Do the splint yourself, whenever possible.

-Consult an orthopedic surgeon for all unstable or displaced fractures.

Patients will have less pain, fewer complications, and better outcomes when splints are applied appropriately and cautiously.​