Overview
Definition:
Splinting is a common method for immobilizing pediatric fractures to promote healing, reduce pain, and prevent further injury
Volar and sugar-tong splints are frequently employed techniques, differing in their application and the joints they encompass, dictated by the fracture location and stability requirements.
Epidemiology:
Pediatric fractures are common, with an incidence of approximately 1-2 per 1000 children per year
The distal radius and ulna, supracondylar humerus, and forearm are among the most frequent sites
These splints are essential for managing a wide range of acute pediatric orthopedic injuries.
Clinical Significance:
Appropriate splinting is critical for achieving optimal functional outcomes in pediatric fractures
Improper splinting can lead to malunion, nonunion, compartment syndrome, neurovascular compromise, and long-term disability
Understanding the nuances of volar versus sugar-tong splints is paramount for safe and effective management, directly impacting patient care and reducing medico-legal risks.
Splint Types Comparison
Volar Splint:
A volar splint is applied to the palmar aspect of the limb
It typically extends from the metacarpophalangeal joints to the proximal forearm
Commonly used for stable distal radius and forearm fractures, it allows for flexion at the elbow and wrist
Its application is simpler and quicker than a sugar-tong splint.
Sugar Tong Splint:
A sugar-tong splint is a U-shaped splint applied to the dorsal and volar aspects of the limb, encircling the elbow or wrist
It provides more comprehensive immobilization, especially for unstable fractures or those involving the elbow joint
It extends from the metacarpophalangeal joints, up around the elbow, and down to the forearm or wrist, effectively preventing pronation/supination and providing good elbow stability.
Indications Volar:
Distal radius fractures (e.g., buckle, greenstick)
Stable forearm fractures
Post-reduction immobilization for certain wrist injuries
Generally preferred for less unstable injuries where elbow immobilization is not required.
Indications Sugar Tong:
Unstable distal radius and ulna fractures
Monteggia and Galeazzi fractures
Elbow dislocations
Supracondylar humerus fractures requiring elbow immobilization
Fractures necessitating prevention of pronation/supination.
Advantages Volar:
Easier and quicker application
Less bulky
Allows for wrist and finger motion if desired
Generally less risk of elbow stiffness if distal injuries.
Advantages Sugar Tong:
Superior immobilization, especially for unstable fractures and elbow injuries
Better control of rotational forces
Reduced risk of displacement for significant forearm injuries
Provides a more robust construct for displaced fractures requiring reduction.
Application Techniques
Materials Needed:
Plaster of Paris (POP) or fiberglass rolls of appropriate width
Stockinette
Webril (cotton padding)
Warm water for plaster
Elastic bandage or ACE wrap for securing the splint
Gloves.
Volar Splint Application:
Apply stockinette from fingertips to above the elbow
Apply Webril padding generously, ensuring no wrinkles, particularly over bony prominences
Immerse POP/fiberglass in warm water, squeeze excess water
Apply three to four layers of plaster/fiberglass around the limb from MCP joints to the proximal forearm, ensuring it lies flat on the palmar aspect
Mold the splint to contour the limb
Secure with an elastic bandage, ensuring adequate but not excessive tightness to avoid neurovascular compromise.
Sugar Tong Splint Application:
Apply stockinette and Webril from fingertips to above the elbow
Place a long plaster/fiberglass strip on the dorsal aspect extending from the MCP joints, up and over the olecranon, and down to the proximal forearm
Place a similar strip on the volar aspect from the MCP joints up and over the distal humerus and down to the proximal forearm
Ensure the two strips are positioned to form a U-shape around the elbow/forearm
Mold the splint to conform to the limb, especially around the olecranon and distal humerus
Secure the two limbs of the U-shape together on the dorsal and volar sides with additional plaster/fiberglass or elastic bandages
Ensure the elbow is typically immobilized at 90 degrees of flexion for a knee-style sugar-tong, or at a position of comfort for forearm fractures.
Common Errors Application:
Insufficient padding leading to pressure sores
Uneven padding causing pressure points
Over-tightening bandages causing neurovascular compromise
Inadequate molding leading to poor immobilization
Incorrect length of splint causing it to slip or become ineffective
Failure to immobilize the correct joints for the specific fracture.
Post Application Care And Monitoring
Neurovascular Assessment:
Crucial post-application assessment includes checking capillary refill in digits, sensation in peripheral nerves (median, ulnar, radial), motor function of digits, and skin temperature and color
Regular reassessment is mandatory, especially in the first 24-48 hours.
Pain Management:
Analgesics (e.g., paracetamol, NSAIDs) are typically sufficient
Opioids may be required for severe pain in the initial phase
Elevation of the limb helps reduce swelling and pain.
Swelling And Edema Management:
Elevation of the affected limb above the level of the heart is paramount
Regular checks for signs of compartment syndrome, including disproportionate pain, pallor, paresthesia, paralysis, and pulselessness (the five P's), are vital.
Follow Up Schedule:
Initial follow-up is usually within 24-72 hours to check for neurovascular status, splint integrity, and pain control
Subsequent follow-up is determined by the fracture type, stability, and patient's age, typically involving X-rays to monitor alignment and callus formation
Splint removal or change is based on clinical and radiographic evidence of healing.
Complications Of Splinting
Pressure Sores:
Caused by inadequate padding, wrinkles in Webril, or direct pressure from the splint
Often occurs over bony prominences like the olecranon or wrist.
Neurovascular Impairment:
Resulting from excessive tightness of the splint or bandage, leading to reduced blood flow or nerve compression
Can manifest as pallor, coolness, paresthesia, or motor deficits.
Compartment Syndrome:
A surgical emergency characterized by increased pressure within a fascial compartment, compromising circulation and tissue viability
Presents with severe pain out of proportion to injury, paresthesia, and decreased sensation.
Stiffness And Contractures:
Prolonged immobilization, especially of joints, can lead to stiffness and loss of range of motion
This is particularly a concern with wrist or elbow immobilization.
Skin Irritation And Rashes:
Allergic reactions to plaster or latex, or maceration due to trapped moisture, can cause skin issues
Proper skin hygiene and timely splint changes are important.
Key Points
Exam Focus:
Understand the indications and contraindications for volar vs
sugar-tong splints based on fracture type and stability
Recognize potential complications and their management, especially compartment syndrome
Correct application technique is crucial for DNB/NEET SS exams.
Clinical Pearls:
Always assess neurovascular status before and after splinting, and document findings meticulously
Educate parents about warning signs of complications
Use fiberglass for a lighter, more water-resistant splint when appropriate
Pediatric bones heal rapidly, so vigilant monitoring is key.
Common Mistakes:
Over-reliance on one splint type without considering fracture characteristics
Inadequate padding or molding
Insufficient neurovascular monitoring
Failure to recognize early signs of compartment syndrome
Delaying definitive management for unstable fractures.