More Tips for Avoiding Injuries Caused by Casts and Splints

In his Photo Essay, "Hazards of Immobilizing Musculoskeletal Injuries" (CONSULTANT,January 2002, page 72), Dr John Connolly points out problems causedwhen ankle injuries are splinted incorrectly in equinus, resulting in excessiveswelling. To avoid such problems, Dr Connolly recommends immobilization withan "air splint" instead.

However, the photograph that depicts the preferred treatment shows an airsplint applied to bare skin (Figure 1A). The product literature cautions thatpatients should "always wear an absorbent sock or ankle wrap when using the[air splint]," and the application instructions repeat the need for a sock or wrap.I have often seen the maceration and skin excoriation that occur when an airsplint is worn on bare skin.
-Arlene Calunas, PA-C
  Dearborn, Mich

I appreciate your comments regardingthe splinting of ankle injuriesin equinus, and thank you for pointingout that the air splint shouldbe applied over an absorbent sockor ankle dressing and not over bareskin. Our patients do, in fact, wearcotton socks under the air splint; weused this photograph to show thatthe air splint can be applied evenwhen the ankle is swollen.I would also mention that theair splint can be removed periodicallyto permit cleansing of the skin. Itneed not be kept permanently on thesprained ankle, so long as the ankle is not bearing weight.
-John F. Connolly, MD
  Academic Chairman, Department
  of Orthopedics
  Orlando Regional Healthcare
  Orlando, Fla

I applaud Dr John Connolly's Photo Essay on immobilizingmusculoskeletal injuries and concur with all his "clinicalpearls." I have 2 more tips to offer, based on my 20 years ofexperience in orthopedics:

Another cause of thermal injuries similar to the one shownin Figure 2 is the use of plastic pillows in many operatingrooms. These pillows are easily cleaned (hence their popularity),but the combination of the heat of a splint and plasticcan result in an easily missed thermal injury of an anesthetizedpatient. In our institution, splints are never placedon a plastic pillow unless the thermal setting is complete. Instead, we use nonplastic pillows and several layers of padding (eg, several sheetsor blankets).When immobilization is mandatory, uniform compression of all tissues in alimb--from toes to upper thigh or from fingers to upper arm--can prevent manyblisters and areas of excessive swelling. In the patient shown in Figure 1B, openareas of tissue left between the layers of elastic bandage allowed swelling to developboth in these unbandaged layers and distally. Uniform compression must be appliedto all areas of the limb that are subject to swelling.-Don Flinn, PA-C
  Oklahoma City

I appreciate your helpful comments. The point you make regarding plasticpillows is a good one and worth emphasizing to everyone who cares for patientswith casts. The proper application of elastic bandages is also important.Unless even compression is applied, bandages can contribute toswelling distal to the wrap. In addition, it is important to encourage patientsto actively exercise the fingers or toes of a wrapped limb to help mobilize tissuefluid and diminish edema distal to the bandage.
-John F. Connolly, MD