Ankle Splinting

Splints are primarily used to stabilize injuries to bones until the patient can be evaluated by a consultant, such as an orthopedic surgeon,1 as well as to achieve immobilization for primary healing or in the preoperative period.

All patients with injuries that are splinted should be referred for evaluation by a consultant in a timely fashion (usually within 2-3 days). I

n general, ankle splints are applied to minimize movement and provide support and comfort by stabilizing an injury at that joint.

Indications

A posterior ankle splint is primarily used for the following injuries:

• High-grade ligamentous sprain of the ankle
• Metatarsal or tarsal fracture ²
• Distal tibia or fibula fracture

Contraindications

No contraindications to ankle splinting are absolute. The following conditions demand immediate evaluation or intervention by a consultant (eg, an orthopedic surgeon), in that treatment by splinting alone is inadequate:

• Complicated fracture
• Open fractures
• Injuries with associated neurovascular compromise

Technical Considerations

Anatomy

The ankle joint is a hinged synovial joint with primarily up-and-down movement (plantar flexion and dorsiflexion). However, when the ranges of motion (ROMs) of the ankle and subtalar joints (talocalcaneal and talocalcaneonavicular) are taken together, the complex functions as a universal joint (see the image below).

The combined movement in the dorsiflexion and plantarflexion directions is greater than 100°; bone-on-bone abutment beyond this range protects the anterior and posterior ankle capsular ligaments from injury. The anterior and posterior ankle capsular ligaments are relatively thin compared with the medial and lateral ankle ligaments.

For more information about the relevant anatomy, see Ankle Joint Anatomy.

Periprocedural Care

Equipment

The equipment involved in ankle splinting includes the following (see the image below):

• Stockinette
• Padding (eg, Webril)
• Ready-made plaster or fiberglass splinting material or plaster splinting material (eg, plaster of Paris), 10-12 sheets (15-20 sheets if the patient is allowed to bear partial weight), 4-6 in. wide
• Bandage or wrap (eg, Bias bandage or ACE wrap), 3-4 in. wide
• Clean, room-temperature water in a basin
• Trauma shears or a pair of medical scissors without pointed ends
• Disposable (Chux) pads and bed sheet
• Tape (if using Bias bandage) or bandage clips (if using non-Velcro ACE wrap)

Equipment for splint. Image courtesy of Kenneth R. Chuang, MD.

Patient Preparation

Anesthesia

Ankle splinting is usually tolerated without the use of anesthesia. However, if significant manipulation or reduction of the injury is required during the splinting process, one of the following anesthetic techniques may be used3 :

• Hematoma block or nerve block
• Procedural sedation with appropriate monitoring and administration by an experienced practitioner ⁴ (for more information, see Procedural Sedation)
• Oral or intravenous analgesics (eg, nonsteroidal anti-inflammatory drugs NSAIDS, opioids)

With the administration of any analgesic agent or the initiation of a formal sedation protocol, care should be taken to avoid oversedation. A complete neurovascular examination should be performed before and after the splint has been applied.

Positioning

Place the patient comfortably in the prone position, with the affected limb in 90° of knee flexion (see the video below). Cover the patient with a sheet to avoid splatter from the wet plaster.
Position the patient prone, with knee flexed to 90 degrees. Cover the patient appropriately. Video courtesy of Kenneth R. Chuang, MD.

Technique

Splinting of Ankle

Explain the procedure to the patient, including risks and benefits, and obtain written informed consent.

Position the patient as described previously (see Periprocedural Care).

Completely expose the injured limb. Remove clothing on the affected extremity, or warn the patient that it may have to be removed with scissors after the splint is placed. Jewelry should also be removed. In particular, toe rings can cause constriction and ischemia of the toes with delayed swelling of the soft tissues. If a ring resists removal, try using soap as a lubricant, or consider a ring cutter.

Apply the stockinette (see the video below). The stockinette should extend from the toes to the proximal calf. When measuring the stockinette, cut longer than the expected splint length. The stockinette should extend 2-3 cm beyond the overlying padding on either end. In turn, the padding should extend 2-3 cm beyond the overlying wet plaster on either end. Together, the stockinette and padding will be pulled over the edges of the wet plaster to create smooth edges.

Wrap the padding (eg, Webril) over the stockinette (see the video below). Begin distally and wrap proximally, overlapping each layer by half the width. The padding should extend 2-3 cm beyond the overlying plaster on both ends. Smooth out creases and avoid wrinkles, unwrapping and rewrapping as necessary. Narrower padding should be used for the foot and ankle to compensate for the angulation of the joint and to prevent wrinkling.

Measure the plaster (see the brief video presentation below) with a roll plaster that is 3-4 inches wide. Using dry plaster, measure the first layer of plaster from the proximal calf to the metatarsal heads. Allow for roughly 5 mm of extra length on either end, as plaster shrinks when wet.

With the desired length pinched off, fold over the plaster. Begin unrolling the plaster and folding until the splint is 10-12 layers thick, for the average-sized adult. In children, who may be especially active and are frequently noncompliant with instructions, additional layers provide added stability.

If prefabricated fiberglass is used, the stockinette and padding steps can usually be skipped. In such cases, follow the manufacturer’s recommendations.

Submerge the plaster in clean, room-temperature water (see the video below). Allow all the bubbles to escape. This starts the lamination process of the plaster and allows the layers to bond together. Squeeze out the excess water. With the fingers, pull out any remaining water. Then, lay the plaster on a flat surface or dry towel, and smooth out wrinkles and folds. This allows for further bonding of the plaster layers.

Position the affected leg with the knee flexed and the ankle in 90° of dorsiflexion. Apply the wet plaster over the padding posteriorly from the high calf to the level of the metatarsals (see the video below). Fold the excess plaster at the edges circumferentially, and smooth the overlapped plaster at the level of the ankle. The underlying stockinette and padding should then be folded over the plaster on both ends, creating smooth edges.

Apply the bandage wrap over the wet plaster (see the video below). Start distally and wrap proximally. Avoid wrapping too tightly. Be sure to completely cover the heel.

While the plaster is still wet, mold the splint into the desired shape (see the video below). While placing pressure on the sole of the foot with one palm to maintain 90° of dorsiflexion, use the other hand to mold the rest of the splint. The splint must maintain as close to 90° of dorsiflexion as possible.

The foot and ankle should remain immobile until the splint is dry. Advise the patient that he or she may feel some warmth released from the plaster as it dries. However, if the heat becomes too intense, unwrap the splint and remove the plaster immediately. Thermal burns can occur.

After the splint has dried, check neurovascular function. The patient should not lose sensation in the toes. Peripheral vascular assessment can be accomplished by checking capillary refill. Ask the patient to wiggle the toes to allow assessment of motor function. Wipe away any plaster that may have dropped onto the patient’s skin.

Modifications of the classic Quigley approach to reduction and splinting of ankle fractures have been described that can readily be performed by a single practitioner.5, 6

Postprocedural Care

Postsplinting radiographs of minimally displaced fractures are not routinely needed and simply delay treatment time while increasing costs.7, 8

Deliver appropriate aftercare instructions, and instruct the patient to rest, elevate, and ice the injured limb. Instruct the patient to remove the splint and return immediately, or go to an emergency department, if he or she experiences weakness or numbness, color change (pale or bluish), increasing pressure or pain, or spreading redness or streaking.

The splint must be kept clean and dry.

Patients can be tempted to use sticks, pens, or hangers to scratch an itch inside the splint. Advise the patient that sticking objects into the splint can wrinkle the padding and lead to pressure sores or cause a break in the skin and lead to an unattended infection.

The splint should be rechecked in 48 hours. Also, arrange for follow-up with a consultant, usually in 2-3 days.

If the patient received any sedation or opioid agents, advise against driving or alcohol consumption.

Complications

Despite best-care practices, complications may arise from the splinting process.

Thermal burns

Thermal burns may occur.9 Patients can expect some warmth as the plaster dries. However, if they report intense heat or any pain, remove the plaster immediately. As more layers of plaster are used, more heat is produced.10

It is important to use clean, room-temperature water; water that is dirty or too warm accelerates the drying time and increases the heat produced. Do not wrap towels or blankets around the splint to shorten drying time; this also produces excess heat.

Pressure sores

To avoid pressure sores, provide extra padding to bony prominences. When wrapping the cotton padding, avoid creases. When creases occur, smooth them out or unwrap and rewrap as needed. When molding the wet plaster, use broad-based pressure. In other words, do not use the fingertips; rather, use the entire palmar surface of the hands and fingers.

Contact dermatitis

This reaction may occur from any of the equipment used in the splinting process. (See Contact Dermatitis.)

Ischemia and neurovascular compromise

Increased pressure from swelling may give rise to ischemia and neurovascular compromise. If moderate to significant swelling is anticipated, cut the cotton padding lengthwise along the lateral side of the calf before applying the wet plaster to the medial side; this allows for expansion of the padding. Also, if using tape to secure the outermost bandage wrap, do not tape circumferentially.

Decreased range of motion from immobilization

Advise the patient that depending on the extent and nature of the initial injury, he or she can often expect long-term pain, arthritis, stiffness, and decreased range of motion, despite best care practices. The aftercare of such injuries often requires physical therapy.

References

1. Howes DS, Kaufman JJ. Plaster splints: techniques and indications. Am Fam Physician. 1984 Sep. 30 (3):215-21. Medline.
2. Hatch RL, Alsobrook JA, Clugston JR. Diagnosis and management of metatarsal fractures. Am Fam Physician. 2007 Sep 15. 76 (6):817-26. Medline.
3. White BJ, Walsh M, Egol KA, Tejwani NC. Intra-articular block compared with conscious sedation for closed reduction of ankle fracture-dislocations. A prospective randomized trial. J Bone Joint Surg Am. 2008 Apr. 90 (4):731-4. Medline.
4. Sacchetti A, Senula G, Strickland J, Dubin R. Procedural sedation in the community emergency department: initial results of the ProSCED registry. Acad Emerg Med. 2007 Jan. 14 (1):41-6. Medline.
5. Skelley NW, Ricci WM. A single-person reduction and splinting technique for ankle injuries. J Orthop Trauma. 2015 Apr. 29 (4):e172-7. Medline.
6. Alton TB, Harnden E, Hagen J, Firoozabadi R. Single provider reduction and splinting of displaced ankle fractures: a modification of Quigley’s classic technique. J Orthop Trauma. 2015 Apr. 29 (4):e166-71. Medline.
7. Chaudhry S, DelSole EM, Egol KA. Post-splinting radiographs of minimally displaced fractures: good medicine or medicolegal protection?. J Bone Joint Surg Am. 2012 Sep 5. 94 (17):e128. Medline.
8. Schuld JC, Volker ML, Anderson SA, Zwank MD. Postsplinting x-rays of nondisplaced hand, wrist, ankle, and foot fractures are unnecessary. Am J Emerg Med. 2016 Aug. 34 (8):1625-6. Medline.
9. Kaplan SS. Burns following application of plaster splint dressings. Report of two cases. J Bone Joint Surg Am. 1981 Apr. 63 (4):670-2. Medline.
10. Halanski MA, Halanski AD, Oza A, Vanderby R, Munoz A, Noonan KJ. Thermal injury with contemporary cast-application techniques and methods to circumvent morbidity. J Bone Joint Surg Am. 2007 Nov. 89 (11):2369-77. Medline.
11. Hutchinson MJ, Hutchinson MR. Factors contributing to the temperature beneath plaster or fiberglass cast material. J Orthop Surg Res. 2008 Feb 25. 3:10. Medline. Full Text.