Inappropriate Splint Application for Pediatric Fractures in the Emergency Department and Urgent Care Environment

Saturday, October 11, 2014: 9:37 AM
Marina Ballroom Salon G (San Diego Marriott Marquis )
Joshua M. Abzug, MD, Aaron Johnson, MD, MS and Brandon S. Schwartz, MPH, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD

Purpose Fractures are common in the pediatric population, with emergency room physician or mid-level practitioners performing most initial evaluations.  These injuries are typically splinted.  However, correct splinting techniques are necessary to safely immobilize the injured limb, and prevent potential complications.  Iatrogenic injuries from inappropriate splint application are a potential public health and legal problem that can lead to fracture malalignment, as well as severe skin and soft-tissue complications.  The purpose of this study was to evaluate all patients who presented in a splint to a pediatric orthopaedic practice, in order to assess both splint adequacy, and iatrogenic complications from improper application.

Methods Consenting patients aged 0 to 18 years who presented to the pediatric orthopaedic clinic for evaluation with a splint in place were prospectively enrolled.  A total of 225 patients who had a mean age of 8 years (range, 0 to 18 years) were prospectively enrolled.  A standardized questionnaire was administered to either the patient or their accompanying parent to obtain information regarding demographics, type of splint, type of facility where the splint was applied, type of practitioner that placed the splint, and the amount of time from splint application until orthopaedic evaluation.  Frontal and lateral photographs were taken of each splint prior to splint removal, and the extremity was examined for any soft tissue complications.  Two blinded members of the pediatric orthopaedic team evaluated the splint for functional position, appropriate length, and presence of elastic bandage on the skin.  Splints were not removed in 31 patients who had undergone fracture reduction.

Results Splints were improperly placed in 93% (210 out of  225) of cases, with improper joint immobilization in 56% (125/225) of cases.   The splint was an inappropriate length in 50% (113/225) of cases, and the elastic bandage was applied directly to the skin in 78% (176/225) of cases.  Skin and soft-tissue complications were observed in 41% (79/194) of patients who had their splint removed.  The most common iatrogenic splint-related complication was excessive edema, seen in 30% (58/194) of patients.  Pressure points were observed on the skin in 19% (36/194) of patients, whereas pressure points overlying bony prominences were seen in 2% (6/194) of cases.  Direct injury to the skin and soft tissue was seen in 6% (11/194) of patients.

Conclusion Many practitioners in pediatric emergency departments and urgent care centers incorrectly apply splints, potentially causing injury.  Factors contributing to splint-related iatrogenic injuries include an inadequate amount of under-splint padding leading to excessive pressure, application of elastic bandage directly to the skin, inadequate fracture immobilization, and inappropriate splint length.  Complications from poor splint placement include swelling, skin breakdown, and poor healing due to inappropriate fracture immobilization.  Healthcare workers who treat pediatric fractures may benefit from more extensive education regarding proper splinting techniques.