What are the indications for splinting vs casting in orthopedic injuries?

Indications for Splinting vs. Casting in Orthopedic Injuries

Rigid immobilization with casts is preferred for displaced fractures, while splints are the optimal choice for acute injuries with anticipated swelling.

General Principles

Splints

• Definition: Noncircumferential immobilizers that accommodate swelling
• Key advantages:
  • Allow for swelling during acute inflammatory phase
  • Easily removed for wound/skin inspection
  • Faster and easier to apply
  • Lower risk of compartment syndrome

Casts

• Definition: Circumferential immobilizers
• Key advantages:
  • Superior immobilization
  • Better maintenance of reduction
  • Better compliance (cannot be removed by patient)

Specific Indications

When to Use Splints

1. Acute injuries with anticipated swelling 1, 2

   • Acute fractures in first 48-72 hours
   • Acute sprains
   • Soft tissue injuries with significant edema

2. Initial stabilization before definitive treatment 1

   • Reduced, displaced, or unstable fractures awaiting orthopedic intervention
   • Temporary immobilization before surgical fixation

3. High-risk patients 3

   • Obtunded or comatose multitrauma patients
   • Very young patients
   • Developmentally delayed patients
   • Patients with spasticity

4. Minimally displaced fractures 4

   • Stable fractures not requiring precise reduction maintenance

When to Use Casts

1. Displaced distal radius fractures 4

   • Fractures with postreduction radial shortening >3 mm
   • Dorsal tilt >10°
   • Intra-articular displacement

2. Definitive treatment of stable fractures 4, 5

   • After initial swelling has subsided (typically 3-5 days)
   • When precise reduction maintenance is required

3. Rigid immobilization for displaced fractures 4

   • The American Academy of Orthopaedic Surgeons suggests rigid immobilization in preference to removable splints for displaced distal radius fractures (moderate strength recommendation) 4

4. Active Charcot neuro-osteoarthropathy 4

   • Total contact cast (TCC) is first choice
   • Knee-high walker made non-removable as second choice

Special Considerations

Ankle Sprains

• Functional support preferred over immobilization 4
• Ankle brace shows greatest effects compared with other types of functional support 4
• Duration: 4-6 weeks of functional support is preferred 4
• Short immobilization period (<10 days) with plaster cast or rigid support can decrease pain and edema in acute lateral ligament injuries 4

Distal Radius Fractures

• Removable splints: Option for minimally displaced distal radius fractures (weak recommendation) 4
• Rigid immobilization: Preferred for displaced distal radius fractures (moderate recommendation) 4
• Surgical fixation: Indicated for fractures with postreduction radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement 4

Pediatric Considerations

• Higher tolerance for immobilization compared to adults
• Faster healing rates allow for shorter immobilization periods
• Growth plate concerns: Proper alignment more critical

Duration of Immobilization

• Short-term use preferred to minimize complications 1
• Excessive immobilization risks:
  • Chronic pain
  • Joint stiffness
  • Muscle atrophy
  • Complex regional pain syndrome

Complications to Monitor

1. Compartment syndrome: More common with circumferential casts
2. Thermal injuries: During cast application
3. Pressure sores: Especially over bony prominences
4. Skin infection and dermatitis
5. Joint stiffness: Due to prolonged immobilization

Follow-up Recommendations

• Radiographic follow-up: At 3 weeks and at cessation of immobilization 5
• Early range of motion: Once stable fixation or healing allows
• Progressive weight bearing: As tolerated after immobilization period
• Directed home exercise program: After immobilization period 5

Common Pitfalls to Avoid

1. Applying casts too tightly in acute injury phase
2. Inadequate padding over bony prominences
3. Failing to educate patients about warning signs of complications
4. Prolonged immobilization leading to stiffness and muscle atrophy
5. Insufficient immobilization of adjacent joints when needed for stability

Remember that proper patient education regarding swelling, signs of vascular compromise, and recommendations for follow-up is crucial after cast or splint application 2.