When are removable wrist splints appropriate for wrist fractures versus sugar tong splints?

Removable Wrist Splints vs. Sugar Tong Splints for Wrist Fractures

Removable wrist splints are appropriate for stable, non-displaced or minimally displaced wrist fractures, while sugar tong splints should be used for unstable fractures with significant displacement or angulation requiring more rigid immobilization. 1

Indications for Removable Wrist Splints

• Stable fractures: Non-displaced or minimally displaced fractures that are unlikely to lose position
• Buckle fractures: Particularly beneficial in pediatric populations
• Later stages of healing: Can be used after initial immobilization with more rigid methods
• When patient compliance with exercises is important: Allows for periodic removal for hygiene and exercises

Benefits of Removable Splints

• Better physical functioning during recovery period 2
• Easier hygiene maintenance (bathing) 2
• Lower complication rates compared to circumferential casts 3
• Allows for progressive range of motion exercises after initial healing period 1
• Accommodates swelling in acute injuries 4

Indications for Sugar Tong Splints

• Unstable fractures: Fractures with significant displacement or angulation
• Post-reduction immobilization: After closed reduction of displaced fractures
• When maximum restriction of forearm rotation is needed: Superior at limiting pronation compared to other splint types 5
• Initial stabilization: Before definitive surgical management for complex fractures
• Fractures at risk of displacement: When maintaining reduction is critical

Benefits of Sugar Tong Splints

• Provides more rigid immobilization than removable splints
• Superior restriction of forearm rotation, particularly pronation 5
• Better maintains reduction in displaced fractures compared to volar-dorsal splinting 6
• Allows for swelling accommodation while providing more support than removable splints

Clinical Decision Algorithm

1. Assess fracture stability and displacement:

   • Stable, non-displaced or minimally displaced → Consider removable splint
   • Unstable, displaced, or requiring reduction → Consider sugar tong splint

2. Consider patient factors:

   • Age: Pediatric buckle fractures respond well to removable splints 2
   • Compliance: Patients unable to follow precautions need more rigid immobilization
   • Swelling: Both accommodate swelling, but sugar tong provides more support

3. Evaluate need for rotation restriction:

   • If forearm rotation restriction is critical → Sugar tong splint provides superior control 5
   • If wrist immobilization alone is sufficient → Removable splint may be adequate

4. Timeline considerations:

   • Initial acute phase (0-2 weeks) → More rigid immobilization if unstable
   • Later healing phase → Consider transitioning to removable splint for rehabilitation

Complications and Monitoring

• Loss of reduction: Higher risk with removable splints in unstable fractures
• Skin complications: Lower with removable splints compared to circumferential casts 3
• Functional outcomes: Better early function with removable splints 2
• Monitoring: All patients require radiographic follow-up at 10-14 days to evaluate position 1

Important Caveats

• No immobilization method completely prevents motion; patient compliance with activity restrictions remains essential
• Excessive immobilization can lead to joint stiffness, muscle atrophy, and complex regional pain syndrome 4
• The trend toward functional bracing and early mobilization must be balanced against the risk of loss of reduction
• Consider transitioning from sugar tong splint to removable splint after initial healing phase (2-3 weeks) to facilitate rehabilitation while maintaining protection

Remember that while removable splints offer better functional outcomes and fewer complications, they may not provide sufficient immobilization for unstable fractures where maintaining reduction is critical.