Volar splinting of the upper extremity can be employed to immobilize hard and soft tissue injuries in addition to painful atraumatic conditions. Hard tissue skeletal injuries that may benefit from volar splinting include distal radius fractures, Colles fractures, and metacarpal or carpal fractures, excluding fractures of the first metacarpal and trapezium. Basic splinting guidelines of skeletal pathology require immobilization of the joint above and below the lesion. Exceptions to this rule include metaphyseal fractures, such as Colles or Smith fractures; metaphyseal fractures behave like injuries within the joint. For more proximal shaft fractures, the principle of volar splinting expands into sugar-tong or Muenster-type splinting, extending above the elbow. Other conditions amenable to volar splinting include acute gouty arthritis, carpal tunnel syndrome, and radial nerve palsy.
Splinting is an adjunct to elevation and ice. Splinting improves patient comfort, facilitates recovery, and protects from further injury. Splints may be used for comfort as a temporizing measure for wrist and hand dislocations or fracture subluxations while awaiting definitive care.Splints differ from casts in that the noncircumferential bandage allows for some degree of soft tissue swelling without undue constriction. Splints can be easily removed for wound care. Splinting may be the definitive treatment or temporary treatment before casting. Although plaster is considered the traditional splinting material, padded fiberglass or preformed plastic splints are commonly encountered in clinical practice.
A fundamental principle of fracture immobilization with splinting is that a splint must extend from at least one joint above to one below the fracture. For example, when splinting a metacarpal fracture, the splint must extend from the mid-forearm above the wrist to beyond the metacarpophalangeal joints. The careful examination and dressing of wounds should precede splint application. The neurovascular status of the affected extremity must be assessed and documented before splint application.
Volar splinting may be indicated to immobilize hard tissue injuries such as distal radial or ulnar fractures and certain metacarpal or carpal fractures, excluding fractures of the first metacarpal or trapezium.Soft tissue injuries that may benefit from volar splinting include extensive skin lacerations and structural injuries to tendons or ligaments.A volar splint may provide symptomatic relief from inflamed, painful, but uninjured joints in patients with acute gout, active rheumatoid arthritis, or other painful inflammatory conditions.
There are no specific contraindications to volar splinting. However, some clinical situations may warrant special consideration before placing a volar splint. Burns, open or contaminated wounds, or unstable fracture patterns must be carefully evaluated to determine if the benefits of a volar splint will outweigh the risks. If the affected limb is tense and edematous, monitoring for compartment syndrome and rapidly extending soft tissue inflammation or infection will be required, potentially making splinting less desirable.
The following equipment is required when fashioning and placing a volar splint:
Volar splinting can be performed by appropriately trained personnel, including physicians, advanced practice providers, nurses, athletic trainers, or technicians. A single operator can perform the procedure.
The clinical situation dictates the length of a volar splint. For a Colles or wrist fracture, the splint must extend from the distal palmar crease to 4 to 5 cm distal to the antecubital fossa. For metacarpal fractures, including Boxer fractures, the splint should extend beyond the metacarpophalangeal joint. For phalangeal fractures, the splint should extend beyond the tips of the digits.
In preparing equipment to place a volar splint, the operator must keep in mind that while plaster is more pliable than fiberglass, it does take longer to set. The hardening of the splint material occurs via an exothermic reaction. The amount of heat released during this reaction is proportional to the number of layers of casting material and the water temperature. When utilizing plaster for volar splinting, the layers of plaster should be limited to 12; 8 to 10 layers will usually suffice. Cool water allows time to mold the splint and reduces the risk of burn.
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