2. Why splint/cast?
Acute musculoskeletal injuries common in
primary care (especially in military!)
• Continuity
• Reduce orthopedic referral rate (experienced FP
in orthopedics only 16-25% fracture referral rate
excluding hip/face fractures)
• Studies concluding that most FP managed
fractures heal well and most complications can
be avoided with appropriate selection of which
fractures to manage
• RVU density! Orthopedics pays
3. RVU “density”
Example: Healthy 5 year old female comes in after
FOOSH injury with nondisplaced torus fx of distal
radius on x-ray, normal exam except for
tenderness over distal radius
• On initial visit: 99213 visit (0.67 RVUs) with CPT
29125, application of short arm splint (0.59 RVUs) with
total RVUs on initial visit: 1.26 RVUs
• THEN patient f/u done 3-4 days later after swelling has
decreased and 99213 coded (0.67 RVUs) and CPT
25500, closed treatment of radial shaft fracture without
manipulation (1.69 RVUs) with total of : 2.36 RVUs
• Follow up in 3 weeks with removal of cast, 99213 (0.67
RVUs)
• Total of 4.29 RVUs for treatment and orthopedic referral
avoided
4. Pre and Post Splint Checks
F – Function
A – Arterial Pulse
C – Capillary Refill
T – Temperature (Skin)
S - Sensation
5. Thumb Spica – 3”
Indications for thumb spica
• Navicular / Scaphoid Fractures
• Thumb Dislocations/Proximal thumb fractures
• Ulnar Collateral Ligament Sprains
• Tendonitis
Key Points
• 3 fingerbreadths from antecubital fossa
• Tip of thumb spiral
• 2 figure of 8 wraps with wrap
6. When do I need an orthopedist?
Indications for orthopedic referral
• Scaphoid Fractures: any displacement or
angulation, non-union or avascular necrosis
develops after conservative treatment, or
scapholunate dissociation (>3mm distance)
• Proximal Thumb Fractures: any intraarticular
fracture, comminution, any fracture where
adequate closed reduction cannot be maintained
• Ulnar Collateral Ligament Injuries: avulsion
fracture with more than 2 mm displacement,
fractures with more than 20% articular surface
involvement, complete rupture of UCL (tested at 30
degrees flexion of MCP after radiographs are
obtained)
7. Volar Splint – 3” or 4”
Indications
• Wrist Sprains
• Carpal Tunnel Syndrome/Night Splints
• Lacerations
• Simple/nondisplaced radius or ulna fractures
Key Points
• palmar crease to 3 fingerbreadths from
antecubital fossa
• 1” fold @ angle of palmar crease
8. Teardrop Splint – 4”-5”
Indications
• 2nd & 3rd Metacarpal Fractures
• Flexor Tendon Repairs or Extensor Tendon
• Crushing Injuries
• Lacerations
Key Points
• Tip of 3rd finger to 3 fingerbreadths from
antecubital fossa
• Cut 2 ½” hole for thumb & tape edges
• Flex metacarpals 45° (70-90° if distal fracture)
and wrist 20-30° extension
9. Boxer Splint – 4”-5”
Indications
• 5th Metacarpal Fractures
• 4th Metacarpal Fractures
Key Points
• Tip of 5th finger to 3 fingerbreadths from
antecubital fossa
• Pad b/t 4th and 5th fingers
• Ulnar gutter
• Mold to position, MCP at 70-90° flexion to
maintain positioning in distal fractures
10. Reverse Sugar Tong – 3”- 4”
Indications
• Colles’ Fracture
• Forearm Fractures
Key Points
• Measure from behind the elbow up both sides
of the arm to the tip of the fingers
• Cut at mid-point leaving 1/2” and slide over
the hand
• Overlap the ends at the elbow, wrap from the
hand down
11. Figure 8 Splint
Indications
• Mid-shaft clavicular fractures (Proximal/distal
clavicular fractures often treated with
sling/swath +/- operative treatment)
Key Points
• Measure so “position of attention” attained
• Advantage of leaving elbow and hand free BUT
requires assistance to put on
• Counsel patient bony deformity possible
• Orthopedic referral rarely indicated for mid-
clavicular fractures
12. Posterior Ankle – 4” - 5”
Indications
• Distal Tib / Fib Fractures
• Ankle Sprains
• Achilles Tendon Tears
• Metatarsal Fractures
Key Points
• 2” below popliteal to 2” beyond toes
• Fold 1” under toes
• Wrap from the toes up
• Figure 8 with tape to hold in position
13. Reinforced Posterior Leg Splint
Butterfly
Indications
• Severe Ankle Sprain
• Metatarsal Fractures
• Hair Line Fractures
• Distal Tibia / Fibula Fractures
• Non Displaced Ankle Fracture
Key Points
• 2” below popliteal to 2” beyond the toes
• At base of heel snip padding
• Cut substrate 3-4” either side of mark
• Fold in Butterfly fashion
• Reinforced side away from patient
14. When do I need an orthopedist?
Referral decisions:
• Avoid managing an orthopedic injury beyond
your training/skill unless proper guidance is
available
• Be able to identify patients with complicated
fractures
Need for surgical intervention to maintain reduction
High risk of non-union
Inability to maintain closed reduction
Significant intraarticular involvement
• Strongly consider referring patients who are
likely to be non-compliant
15. Avoiding pitfalls
Worst outcomes in fracture management:
• Fractures requiring reduction
• Intraarticular fractures
• Scaphoid fractures
Reference resources:
• Up To Date ®
• Fracture Management For Primary Care, by
Eiff, Hatch, and Calmbach
• Rockwood and Green’s
