Lower Extremity Stirrup “Sugar-Tong” Splint. This splint is indicated for additional ankle stabilization. It runs in a U-shape (not unlike a forearm sugar-tong splint) from just below the knee around the calcaneus, and it must be wide enough to encase the ankle but not so wide that the two sides overlap when molded. It is very important to add extra padding around both malleoli and beneath the calcaneus to reduce the likelihood of pressure sores. Crutches are essential to avoid weight-bearing in patients old enough to use them. Some pediatric orthopedists advise avoiding this type of splint in the smaller, noncompliant, active child.
Complications
Although splinting has many advantages over casting in the acute-care setting, several potential complications may develop. Although rare, thermal burns to the underlying skin may occur if excessively warm or hot water is used on plaster or fiberglass due to the exothermic reaction during the hardening process. Therefore, the use of room-temperature water is always recommended. Despite the noncircumferential nature of a splint, it is still possible to develop significant swelling following splint application, which can lead to neurovascular compromise, compartment syndrome, infection, or pressure ulcers.7 The patient and caregiver should be advised to return to the ED immediately for evaluation if serious signs and symptoms such as pain, numbness, tingling, dusky color of skin, or poor capillary refill develop.
Case 1 Conclusion
The EP in this case elected to obtain plain X-rays of the patient’s left forearm, including the wrist and elbow. The results demonstrated a disruption of the cortical integrity of the distal radius, consistent with a buckle fracture. The angulation was estimated at merely 10˚. The bones of the wrist and elbow appeared normal. The EP concluded that a consult with orthopedics was not required urgently, and immobilized the patient’s arm using a fiberglass sugar-tong splint, keeping her elbow at 90˚, the forearm in a neutral position, and hand slightly dorsiflexed. A nurse assisted in keeping the child still to ensure the splint was shaped around the arm and hardened in this position. The child was provided with a sling, and supportive-care measures, including analgesia with nonsteroidal anti-inflammatory drugs as needed, ice, rest, and the importance of keeping the splint dry, were reviewed with her parents. The EP also stressed the importance of surveying for any loss of sensation or perfusion to the patient’s hand and fingers, and recommended follow up with orthopedics 1 week from discharge.
Case 2 Conclusion
Multiple views of the patient’s ankle were obtained on X-ray and showed no apparent fracture or dislocation. Additional films of the opposite ankle were obtained for comparison, but both appeared quite similar except for mild soft-tissue swelling of the affected side. Since point tenderness was reproducible over the distal fibular physis, the EP elected to place a short-leg posterior splint, maintaining good anatomic position with extra padding around the malleoli. The parents were instructed on proper elevation, ice to reduce inflammation, and the use of pain medication if needed.
One week after discharge, the treating EP received a letter from the child’s orthopedist, informing him that at the follow-up appointment, a repeat ankle film revealed periosteal changes and a type I Salter-Harris distal fibula fracture. Immobilization for an additional 3 weeks and supportive care was indicated.
Dr Del Re is an instructor of pediatrics and an intermediate care pediatrician, Rady Children’s Hospital, San Diego, California. Dr Clingenpeel is a fellowship director, pediatric emergency medicine, and associate professor of pediatrics, Eastern Virginia Medical School, Norfolk.