Article, Orthopedics

Upper extremity quad splint: indications and technique

a b s t r a c t

Patients experiencing high-energy trauma evaluated at level I trauma centers often present with multiple injuries and varying levels of hemodynamic instability. The polytrauma patient requires immediate assessment and stabilization of their orthopedic injuries once the primary trauma survey is complete, and oftentimes, operative fixation of injuries is delayed while patients are resuscitated by general trauma services. The authors describe the application of the upper extremity “quad” splint which includes components of a sugar tong, intrinsic plus, thumb spica, and dorsal extension blocking splint and its indication for patients with multiple upper extremity fractures distal to the humerus. This splint is efficiently applied using minimal material while simultaneously allowing for the stabilizing aspects of 4 splints commonly applied in the emergency setting.

(C) 2015

Introduction

Sugar tong splint

The sugar tong splint is an upper extremity splint used in injuries where excessive pronation and supination may be detrimental to the injury pattern [1]. Specifically, the application of a sugar tong splint has shown to reduce pronation and supination up to 30% [1]. Common indications include acute Distal radius fractures, distal ulnar fractures, both bone forearm fractures, and distal radioulnar joint injuries including those of the triangular fibrocartilage complex [2,3]. To apply, appro- priately sized splint material (commonly plaster to facilitate molding) is measured from the metacarpophalangeal (MCP) joint dorsally Thumb spica splint“>around the elbow to the midpalmar surface volarly. Next, padding is applied with special attention to the bony prominences about the elbow. The splint material is applied, and a 3-point mold is performed to correct any dorsal or volar angulation in the Fracture pattern. The sugar tong splint is used in both pediatric and adult populations and has been found to be up to 96% effecting in maintaining reduction of distal forearm fractures [4]. This splint does not block motion at the MCP joints.

Intrinsic plus splint

The intrinsic plus splint is most commonly used for fractures of the metacarpal bones or proximal phalanges with greater than 90% success in maintenance of reduction for nondisplaced fractures [5]. Depending

? The authors have no financial disclosures.

* Corresponding author. Department of Orthopaedics, Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 02903. Tel.: +1 401 444 4030; fax: +1 401

444 6182.

on the affected ray, a radial (second or third ray) or ulnar (fourth or fifth ray) gutter may be used to immobilize the affected portion of the hand. To create an intrinsic plus splint, padding is applied to the appro- priate digits, and a plaster gutter is placed either ulnarly (from the mid forearm proximally to the distal phalanx of the fourth and fifth digits distally) or radially (from the mid forearm proximally to the distal phalanx of the second and third digits distally) with the hand in the Edinburgh position [6]. Specifically, the wrist is placed at 0? to 30? of extension, the MCP joints at 70? to 90? of flexion, and the interphalangeal (IP) joints in full extension. The use of this position prevents contractures of the hand by placing tension on the collateral ligaments and has also been found to be useful in maintaining the reduction of metacarpal fractures [5,6].

Thumb spica splint

Thumb spica splinting is often used for injuries of the carpus or thumb where immobilization of the thumb is necessary [7]. These include fractures of the scaphoid, first metacarpal (Bennett and Rolando fractures), ulnar collateral ligament injury of the thumb (Skier’s thumb), de Quervain tendinitis, or lunate injuries [7]. To create a thumb spica splint, padding is placed first followed by the application of a plaster strut radially from the forearm proximally to the IP joint distally, circumferentially around the thumb. For scaphoid fractures in particu- lar, limited evidence suggests that a long arm spica extending more proximally on the forearm leads to faster rates of union for proximal scaphoid fractures compared to a short arm spica (9.5% vs 12.7%), although there is less evidence for spica length in the acute setting [8]. Similar to the Edinburgh position, the wrist is placed in 20? to 30? of extension, and the thumb is placed in a neutral position, inline with the radius and index finger.

http://dx.doi.org/10.1016/j.ajem.2015.09.027

0735-6757/(C) 2015

case presentation“>Thumb or finger extension blocking splint

Extension blocking splints are used in the management of dorsal subluxations, dislocations, fracture subluxations, and fracture- dislocations of the proximal and distal interphalangeal (PIP and DIP) joints of the fingers and the IP joint of the thumb [9-11]. Extension blocking splints have also been used to manage volar plate injuries which are usually associated with hyperextension [9,12]. The purpose of an extension blocking splint is to maintain a congruent finger or thumb IP joint reduction while allowing for flexion to help reduce joint stiffness [9,12].

The extension blocking splint is created from a padded material such as an aluminum foam splint or from plaster or fiberglass that is padded with webril [13]. The material should be contoured on the finger to maintain IP joint flexion at 15? to 30? at the desired joint [9]. The splint length shoulder be extended as far as possible proximally and distally without restricting motion of the uninjured adjacent joints [14]. The MCP joint may need to be incorporated into the splint if it needs to be immobilized to maintain reduction of the injured joint [9]. Correct liga- mentous stress at each joint incorporated into the splint allows full motion of the uninjured joints [14]. Serial radiographic imaging must be performed to confirm that joint congruence is maintained [9].

Case presentation

The authors encountered a 60-year-old man involved in a motor- cycle accident who sustained multiple upper extremity injuries including a left radial styloid fracture, left ulnar styloid fracture, left first metacarpal fracture, and left thumb IP joint fracture- dislocation (Fig. 1A-C) as well as a pneumothorax and right fifth to seventh rib fractures. The patient underwent closed reduction of his thumb IP joint fracture-dislocation, followed by closed reduction of his first metacarpal fracture and radial styloid fractures. To main- tain the fracture and joint alignment that result from closed reduc- tions, the patient was placed in a sugar tong splint that extended to the tips of the fingers both volar and dorsal. A traditional 3 point “C” mold was applied to hold the radial styloid reduced while the meta- carpals were flexed to 70? with the PIP and DIP joints of the finger joints were extended to reduce the first metacarpal similar to the intrinsic plus splint. A thumb spica extension was added to the radial aspect of the splint with the thumb metacarpal extended and the thumb IP joint flexed to act as both a thumb spica splint and dorsal extension blocking splint to prevent dislocation of the thumb IP (Fig. 1D-F). Writ- ten consent was obtained from the patient for use of his imaging and presentation in this report.

Fig. 1. A, Anteroposterior view of the wrist and hand showing thump IP Joint dislocation (white arrow), first metacarpal fracture (red arrow), and radial styloid fracture (blue arrow). B, Oblique. C, Lateral. D-F, Postreduction films, anteroposterior, oblique, and lateral after applying the quad splint.

Fig. 2. A, Layout of the material needed for the quad splint. B, Rolled out plaster for splinting, notice the 1-in tear on the spica component (white arrow). C, Patient wrapped circumferentially in webril cast padding.

Methods and materials

Materials

Two health care providers who understand the forces that are responsible for fracture deformities as well as the principles of sugar tong, intrinsic plus, thumb spica, and dorsal extension blocking splints are required to successfully apply the upper extremity quad splint. Material necessary to create the upper extremity quad splint includes three 4-in plaster rolls, two 4-in webril cast padding, three 2-in webril cast padding, four 4-in ace wraps, and basin filled with water at Room temperature (Fig. 2A). First, the 4-in plaster rolls are rolled out to create a slab of 8 layers of plaster. The length of this slab is determined by mea- suring the distance from the volar aspect of the tip of the fingers in an intrinsic plus to the posterior elbow and then to the dorsal aspect of the tip of the fingers in an intrinsic plus position. This slab is used for the intrinsic plus and sugar tong components of the splint. The second slab is created by rolling out another 8-layer slab of orthopedic plaster. The length of this slab is determined by measuring the distance from the tip of the thumb to the middle of the forearm. A 1-in slit in the slab is created on both sides at the level of the thumb carpometacarpal (CMC) joint (Fig. 2B).

Technique

Padding

The 2 rolls of 4-in webril cast padding and 3 rolls of 2-in webril cast padding are used to create a smooth 4 layers of webril padding that will protect the skin from the plaster. The posterior elbow should be padded with an additional 4 layers of 4-in webril cast padding. The webril padding will incorporate the arm from mid upper arm to the tips of all the fingers (Fig. 2C).

Intrinsic plus and sugar tong component

Once the webril padding is applied, the next step is to apply the longer slab of plaster that extends from the volar aspect of the tip of the fingers, wraps around the posterior elbow, and ends at the dorsal aspect of the tip of the fingers in an intrinsic plus position (Fig. 3A). Before applying the plaster to the arm, the plaster is soaked in the basin of water and wrung out thoroughly to facilitate the rate at which the plaster sets. Care must be taken not to use warm or hot water as this can burn the patient. This is then overwrapped with two or three 4-in ace wraps until the plaster is covered. Next, 2 health care providers must independently hold the intrinsic plus mold and relevant sugar tong mold until the plaster firmly sets which could take up to

Fig. 3. A, The sugar tong component is applied, not the distal coverage of the fingertips volar and dorsal on the hand. B, The “C” mold being applied after ACE bandage application on the distal radius, with an intrinsic plus mold being applied on the MCP and IP joints of the fingers.

Fig. 4. A, Application of the spice component of the quad splint. B, Molding of the spice and dorsal extension blocking component, note the clinician’s thumb (black arrow) serving to both hyperextend the thumb MCP and act as a post to mold the extension blocking aspect of the spica component around.

10 minutes (Fig. 3B). Of note, the position and orientation of the mold- ing maneuver applied to the sugar tong component will vary signifi- cantly depending the fracture pattern of the distal radius or the forearm.

Thumb spica and dorsal extension blocking components

Next, the operators applying the splint must turn their attention to the thumb spica and dorsal extension blocking components. The shorter slab is applied to the radial border of the forearm and thumb such that the slits that were created line up with the CMC joint (Fig. 4A). This allows the plaster to smoothly conform to the shape of the thumb. Before applying the plaster to the arm, the plaster is soaked in the basin of water and wrung out as much as possible. Although 1 operator holds the plaster in place, the second operator secures it with a 4-in ace wrap. Subsequently, 1 operator simultaneously holds the thumb spica and dorsal extension blocking splint component of the splint until the plaster firmly sets (Fig. 4B; Fig. 5).

Discussion

Level I trauma centers frequently encounter multiply injured patients. A large study by The German Trauma registry group of 24 885 patients found that 58.6% had extremity fractures with an

average of 2.1 extremity fractures per case [15]. Of the extremity frac- tures reported 19.4% were distal to the elbow and involved the radius, ulna, hand, or wrist [15]. The upper extremity quad splint allows for efficient and effective stabilization of the multiple-injured upper extremity. It is ideal for patients who have multiple fractures distal to the elbow requiring immobilization before operative fixation. The sugar tong component allows for stabilization of any type of radius or ulna fracture, whereas the intrinsic plus component allows for reduc- tion of metacarpal fractures. It could also be modified to act as either a flexion or extension blocking splint in the event of finger PIP or DIP joint fracture-dislocations. Adding a spica component immobilizes the thumb. Distal to the thumb IP joint, the distal phalanx of the thumb may be splinted in either flexion to prevent dorsal subluxation or exten- sion to prevent volar subluxation. When applying this splint, it is crucial that 2 clinicians be available to simultaneously mold the intrinsic plus and sugar tong component of the splint.

It is also important to appropriately size the plaster so that it is noncircumferential on the patient. Many high-energy trauma patients get admitted to the hospital and require fluid resuscitation which when combined with local edema and fracture hematoma can lead to increased swelling and potential compartment syndrome. The authors recommend that these patients receive strict ice and elevation in a

Fig. 5. Completed quad splint on a patient.

foam pillow to decrease swelling in the immediate postinjury period. If the injuries are determined to be nonoperative in nature, the splint can be exchanged for a cast with similar molds upon discharge.

Conclusion

The upper extremity quad splint is a quick and simple way to immo- bilize a patient with multiple Upper extremity fractures while using the minimal amount of material necessary. By combining the Reduction methods used by the sugar tong, intrinsic plus, thumb spica, and dorsal extension blocking splint into 2 separate plaster components, the splint remains pliable enough to apply a mold that will hold a reduction while being low profile enough to allow for swelling in the postinjury period. Efforts to apply each of the components of the splints as separate enti- ties would lead to a large bulky splint which could not be appropriately molded and may cause iatrogenic burns to the patient given the amount of plaster it would require.

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