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Clinical Procedures > Musculoskeletal Procedures
Splinting, Sugar-Tong Forearm
Article Last Updated: Oct 30, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 14  
Author: Kenneth R Chuang, MD, Attending Physician, Emergency Department, Long Beach Memorial Medical Center and Miller Children's Hospital
Coauthor(s):
Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Editors: Erik D Schraga, MD, Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
sugar-tong, sugar-tong forearm, forearm splint, sugar-tong splint, wrist fracture, distal radius fracture, splinting, broken arm, Colles fracture, Smith fracture, Barton fracture, chauffeur fracture, Galeazzi fracture, forearm fracture
Splints are generally applied to decrease movement to provide support and comfort through stabilization of an injury. In the emergency department, splints are primarily used to stabilize nonemergent injuries to bones until the patient can be evaluated by a consultant such as an orthopedic surgeon, at which time definitive casting can be performed.1 Splints can also serve as initial immobilization in the presurgical period or can immobilize an injury for primary healing.1 All patients with injuries that are splinted should be referred for evaluation by a consultant in a timely fashion (depending on the indication, this can vary between 2-14 days).
A sugar-tong forearm splint is primarily used for the following fractures:
- Although no true contraindications exist to the placement of a splint, certain injuries require immediate evaluation or intervention by a consultant (eg, orthopedic surgeon, hand surgeon, plastic surgeon) and, as such, may not necessitate splinting. Such injuries include the following:
- Complicated fractures
- Open fractures
- Injuries with associated neurovascular compromise
Splinting is usually tolerated without the use of anesthesia. However, if significant manipulation or reduction of the injury is required during the splinting process, anesthetic techniques may be used. Acceptable techniques include the following:
- Administration of a hematoma block or nerve block
- Procedural sedation with appropriate monitoring and administration by an experienced physician (For more information, see Procedural Sedation.)
- Administration of oral or intravenous pain medications, including nonsteroidal anti-inflammatory drugs (NSAIDS) or opioid analgesic agents
With the administration of any analgesic agent or the initiation of a formal sedation protocol, care should be taken to avoid oversedation. A complete neurovascular examination should be performed before and after the splint has been applied.
- Stockinette
- Padding (eg, Webril)
- Bandage or wrap (eg, Bias bandage, Ace wrap)
- Clean, room-temperature water in a basin
- Trauma shears or a pair of medical scissors without pointed ends
- Chux pads and bed sheet
- Tape or bandage clips
- Plaster or prefabricated fiberglass splint material
Equipment for splint. Image courtesy of Kenneth R. Chuang, MD.
- Place the patient in a comfortable position (eg, seated or reclined).
- Cover the patient with a sheet to avoid splatter from the wet plaster.
Cover patient appropriately. Video courtesy of Kenneth R. Chuang, MD. - Completely expose the injured limb. Jewelry should also be removed. In particular, rings can cause constriction and ischemia of the fingers with delayed swelling of the soft tissues. If unable to remove a ring, try using soap as a lubricant or consider a ring cutter.
Remove jewelry and rings to avoid ischemia from swelling. Video courtesy of Kenneth R. Chuang, MD.
- Explain the procedure to the patient, including risks and benefits. Obtain informed consent.
- Position the patient as described above. See Positioning.
- Apply stockinette. The stockinette should extend from the mid humerus to beyond the fingertips. Cut an adequate hole for the thumb, being careful to avoid constriction of the thumb. When measuring the stockinette, allow for extra length. The stockinette should extend 2-3 cm beyond the overlying padding on either end. In turn, the padding should extend 2-3 cm beyond the overlying wet plaster on either end. Together, the stockinette and padding should be pulled over the edges of the wet plaster to create smooth edges.
Stockinette application for sugar-tong forearm splint. Video courtesy of Kenneth R. Chuang, MD. - Wrap the padding (eg, Webril) over the stockinette. Begin distal and proceed proximally. Overlap each layer by half the width. Also allow for extra length. The padding should extend 2-3 cm beyond the overlying plaster on both ends. Smooth out creases, unwrapping and rewrapping as necessary. Apply extra padding to the bony prominences and epicondyles of the elbow, to the bony prominences of the wrist, to the metacarpophalangeal joints, and to the base of the thumb.
Cotton padding application for sugar-tong forearm splint. Video courtesy of Kenneth R. Chuang, MD. - Measure the plaster. For the average-sized adult, plaster for the sugar-tong forearm splint should be 8-10 layers thick. Use plaster that is 3-4 inches wide. With a roll of dry plaster, measure the first layer of plaster into the shape of a sugar-tong around the elbow. Start from the level of the metacarpal heads along the palmar side of the hand and extend proximally toward the elbow, around the elbow, and back distally to the metacarpal heads on the dorsum of the hand. Allow for roughly 5 mm of extra length on either end, as plaster shrinks when wet. Then, with the desired length pinched off, fold over the plaster and begin unrolling the plaster and folding until the splint is 8-10 layers thick.
Measuring dry plaster for sugar-tong forearm splint. Video courtesy of Kenneth R. Chuang, MD. - If using prefabricated fiberglass, the stockinette and padding steps can usually be skipped. In this case, follow the manufacturer recommendations.
- Submerge the plaster in clean, room-temperature water. Allow all the bubbles to escape. This starts the lamination process of the plaster and allows the layers to bond together. Squeeze out the excess water. With the fingers, pull out any remaining water. Then, lay the plaster on a flat surface or dry towel and smooth out wrinkles and folds. This allows for further bonding of the plaster layers.
Wetting the plaster for sugar-tong forearm splint. Video courtesy of Kenneth R. Chuang, MD. - Position the affected arm with the palm facing toward the body and the elbow flexed. Apply the wet plaster over the padding. Apply the wet plaster in the same manner that the dry plaster was measured. Start from the level of the metacarpal heads along the palmar side of the hand and extend proximally toward the elbow, around the elbow, and back distally to the metacarpal heads on the dorsum of the hand. At this point, someone other than the person applying the cast needs to hold the 2 ends of the wet plaster as the rest of the cast is applied. The patient may be able to do this with his or her other hand; if not, an assistant must be used. Fold outward excess plaster on the ends. The underlying stockinette and padding should then be folded outward, creating a smooth edge.
Applying wet plaster for sugar-tong forearm splint. Video courtesy of Kenneth R. Chuang, MD. - Apply the bandage wrap over the wet plaster. Start distally and wrap proximally. Avoid wrapping too tightly. Cut an adequate hole for the thumb.
Applying bandage wrap for sugar-tong forearm splint. Video courtesy of Kenneth R. Chuang, MD. - While the plaster is still wet, mold the splint into the desired shape. The elbow should be flexed to 90 degrees. The wrist and hand should be in a neutral position. Extend the wrist to 20 degrees, abduct the thumb, and flex the metacarpophalangeal joints to 70 degrees. The hand, wrist, forearm, and elbow should remain immobile until the splint is dry. Advise the patient that he or she may feel some warmth released from the plaster as it dries. However, if the heat becomes too intense, unwrap the splint and remove the plaster immediately. Thermal burns can occur.2
Molding the sugar-tong forearm splint. Video courtesy of Kenneth R. Chuang, MD. - Check for neurovascular function and capillary refill after the splint has dried. Wipe away any plaster that may have dropped onto the patient's skin.
Test neurovascular function and capillary refill. Video courtesy of Kenneth R. Chuang, MD. - Deliver appropriate aftercare instructions.
- Instruct the patient to rest, elevate, and ice the injured limb.
- Instruct the patient to remove the splint and return immediately, or go to an emergency department, if he or she experiences weakness or numbness, color change (pale or bluish), increasing pressure or pain, or spreading redness or streaking.
- Keep the splint clean and dry.
- Do not stick any items into the splint. Patients can be tempted to use sticks, pens, or hangers to scratch an itch. Advise the patient that sticking objects into the splint can wrinkle the padding and lead to pressure sores or cause a break in the skin and lead to an unattended infection.
- The splint should be rechecked in 48 hours. Also, arrange for follow-up with a consultant, usually in 2-3 days.
- If the patient received any sedation or opioids, advise against driving or alcohol consumption.
Sugar-tong forearm splint. Image courtesy of Kenneth R. Chuang, MD.
- To assist in achieving neutral position of the hand and wrist, some physicians advocate having the patient hold a can or a bandage wrap. Alternatively, the patient can imagine holding a wine glass. With either method, maintain the wrist at 20 degrees extension.
- For injuries or reductions that require shorter drying times, faster-setting plaster is available (eg, Specialist Extra Fast Setting Plaster). However, as the plaster dries faster, the risk of thermal injury increases. For most splints, regular plaster (eg, Specialist Fast Setting Plaster) is appropriate.
- Consider prescribing an antihistamine (eg, Benadryl) for itching. However, if the itching persists or worsens, evaluate the splint for complications.
- A double sugar-tong splint is a standard sugar-tong splint with the addition of a strap of plaster that starts from the proximal humerus medially and extends around the elbow to the proximal humerus laterally. In addition to limiting pronation and supination, which is provided by the standard sugar-tong splint, the double sugar-tong splint also limits flexion and extension of the elbow. The utility of a double sugar-tong splint is similar to that of the long posterior elbow splint; it is primarily used for elbow injuries.
- A Colles fracture is the most common distal radial fracture. The classic mechanism of injury is a fall on an outstretched hand (FOOSH) with the wrist flexed dorsally. The distal segment of the fracture is displaced dorsally. In the less common Smith fracture, the distal segment of the fracture is displaced volarly.
- Thermal burn: Patients can expect some warmth as the plaster dries. However, if they report intense heat or any pain, remove the plaster immediately.
- As more layers of plaster are used, more heat is produced.
- Use clean, room-temperature water. Water that is dirty or too warm accelerates the drying time and increases the heat produced.
- Do not wrap towels or blankets around the splint to shorten drying time. This produces excess heat.
- Pressure sores: Provide extra padding to bony prominences. When wrapping the cotton padding, avoid creases. When creases occur, smooth them out or unwrap and rewrap as needed. When molding the wet plaster, use broad-based pressure. In other words, do not use the fingertips; rather, use the entire palmar surface of the hands and fingers.
- Contact dermatitis: Contact dermatitis can occur. For details, see Contact Dermatitis.
- Ischemia and neurovascular compromise: These complications may be caused by increased pressure from swelling. If using tape to secure the outermost bandage wrap, do not tape circumferentially.
- Decreased range of motion from immobilization: Advise the patient that, depending on the extent and nature of the initial injury, he or she can often expect long-term pain, arthritis, stiffness, and decreased range of motion, despite best care practices. The aftercare of such injuries often requires physical therapy.
Emergency Medicine: The Practice Journal for Emergency and Urgent Care: Managing Common Upper Extremity Fractures For patient education, please see the eMedicineHealth.com article Broken Arm.
Special thanks to Dr. Iris Gluzman and Mrs. Leni L. Chuang.
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Equipment for splint. Image courtesy of Kenneth R. Chuang, MD. |
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Cover patient appropriately. Video courtesy of Kenneth R. Chuang, MD. |
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Remove jewelry and rings to avoid ischemia from swelling. Video courtesy of Kenneth R. Chuang, MD. |
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Stockinette application for sugar-tong forearm splint. Video courtesy of Kenneth R. Chuang, MD. |
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Cotton padding application for sugar-tong forearm splint. Video courtesy of Kenneth R. Chuang, MD. |
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Measuring dry plaster for sugar-tong forearm splint. Video courtesy of Kenneth R. Chuang, MD. |
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Wetting the plaster for sugar-tong forearm splint. Video courtesy of Kenneth R. Chuang, MD. |
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Applying wet plaster for sugar-tong forearm splint. Video courtesy of Kenneth R. Chuang, MD. |
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Applying bandage wrap for sugar-tong forearm splint. Video courtesy of Kenneth R. Chuang, MD. |
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Molding the sugar-tong forearm splint. Video courtesy of Kenneth R. Chuang, MD. |
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Test neurovascular function and capillary refill. Video courtesy of Kenneth R. Chuang, MD. |
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Sugar-tong forearm splint. Image courtesy of Kenneth R. Chuang, MD. |
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- Howes DS, Kaufman JJ. Plaster splints: techniques and indications. Am Fam Physician. Sep 1984;30(3):215-21. [Medline].
- Kaplan SS. Burns following application of plaster splint dressings. Report of two cases. J Bone Joint Surg Am. Apr 1981;63(4):670-2. [Medline].
- Chudnofsky C, Byers S. Splinting techniques. In: Roberts J, Hedges J. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia: WB Saunders Company; 2004:989.
- Menkes J. Initial evaluation and management of orthopedic injuries. In: Tintinalli J, Kelen G, Stapczynski J. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York: McGraw-Hill Professional; 2003:1651.
Splinting, Sugar-Tong Forearm excerpt Article Last Updated: Oct 30, 2007
Topic originally published: Oct 30, 2007
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