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Clinical Procedures > Musculoskeletal Procedures
Splinting, Thumb Spica
Article Last Updated: Jun 22, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 15  
Author: Kenneth R Chuang, MD, Staff Physician, Department of Emergency Medicine, Olive View Medical Center-University of California Los Angeles
Coauthor(s):
Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Editors: Andrew K Chang, MD, Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Luis M Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Gil Z Shlamovitz, MD, Attending Physician, Windham Memorial Community Hospital; 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:
thumb spica, splinting, thumb fracture, broken thumb, broken metacarpal, gamekeeper’s thumb, scaphoid, lunate, ulnar collateral ligament, metacarpal fracture, splinting, de Quervain tenosynovitis, UCL strain, wrist flexors, flexion contracture, wrist immobilization, wrist extensors, plaster splint, thumb injury, anatomical snuffbox, occult fracture, scaphoid injury, axial load, MCP, UCL injury, UCL weakness
In general, splints are applied to decrease movement and provide support and comfort through stabilization of an injury. Splints are primarily used to secure nonemergent injuries to bones until they can be evaluated by a consultant such as an orthopedic surgeon. Splints are also used to temporarily immobilize an extremity prior to surgery (eg, open fracture) or to assist in primary healing. Unlike casts, splints are noncircumferential and often preferred in the emergency department setting, since injuries are often acute and continued swelling can occur. All patients with injuries that are splinted should be referred for evaluation by a consultant in a timely fashion (usually within 2-7 days, depending on the reason for the splint).
A thumb spica splint can be used for various injuries that include the following: - Scaphoid injuries
- Lunate injuries
- First metacarpal fractures
- Injury to the ulnar collateral ligament
- Positioning for de Quervain tenosynovitis
- Absolute contraindications – None
- Relative contraindications in injuries that require immediate evaluation or intervention by a consultant (eg, orthopedic surgeon, hand surgeon, plastic surgeon)
- 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
- Conscious sedation with appropriate monitoring and administration by an experienced physician
- 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 after the splint has been applied.
- Stockinette
- Padding (eg, Webril)
- Plaster of Paris or prefabricated fiberglass (eg, Orthoglass)
- Bandage or wrap (eg, Bias bandage or Ace wrap)
- Clean, room-temperature water in a basin
- Trauma shears or a pair of medical scissors without pointed ends
- Chucks pads and bed sheet
- Tape or bandage clips
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. Cut longitudinally at the distal end of the stockinette to allow covering for 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 will extend 2-3 cm beyond the overlying wet plaster on either end. Together, the stockinette and padding will be pulled over the edges of the wet plaster to create smooth edges.
Stockinette application for thumb spica splint. Video courtesy of Kenneth R. Chuang, MD. - Wrap the padding over the stockinette. 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 of the wrist and to the metacarpophalangeal and interphalangeal joints of the thumb.
Cotton padding application for thumb spica splint. Video courtesy of Kenneth R. Chuang, MD. - Measure the plaster. For an average-sized adult, plaster for the thumb spica splint should be 8-10 layers thick. Use plaster that is 3-4 in wide. After counting out the layers, measure the plaster from the level of the interphalangeal joint of the thumb to the proximal third of the forearm. Then, at the level of the metacarpophalangeal joint, cut a triangle 1.5 cm deep along both edges. Cutting the triangles avoids amassing of plaster when the thumb is abducted in the molding step. Allow for roughly 5 mm extra length on either end, as plaster shrinks when wet. Excess wet plaster, on the ends, will be folded over.
Measuring dry plaster for thumb spica splint. Video courtesy of Kenneth R. Chuang, MD. - Submerge the plaster in clean, room-temperature water. Allow all the bubbles to escape. This starts the lamination process of the plaster and allows for the layers to bond together. Squeeze out the excess water. With the fingers, strip out the 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. Video courtesy of Kenneth R. Chuang, MD. - Apply the wet plaster, over the padding, to the lateral or radial surface of the forearm, extending along the length of the thumb to the interphalangeal joint. Fold outward excess plaster on the ends. The underlying stockinette and padding should then be folded outward on both ends, creating smooth edges.
Applying wet plaster for thumb spica splint. Video courtesy of Kenneth R. Chuang, MD. - Apply the bandage wrap over the wet plaster. Start distally, at the interphalangeal joint of the thumb, and wrap proximally. Avoid wrapping too tightly.
Applying bandage wrap for thumb spica splint. Video courtesy of Kenneth R. Chuang, MD - While the plaster is still wet, mold the splint into the desired shape. The wrist and hand should be in a neutral position. Extend the wrist to 20° and abduct the thumb. To assist in achieving neutral position, ask the patient to imagine holding a wine glass, or hand the patient a bandage wrap to hold. The hand, wrist, and forearm 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, since thermal burns can occur.
Molding the thumb spica splint. Video courtesy of Kenneth R. Chuang, MD. - Check for neurovascular function and capillary refill after the splint has dried. Recall that the median nerve provides sensory function to the palmar side of the thumb and second and third digits and the lateral half of the fourth digit and, dorsally, to the distal half of the second and third digits and the lateral half of the fourth digit. The ulnar nerve provides sensory function to the palmar and dorsal aspects of the fifth digit and the medial half of the fourth digit. The radial nerve provides sensory function to the dorsal surface of the hand and to the web space between the first and second digits. Remember to check motor function, as well. 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.
- Arrange for follow-up with a consultant, usually in 2-7 days, depending on the reason for the splint.
- If the patient received any sedation or opioids, advise against driving or alcohol consumption.
Thumb spica 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° extension. If the wrist is immobilized straight or in flexion, a flexion contracture can develop because the wrist extensors may be unable to overcome potentially shortened wrist flexors.
- For injuries or reductions that require shorter drying times, faster-setting plaster is available (eg, Specialist Extra Fast Setting Plaster). However, as 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, diphenhydramine [Benadryl]) for itching. However, if the itching persists or worsens, the splint should be evaluated for complications.
- On physical examination, injury to the scaphoid can be tested by compression dorsally at the anatomical snuffbox, compression of the wrist volarly directly over the scaphoid, and by axial loading of the thumb. Pain upon these compressions is suggestive of scaphoid injury. Flexion of the MCPs does not transmit pressure or forces to the scaphoid.
- An injury or fracture to the scaphoid is difficult to detect by radiograph. When a radiograph is obtained to rule out fracture but is read as negative, an occult fracture cannot be ruled out. The patient should be advised of this possibility. Such fractures might only be identified on delayed radiographs. A patient who has clinical evidence of a scaphoid injury on physical examination should be placed in a thumb spica splint and should receive close follow-up.
- The term "gamekeeper’s thumb" originates from a description of injuries sustained by Scottish rabbit gamekeepers. Repetitive and sudden valgus forces placed on the gamekeeper’s thumbs, when they killed rabbits by breaking their necks, resulted in UCL injuries. On physical examination, a UCL injury presents as pain, weakness, and instability during challenge of a pinched grasp between the thumb and fifth digit.
- Thermal burn: Patients can expect some warmth as the plaster dries. However, if the patient reports intense heat or any pain, remove the plaster immediately, as thermal burns can occur.
- 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 to mold the plaster.
- Contact dermatitis: See Contact Dermatitis.
- Ischemia and neurovascular compromise: These complications may be caused by increased pressure from swelling. If moderate to significant swelling is anticipated, cut the cotton padding lengthwise along the medial or ulnar side of the forearm, before application of the wet plaster on the radial side. This allows for expansion of the padding. If using tape to secure the outermost bandage wrap, do not tape circumferentially.
- Decreased range of motion due to 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.
American College of Emergency Physicians
1125 Executive Cir
Irving, Tex 75038-2522
800-798-1822
American Medical Society for Sports Medicine
11639 Earnshaw
Overland Park, Kan 66210
913-327-1415
Web Links
eMedicine from WebMD: Gamekeeper's Thumb eMedicine from WebMD: Carpal Bone Injuries eMedicine from WebMD: Scaphoid Injury eMedicine from WebMD: Ulnar Collateral Ligament Injury eMedicine from WebMD: Hand Injury, Soft Tissue eMedicine from WebMD: Metacarpal Fractures eMedicine from WebMD: De Quervain Tenosynovitis MedlinePlus: Hand Injuries and Disorders
Special thanks to Mrs. Leni L. Chuang and Dr. Iris Gluzman.
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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 thumb spica splint. Video courtesy of Kenneth R. Chuang, MD. |
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Cotton padding application for thumb spica splint. Video courtesy of Kenneth R. Chuang, MD. |
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Measuring dry plaster for thumb spica splint. Video courtesy of Kenneth R. Chuang, MD. |
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Wetting the plaster. Video courtesy of Kenneth R. Chuang, MD. |
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Applying wet plaster for thumb spica splint. Video courtesy of Kenneth R. Chuang, MD. |
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Applying bandage wrap for thumb spica splint. Video courtesy of Kenneth R. Chuang, MD |
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Molding the thumb spica 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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Thumb spica splint. Image courtesy of Kenneth R. Chuang, MD. |
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Test for ulnar collateral ligament injury (gamekeeper's thumb). |
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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].
- 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, Thumb Spica excerpt Article Last Updated: Jun 22, 2007
Topic originally published: Jun 22, 2007
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