Application of Temporary Splints

Symposium on the Management of Limb Fractures in Small Animals

Application of Temporary Splints Charles D. Knecht, V.M.D. *

Accidents are endemic in our society. The first goal of the clinician presented with a trauma patient is the rapid but thorough physical examination of that patient followed by the treatment or prevention of shock. Because of the complexity of effects in trauma, a thorough evaluation of the cardiovascular and respiratory systems is necessary. Extensive treatment of these systems may be an absolute necessity for the continued life of the patient. Such extensive treatment and continued evaluation of the effects of treatment may prevent definitive early treatment of lesions of the musculoskeletal system. The clinician presented with such a trauma patient must not forget the projected need for repair of fractures and other lesions during the course of emergency care. Simple fractures of an oblique nature may become compound during a few hours of cage confinement and vigorous treatment. Vessels may be ruptured which further deepen the state of shock. Fluid extravasation may depress the anim51l and delay the subsequent healing of fractures by the presence of edema or other fluid accumulations in the tissues in and around the bones. In addition, movement of fractured bone fragments contributes to periosteal stripping which delays bone healing and is a potential source of injury to closely applied peripheral nerves. Although definitive treatment for fracture repair may be contraindicated at this time, prompt temporary splintage should be applied.

GENERAL INDICATIONS The general indications for temporary splintage in the emergency patient are stabilization of the fracture, pre.vention of edema, and reduction of subsequent self-induced trauma. The stabilization achieved, although not perfect, tends to reduce the likelihood of periosteal stripping, hemorrhage, and subsequent complications re*Professor and Chief of Surgery, Small Animal Clinic, School of Veterinary Medicine, Purdue University, West Lafayette, Indiana. Veterinary Clinics of' North America- Vol. 5, No. 2, May 1975

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lated to injury of the surrounding vessels and nerves by the fractured fragments. Stabilization also reduces pain and lessens the deepening of shock due to pain. At the same time, a firm well padded bandage incorporating the injury and the limb distal to the injury prevents secondary edema which might later complicate op en or closed surgical approach and lessens hemorrhage at the fracture site. First Aid at Home Veterinary receptionists are often poorl y trained in telephon e advice to clients with an emergency pa tient. The marked te ndency to p resent the a nimal a t the ea rliest possible time for definitive examination and treatme n t may p reclude the common first aid ad vice to stop the initial bleeding from superficial areas by pressure bandages, handle the animal gently to prevent further trauma, and temporarily immobilize suspected limb fractures. Open surgical wounds on the limbs may h er ald compound fractu res. Simple clean bandagin g at ho me to p re-· vent further conta mination may eventually result in the saving of limbs. The animal with a suspected forelimb fractu re may h ave the limb wrapped in a rolled magazine fixed with adhesive tap e (Fig. l ) as a temporary splint during transport to the veterinary clinic. Forelimb fractures can easily be protected by such temporary splintage. Sudde n posterior par esis or p ar alysis following an injury su ggests that the animal should not be lifted b y the front or rear limbs but should be placed on a bla nket or palle t (Fig. 2) for transport to prevent

Figure 1.

Magazine splint.

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Figure 2.

A window screen stretcher.

subsequent overriding of potential spinal fractures. A few simple statements of advice to the client at the time of injury followed by minor rapid first aid procedures are an essential part of success in fracture repa1r.

SPECIFIC INDICATIONS AND TECHNIQUES The indication for specific temporary splintage is gained from the rapid physical examination. More definitive and detailed palpation as well as radiographic examination may be delayed. The following techniques tend to fulfill the general indications for emergency splintage techniques and require only presumptive diagnosis.

Tape Hobbles* Abduction of the rear limbs may result from posterior paralysis or paresis, but is most often the result of fractures of the pelvis or frac*EDITOR•s NOTE ON TAPE HOBBLES

Hobbles may frequently be overlooked as a method of protecting the injured limb and preventing additional trauma. The principal effect is one of limiting rotational stress to the limb and prevention of abduction or adduction stress as the animal may change positions either on his own or during transportation or early supportive and diagnostic procedures. It is very useful in animals with short legs or patients with extensive soft tissue involvement which may prevent application of more definitive methods for immobilization of the fragments and protection of the soft tissues. The method is not only effective as a temporary splint but may also be used following certain types of skeletal fixation as a protective measure to limit angular and torsional stress on the repaired bone. The hobble may be effective for protection of high femoral and humeral fractures and in some instances for scapular and pelvic fractures. It can afford some protection for limb fractures at any level and may be very effective when multiple limb fractures are present. The usual method is to pad both metacarpal or metatarsal areas with a small amount of cast padding or dressing sponge. Each area is then encircled with one or two inch adhesive tape (depending upon the size of the patient) leaving the ends of the tape projecting medially as a tab to be joined to the tab on the opposite limb. The two tape tabs are then joined with additional strips of tape to provide the proper freedom of movement between the feet. Usually the distance between the feet is about that of a normal standing position. When the hobbles are used to protect the limb with extensive instability or when both proximal and distal instabilities are present, the metacarpal or metatarsal area can be more thoroughly padded and the two feet bandaged together from the toes to the carpus or back.

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ture-dislocation of the pelvic symphysis and sacroiliac joints. Tape hobbles are rarely indicated on the forelimbs because abduction of the forelimb is almost always the result of fractures of the long bones or paralysis of the roots or integral parts of the brachial plexis. Adhesive tape may be applied to the rear limbs of the dog to prevent abduction. Adhesive tape of a size which will cover at least one half the length of the metatarsal bones (two inch) is placed in stirrup fashion around the lateral metatarsus of one hind leg with tape applied to tape on the medial surface (Fig. 3). The adhesive tape is continued between the legs and applied to the cranial and late ral surface of the metatarsus of the contralateral limb. It should be placed so that the separation of the limbs is approximately equal to the separation of the greater trochanters. The tape is continued caudally to the original limb and reapplied to the adhesive tape between the two limbs. A ring of tape on the metatarsus is not indicated and is likely to contribute to peripheral edema or necrosis in the area of application. Tape hobbles are contraindicated in the presence of wounds of the metatarsal region, pronounced edema at or distal to the metatarsus, and when palpation of the limbs indicates reduced blood flow by normal texture but cool clammy touch. Application in this instance might result in avascular necrosis under the adhesive tape requiring extensive regeneration of the skin or grafting.

Figure 3.

Adhesive tape h obbles.

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Modified Robert Jones Bandage

The modified Robert Jones bandage is a combination of cast padding and elastic adhesive tape. It is indicated only when the prevention of edema is primary and stabilization of the fracture is of minimal concern. Swelling of the metaphyseal region following injury in young animals may indicate physeal or metaphyseal fractures with minimal separation. Such fractures may be temporarily splinted with well padded bandages that offer little additional stability. Extensive wounds in the skin which prohibit accurate palpation may similarly be covered with a simple padded bandage until radiographic confirmation is achieved. The modified Robert Jones bandage is made by applying cast padding from the foot proximally to the upper humerus or femur (Fig. 4). The cast padding is overlapped 50 per cent as it is applied from the foot proximally and returned to the foot. The middle two toes should be exposed. The padding is covered with overlapping elastic adhesive

Figure 4 . Modified Robert Jones bandage.

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tape from distal to proximal. Two or three inch elastic tape is indicated because one inch tape offers little stability. Simple padded bandaging is contraindicated where complete fracture of the long bones has occurred and in all other fractures or joint dislocations where stability rather than edema is the primary consideration. Robert Jones Bandage

The Robert Jones bandage offers the best of both worlds for temporary splintage. Although large in size, it affords excellent stability for fractures of the limbs distal to the middle of the humerus and femur. It additionally offers excellent control of edema and reduction of existing edema. Because of the heavy padding, it tends to prevent further trauma as a result of fractured fragments moving against soft tissues. The Robert Jones bandage is indicated for all fractures of the peripheral limbs from the mid-shaft of the humerus and the mid-shaft of the femur distally where accurate stability is desired. The Robert Jones bandage is made by attaching two strips of adhesive tape to the cranial an d caudal surface of the foot and allowing them to remain exposed. The limb from the foot upward is wrapped firmly with full thickness absorbent cotton roll (Fig. 5). The r oll is extended as far proximal as possible and returned to the foot, overlapping 50 per cent of the width of the roll as the limb is wrapped. The

Figure 5.

Robert J ones ba ndage.

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tape at the end of the foot is then incorporated in a layer of elastic gauze applied around the absorbent cotton. The elastic bandage is applied firmly and is covered with a final layer of elastic tape. When completed the Robert Jones bandage is firm to the touch and resounds when tapped as does a ripe watermelon. The contraindications for Robert Jones bandage include fractures of the proximal end of the femur and humerus where the weight of the bandage is likely to cause angular displacement of the fractured fragments. In these patients, the cotton may be continued around the body and covered with elastic gauze and elastic tape to prevent abduction and adduction of the limb at the proximal end of the bandaging mateial. Coaptation Splints Coaptation splints are applied in close proximity to the shape of the limb to which they are applied. Coaptation splints are indicated in fractures of the bones of the limbs distal to the elbow and the stifle. They offer little stability for fractures above these joints. A marked similarity in design is common to coaptation splints. The choice of material used varies with availability, size of the animal, type of fracture, and personal preference. Adhesive tape strips should be applied cranially and caudally to the foot and are fixed with a spiral of adhesive tape. Fixation with a ring of tape is never indicated. The adhesive tape is continued distal to the foot and applied to the splint. Coaptation splints may be made from tongue depressors, metal shoes, yucca board, plastic splint materials, basswood or plywood, or any other firm substance. · In each instance, the leg should be well padded with a full thickness (half thickness in small animals) of absorbent cotton roll. Metal shoes, yucca board, or tongue depressors are applied to the caudal surface and basswood, plywood, or plastic to the lateral surface. The splint material is fixed with a firm wrap of plain or elastic gauze and covered with elastic tape. Even pressure should be applied from the foot proximally. (See the article on "Principles and Application of Traction and Coaptation Splints" elsewhere in this symposium.) The contraindications for coaptation splints include fracture and fracture-dislocations from the elbow and stifle proximally. Fractures located at the point where the splint ends will suffer greater trauma as a result of application than from the absence of splintage. Schroeder-Thomas Splint A modified Thomas splint is indicated in fractures of the limb where accurate immobilization of the limb from the mid-shaft of the humerus or femur to the foot is required but rapid immobilization is indicated. The shape of a proper Schroeder-Thomas splint depends

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upon the type of fracture. Where the splint is applied for emergency stabilization only, the Schroeder-Thomas splint need not be properly structured (see the article on "Principles and Application of Traction and Coaptation Splints") but may be structured as the T ho mas splint. The latter is a walking splint d esign ed with a ring around the groin and rods projecting directly to the bottom of the foot. Although accurate reduction and fixation is not possible with the Thomas splint, sufficient immobilization is obtained for emergency treatment. In application, an elliptical ring is made to closely approximate the limb a t the body. The ve ntral surface o f the r in g is padded a nd the rod sha ped to extend in a straight line cranial and caudal to the limb. The rods are joined and ta ped together distal to the foot , leaving a one to three inch segment below the foot which is perpendicular to the long axis of the foot (Fig. 6). Even in temporary splints the ring at the proximal e nd should be longer front to back than it is top to bottom and sho uld be be nt medially on its ventral aspect to conform to th e a n gle o f d e partu re of the limb fro m the body. The ring itself sh ould not be excessively padded because it will p roduce a p ressu re r ing.

Figure 6.

Tem porary T ho mas splin t.

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In addition to aluminum splint rod , Johnson and Johnson Combine Roll* should be used to pad and fix the limb. When applied from the foot proximally, Combine Roll prevents motion of the fractured fragments and reduces and prevents edema. The foot is taped to the splint rod distally. Combine Roll is wrapped around the limb by placing the combine lateral to the rods and medial to the limb. The short end is in the direction toward which the limb is to be pulled. The long end is wrapped around the lateral limb, around the rod behind the limb, and between the limb and splint rod cranially. The layers of Combine bandage are placed from the foot proximally so that they are apposed with no space between the individual full or half-width layers of bandage. A loose layer of adhesive tape is applied to hold the Combine bandage during subsequent examination. A piece of stockinette placed over the Combine Roll will hold it in better apposition. Contraindications of the emergency Thomas splint include fractures of the proximal humerus and distal scapula as well as fractures of the femoral neck and dislocations of the coxofemoral joint. The emergency Thomas splint should never be used for permanent fixation of fractures of the limbs without modification specifically indicated by the bone fractured. Fixation of the stifle and elbow in complete extension for more than a few days is contraindicated in all fractures. *Com bine Roll , Johnson & Johnson Co. , New Brunswick , N.J.

Figure 7.

Shoulder sling.

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Shoulder Sling The shoulder sling is indicated for fracture of the scapula, fracture-dislocation of the scapulohumeral joint, and fracture of the proximal humerus. The sling is easily and rapidly applied from elastic gauze (Kling)* wrapped around the animal's body and covered with adhesive tape (Fig. 7). The limb should be flexed with the carpus slightly above the elbow. The elastic gauze is wrapped around the limb and the body, passing cranial and caudal to the opposite forelimb. The elastic gauze is covered with elastic adhesive tape to fix the limb closely to the body. The wrap may cross below the carpus allowing the foot to remain exposed or may completely enclose the limb and foot with the carpus in full flexion and slight pronation. In either instance, the sling is temporary unless the limb is more rigidly fixed with an adhesive tape stirrup around the distal radius and ulna. The contraindications for the shoulder sling include oblique fractures of the distal third of the humerus where compression by the sling is likely to result in overriding of the fractured fragments and jeopardy to the radial nerve, and in fractures of the olecranon process of the ulna where severe flexion results in greater distraction of the olecranon from the shaft of the ulna.

SUMMARY Emergency splintage is a variety of first aid. The procedures which one might expect to find performed before the patient enters the hospital for definitive diagnostic treatment are too often ignored in a busy and otherwise excellent veterinary practice. Simple entrance in the hospital and cage confinement do not appreciably lessen the likelihood of increased self-trauma. The manipulation inherent in physical and radiographic examination of the injured and painful animal is an even greater indication for immobilization to prevent additional trauma. The clinician is dutybound to place a proper splint on the affected animal to lessen subsequent trauma and to prevent edema. The techniques presented allow this application with minimal time and expense and maximal support and protection to the patient. ACKNOWLEDGMENT

The author is indebted to Mr. David Williams of Purdue University for the illustrations. *Kling, Johnson & Johnson Co., New Brunswick, N.J.

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REFERENCES l. Cofield, R. B.: Technique in handling simple and compound fractures. N. Am. Vet.,

15:32, 1934. 2. Frost, R. C.: The closed reduction and repair of radio-ulnar fractures in the dog. J. Sm. Anim. Pract., 6:197, 1965. 3. Jenny, J.: Today's standard of fracture treatment in small animals. Proc. 89th Ann. Meet., A.V.M.A., 187:1952, 1953. 4. Knecht, C. D.: Cast and splints. Archives, 3:58, 197 4. 5. Knecht, C. D., Welser, J. W., Allen, A. R., et al.: Fundamental Techniques in Veterinary Surgery. Philadelphia, W. B. Saunders Company, 1975, Chapters 5 and 7. 6. Schroeder, E. F.: The traction principle in treating fractures and dislocations in the dog and cat. N. Amer. Vet., 14:32, 1933. Small Animal Clinic Purdue University School of Veterinary Medicine West Lafayette, Indiana 47907