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Appropriateness and Adequacy of Splints Applied for Pediatric Fractures in an Emergency Department/Urgent Care Environment
Aaron J. Johnson1; Brandon Schwartz1; Joshua Abzug, MD2
1Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD; 2Orthopaedics, University of Maryland School of Medicine, Timonium, MD

Introduction: Upper extremity fractures are common in pediatric patients, with emergency room physicians or mid-level practitioners performing most evaluations. These injuries are typically splinted. However, correct splinting techniques are necessary to prevent potential complications. Iatrogenic injuries from are a potential public health and legal problem that can lead to fracture malalignment, as well as severe complications. The purpose of this study was to evaluate all patients who presented in a splint to a pediatric orthopaedic practice, in order to assess both splint adequacy, and iatrogenic complications from improper application.

Materials and Methods: Consenting patients aged 0 to 18 years who presented to the pediatric orthopaedic clinic with a splint in place were prospectively enrolled. A total of 205 patients who had a mean age of 9 years (range, 0 to 18 years) were enrolled. A questionnaire was administered to either the patient or their accompanying parent to obtain information regarding demographics, type of splint, type of facility where the splint was applied, type of practitioner that placed the splint, and the amount of time from splint application until orthopaedic evaluation. Photographs were taken of each splint prior to removal, and the extremity was examined for any soft tissue complications. Two blinded members of the pediatric orthopaedic team evaluated the splint for functional position, length, and elastic bandage position. Splints were not removed in 31 patients who had undergone fracture reduction.

Results: Upper extremity slints were improperly placed in 93% (190/205) of cases, with improper joint immobilization in 51% (104/205) of cases. The splint length was inappropriate in 57% (117/205). The elastic bandage was applied directly to skin in 83% (170/205), with excessive distal edema present in 21% (36/170). Soft-tissue complications were observed in 35% (61/174) of patients who had their splint removed. Pressure points were observed on the skin in 16% (27/174) of patients, whereas pressure points overlying bony prominences were seen in 1% (2/174) of cases. Direct injury to the skin and soft tissue was seen in 4% (7/174) of patients.

Conclusion: Many practitioners in pediatric emergency departments and urgent care centers incorrectly apply splints. Factors contributing to iatrogenic injuries include an inadequate padding leading to excessive pressure, application of elastic bandage directly to the skin, inadequate fracture immobilization, and inappropriate splint length. Complications from poor splint placement include swelling, skin breakdown, and poor bone healing. Healthcare workers who treat pediatric fractures may benefit from more extensive education regarding proper splinting techniques.

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