Immobilisation - short arm backslab

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Indications

Distal radius and/or ulna fractures

Carpal fractures (except scaphoid)

Contraindications (absolute in bold)

None

Alternatives

Open reduction with internal fixation

Informed consent

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Failure (reduction or immobilisation)

Thermal burns (from heat released during setting of plaster)

Neurovascular compromise

Pruritis

Dermatitis

Abrasions and pressure sores (with risk of infection)

Joint stiffness

Procedural hygiene

Standard precautions

PPE: non-sterile gloves, apron

Area

Plaster room or bed space

Staff

Procedural clinician

Equipment

Stockinette (optional)

7.5cm cotton padding (slightly narrower than arm diameter)

10cm for backslab plaster (slightly wider than arm diameter)

Trauma scissors

Bowl of cold water

Crepe bandages

Tape

Positioning

Sitting with elbow supported on table and flexed to 90 degrees

Thumb pointing to own shoulder

Forearm: neutral pronation/supination (stop sign position)

Wrist: 20-30 degrees extension unless otherwise requested

Cast

Estimate plaster length by laying dry splint next to the area to be splinted

Layers: 8-10 layers along volar arm

Distal margin: distal palmar crease on palm of hand

Proximal margin: 3cm below elbow crease

Cut a semicircle a third the width of the plaster slab at the thenar eminence

Medication

Consider paracetamol 1g, ibuprofen 400mg and oxycodone 5mg (pain relief one hour pre procedure)

Consider fentanyl 25-50mcg IV (pain relief pre-procedure adjusted to co-morbid status)

Consider fentanyl 100mcg IV (1.5mcg/kg pain relief pre-procedure adjusted to co-morbid status)

Sequence

Ensure adequate analgesia prior to procedure

Inspect the extremity prior before splinting, document lesions repairing or dressing as normal

Apply stockinette to arm beyond margins of plaster (allowing folded to a smooth edge)

Cut a small hole on stockinette for thumb

Apply 2-3 layers of cotton padding beyond plaster margins, tearing or cutting as it passes through the first webspace

Ensure wrist is well padded and padding overlaps itself by 25-50% with minimal creases

Submerge the pre-prepared dry backslab in water until bubbling stops, then remove

Squeeze out excess water, smooth on a flat surface and apply along volar border of forearm

If unstable or post reduction add a similar dorsal backslab as well as the volar slab

Turn back padding around distal and proximal margins of plaster

Apply crepe bandage firmly over slab and fasten with tape

Gently mould plaster to patient anatomy (palm particularly) maintaining wrist and elbow position until hardened

Post-procedure care

Check X-ray, circulation and limb function:

Confirm fracture reduction with post-procedure X-ray

Check capillary refill and comfort (loosen crepe bandage or re-splint if required)

Check plaster is in correct position at elbow and palm

Check full elbow and MCP flexion/extension of digits 1-5

Check opposition of thumb to at least middle finger

Provide plaster care instructions:

Elevate limb when possible using a sling (decreases pain and swelling)

Avoid applying pressure and heat to the cast

Do not wet the plaster (use plastic bag to protect plaster while in shower)

Return for assessment if damaged cast, increasing pain, numbness or skin colour changes

Provide temporary cast plaster care patient fact sheet

Tips

A sandwich (volar and dorsal) backslab is preferred for unstable fractures

Temporary casting of open fractures requires covering open wounds with saline-moistened sterile gauze

Always use clean cold water (avoiding thermal injury and allowing for 10 minutes moulding time)

Extra padding at bony prominences avoids pressure areas (olecranon, radial and ulnar styloid)

All backslabs are temporary requiring definitive management after two weeks (e.g. full cast)

Discussion

There are a variety of splinting techniques in common emergency department practice. Indications for specific casts and recommended methods of application may vary depending on your institution. If in doubt seek local advice from an experienced provider or discuss with your orthopaedic team.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

NSW Agency for Clinical Innovation. Orthopaedic/musculoskeletal. Sydney: ACI; 2020. Available from https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/orthopaedic-and-musculoskeletal

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Eiff MP, Hatch R. Fracture management for primary care. 3rd ed. Philadelphia PA: Saunders; 2011.

Stracciolini A. Basic techniques for splinting of musculoskeletal injuries In: UpToDate. Waltham (MA): UpToDate. 2019 April 18. Available from: https://www.uptodate.com/contents/basic-techniques-for-splinting-of-musculoskeletal-injuries

Liverpool hospital emergency department: Plaster booklet (2019)

© Agency for Clinical Innovation 2021

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