EM · Procedural & diagnostic ED skills
Splinting and immobilisation in the emergency department
Also known as Backslab · Plaster backslab · Plaster of Paris splint · POP cylinder · Thomas splint · Traction splint · Cervical collar · Spinal board · SAM splint · Sling and swath · Immobilisation
Splinting and immobilisation in the ED — the governing principle (immobilise the joint above and below the fracture), the device set (plaster backslab for Colles and ankle, POP cylinder for the knee, Thomas splint for the femur, sling and swath for the clavicle, rigid cervical collar and spinal board for suspected spinal injury, malleable SAM splint for the field), the layered application technique (stockinette, wool padding, plaster slabs dipped in cool water and moulded in the position of function), and the complications the Fellowship candidate must name and prevent — compartment syndrome (the 5 Ps of pain out of proportion, pallor, paraesthesia, paralysis, pulselessness), pressure sores over bony prominences, and thermal injury from the exothermic setting reaction. The central SCQ distinction is the backslab (non-circumferential, accommodates swelling, the ED acute-phase default) versus the circumferential cast (rigid, definitive, applied only after swelling resolves). ACEM Fellowship, globally tagged.
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- Fracture and dislocation reduction in the ED
- Cervical spine injury and clearance in trauma
- Paediatric trauma — the modified approach
- Wound assessment and management
- Local anaesthesia and topical agents
- Procedural sedation in the emergency department
- Acute limb ischaemia (the emergency of the 6 Ps)
- Consent, capacity and the medico-legal framework in the emergency department
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Red flags
- Never apply a circumferential cast to an acute fracture in the first 24 to 72 hours — splint with a backslab that accommodates the swelling; a circumferential cast on a swelling limb is the iatrogenic cause of compartment syndrome
- Suspect compartment syndrome in any casted limb with pain out of proportion or pain on passive stretch, even with a pulse present and even in the sedated or the young child — pulselessness is a late, pre-terminal sign; split the cast to skin immediately and call orthopaedics for fasciotomy
- Dip plaster in cool or tepid water, never hot — the calcium sulphate setting reaction is exothermic, and hot water with thick multi-layer slabs can produce full-thickness burns under the cast
- A cervical collar alone does NOT immobilise the cervical spine — it permits up to 30 degrees of motion; combine with manual in-line stabilisation, head blocks and torso straps, and log-roll the patient off a rigid spinal board within 30 minutes to prevent pressure sores and respiratory compromise
- Pad every bony prominence — malleoli, olecranon, ulnar and radial styloids, fibular head, metatarsal heads and heel — before the plaster is applied; an unpadded prominence under a rigid splint ulcerates within hours
Meet the patient
A 72-year-old woman has just had her displaced distal radius fracture reduced under ketamine sedation in your resus bay. The post-reduction films look good, and you are about to apply the backslab when the nursing student asks why you do not simply put her in a full plaster cast, "like the one she will go home in".[1]
The two questions that decide every splinting answer — and this one — are two examiner will press you on: is this limb still swelling? (the backslab-versus-cast fork) and can I lose this limb to a complication I caused? (the 5 Ps of compartment syndrome). Hold those two questions and the technique below slots into place.[1]
References13ShowHide
- [1]Barvelink B, Reijman M, Smidt S, et al. Redisplacement of reduced distal radius fractures in adults: does the type of casting play a role? The CAST study, a multicentre cluster randomized controlled trial Bone Joint J, 2024.PMID 38945541
- [2]Jorgensen A, Kahan J, Moran J, et al. Assessment of complications associated with casting of acute distal radius fractures in adults Am J Emerg Med, 2022.PMID 35397351
- [3]McQueen MM, Court-Brown CM. Predictors of Compartment Syndrome After Tibial Fracture J Orthop Trauma, 2015.PMID 25882967
- [4]Chu RS, Browne GJ, Lam LT Traction splinting of femoral shaft fractures in a paediatric emergency department: time is of the essence? Emerg Med (Fremantle), 2003.PMID 14992059
- [5]Pandor A, Essat M, Sutton A, et al. Cervical spine immobilisation following blunt trauma in pre-hospital and emergency care: A systematic review PLoS One, 2024.PMID 38662734
- [6]Lee C, Lightdale-Miric N, Chang E, et al. Silent compartment syndrome in children: a report of five cases J Pediatr Orthop B, 2014.PMID 24921836
- [7]Gannaway JK, Hunter JR. Thermal effects of casting materials Clin Orthop Relat Res, 1983.PMID 6641053
- [8]Burghardt RD, Anderson JG, Reed RA, et al. Exothermic properties of plaster-synthetic composite casts J Child Orthop, 2014.PMID 24554128
- [9]Difazio RL, Harris M, Feldman L, et al. Reducing the Incidence of Cast-related Skin Complications in Children Treated With Cast Immobilization J Pediatr Orthop, 2017.PMID 26683501
- [10]Wiles MD, Iliff HA, Brooks K, et al. Airway management in patients with suspected or confirmed cervical spine injury: Guidelines from the Difficult Airway Society (DAS), Association of Anaesthetists (AoA), British Society of Orthopaedic Anaesthetists (BSOA), Intensive Care Society (ICS), Neuro Anaesthesia and Critical Care Society (NACCS), Faculty of Prehospital Care and Royal College of Emergency Medicine (RCEM) Anaesthesia, 2024.PMID 38699880
- [11]Irajpour A, Kaji NS, Nazari F, et al. A comparison between the effects of simple and traction splints on pain intensity in patients with femur fractures Iran J Nurs Midwifery Res, 2012.PMID 23922601
- [12]Lenza M, Faloppa F Conservative interventions for treating middle third clavicle fractures in adolescents and adults Cochrane Database Syst Rev, 2016.PMID 27977849
- [13]Garfin SR, Mubarak SJ, Evans KL, et al. Quantification of intracompartmental pressure and volume under plaster casts J Bone Joint Surg Am, 1981.PMID 7204445