What is the complication?

Patient had been utilizing the cam boot without much padding, causing a pressure wound. 

After proper workup to rule out emergent infection, he can be referred to wound care or back to his primary care provider. As his ankle pain has resolved he can be advised to discontinue the cam boot. 

How common is this?

A 2023 study found that up to 40% of patients that were splinted in the emergency department developed soft tissue complications, including skin ulceration in 6% of patients [6]. 

What are other complications to look out for in post-splint situations?

Compartment Syndrome 

Compartment syndrome is impaired local circulation due to increased pressure within an osteofascial compartment and is a surgical emergency [3].  Patients are at increased risk for compartment syndrome if the splint is circumferential and applied too tightly. It can present anywhere from a few to 48 hours after the inciting injury. 

• Pearl: Although compartment syndrome is typically identified by the 5 P’s (pain, pulselessness, paresthesia, paralysis, and pallor), these are often late findings. Therefore it is important to perform serial exams.

Physical exam should include:

• Inspection of the skin for swelling, lesions, or color change

• Palpation over the compartment, with attention to temperature, tension, tenderness

• Pulse check

• Evaluation for two-point discrimination and sensation

• Motor function 

This condition requires immediate surgical consultation and the splint should be immediately removed.  

Heat Injury

Because hardening of splint material is an exothermic process, this can increase risk of skin burns. This can be avoided by using cool or room temperature water during activation of splinting material. Additionally, efforts should be made to avoid under-padded or unpadded areas over the skin. 

Infection

Because of the moist, warm environment under the splint, bacterial and fungal infections can develop [4]. Patients should be advised to keep their splint as dry and clean as possible. 

What is the management of post-splint pain and swelling?

Elevation should be prioritized to reduce swelling, while mobility of non-splinted joints is important to prevent atrophy and stiffness [1]. 

Icing is a controversial modality of treatment for soft tissue injuries. Although icing can help reduce pain and swelling, there is little evidence that icing improves clinical outcomes [5]. Furthermore, careful measures should be taken to not get the splint wet from icing, as this can also lead to thermal injuries as mentioned above. 

What should patients be educated on?

After splinting in the ED, patients should have outpatient follow up within seven days [2]. 

Patients should be educated on keeping the splint clean, dry, and elevated to reduce swelling. Strict return precautions should be given for loss of neurovascular compromise, worsening pain above what is to be expected, or any of the above listed complications [1].