Splinting Series Part 2: Lower Extremity
Author: Kayla Darris, MD
Peer-Reviewer: Mark Hopkins, MD, CAQ-SM; Matthew Negaard, CAQ-SM
Final Editor: Alex Tomesch, MD, CAQ-SM
A 5 year old presents to the ED with significant pain and inability to bear weight on his right leg after twisting attempting to catch a ball while playing with his brothers. On exam, he has pain and swelling over the distal tibia and is neurovascularly intact.
Image 1. Xray of the left foot. Case courtesy of Fadi Ali, Radiopaedia.org, rID: 84977
References
[1] Wang Y, Doyle M, Smit K, Varshney T, Carsen S. The Toddler's Fracture. Pediatr Emerg Care. 2022 Jan 1;38(1):36-39. doi: 10.1097/PEC.0000000000002600. PMID: 34986580.
[2] Patel NK, Horstman J, Kuester V, Sambandam S, Mounasamy V. Pediatric Tibial Shaft Fractures. Indian J Orthop. 2018 Sep-Oct;52(5):522-528. doi: 10.4103/ortho.IJOrtho_486_17. PMID: 30237610; PMCID: PMC6142797.
[3] Boyd AS, Benjamin HJ, Asplund C. Splints and casts: indications and methods. Am Fam Physician. 2009 Sep 1;80(5):491-9. PMID: 19725490.
[4] Denq, W., & Hockstein, M. (2020, August 8). Splinter series: Common ed splint techniques 104. ALiEM. https://www.aliem.com/
[5] Tintinalli, J., Ma, J., Yealy, D., Meckler, G., Joseph, S., Cline, D., & Thomas, S. (Eds.). (2020). Tintinall’s emergency medicine: A comprehensive study guide (9th ed.). McGraw Hill.
[6] Sprouse RA, McLaughlin AM, Harris GD. Braces and Splints for Common Musculoskeletal Conditions. Am Fam Physician. 2018 Nov 15;98(10):570-576. PMID: 30365284.
[7] Bica D, Sprouse RA, Armen J. Diagnosis and Management of Common Foot Fractures. Am Fam Physician. 2016 Feb 1;93(3):183-91. PMID: 26926612.
[8] Matthew Negaard, M. (2019, October 31). Splinter series: A toddler’s missed step. ALiEM. https://www.aliem.com/
Injury |
Splint |
Alternatives |
Soft Tissue Knee Injuries |
Splinting not recommended |
Patellofemoral Pain: Patellar stabilizing brace |
Patellar Tendinopathy: Patellar tendon strap |
||
Ligamentous/Meniscus Injury: Hinged knee brace |
||
Patella Fractures |
Posterior Knee Splint |
Knee Immobilizer |
Proximal Tibia/Fibula Fracture |
Posterior Long Leg |
- |
Distal Tibia/Fibula Fracture |
Posterior Short Leg |
- |
High Ankle Sprain |
Stirrup (not preferred) |
Boot, Soft Lace-Up or Semi-rigid Air Brace |
Tarsal Fracture |
Posterior Short Leg |
Boot |
Metatarsal Fracture |
Posterior Short Leg |
High-top walking boot, Post-op shoe |
Phalanx Fracture |
Posterior Short Leg |
Buddy taping, High-top walking boot, Rigid Sole Shoe |
Appendix A: Quick Reference Guide for appropriate splint selection in lower extremity injuries [3-7]
Splint |
Indications |
Origin |
Insertion |
Functional Position |
Posterior Knee Splint |
Quadriceps or patellar tendon rupture, Patellar Fracture or unstable dislocation |
Just below the gluteal crease |
Just proximal to the malleoli |
Knee in 10 to 20 degrees of flexion |
Posterior Long Leg |
Proximal tibial fractures (including tibial plateau fractures), pediatric femoral shaft fractures |
Just below the gluteal crease |
Plantar surface of the distal metatarsals |
Knee in 5 to 10 degrees of flexion, ankle at 90 degrees of flexion |
Posterior Short Leg |
Distal tibia/fibula fractures, tarsal fractures, metatarsal fractures, lisfranc injuries, phalanx fractures, high grade ankle sprains |
2 inches below the femoral head (to avoid compression of the common peroneal nerve) |
Plantar surface of the distal metatarsals |
Ankle at 90 degrees of flexion *In Achilles ruptures or Dancer's fractures, the position of functions is the Equinus position |
Ankle Stirrup |
Isolated malleolar fractures, high grade ankle sprains, reduced ankle dislocations |
At least 2 inches below the femoral head (to avoid compression of the common peroneal nerve) |
Extension underneath the plantar surface of the foot, with return to the origin on the medial side of the leg |
Ankle at 90 degrees of flexion |
Appendix B: Quick Reference Guide for correct positioning of lower extremity splints [3-6]