Principles of Casting and Splinting

ANNE S. BOYD, MD, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

HOLLY J. BENJAMIN, MD, University of Chicago, Chicago, Illinois
CHAD ASPLUND, MAJ, MC, USA, Eisenhower Army Medical Center, Fort Gordon, Georgia

The ability to properly apply casts and splints is a technical skill easily mastered with practice and an understand-
ing of basic principles. The initial approach to casting and splinting requires a thorough assessment of the injured
extremity for proper diagnosis. Once the need for immobilization is ascertained, casting and splinting start with
application of stockinette, followed by padding. Splinting involves subsequent application of a noncircumferential
support held in place by an elastic bandage. Splints are faster and easier to apply; allow for the natural swelling that
occurs during the acute inflammatory phase of an injury; are easily
removed for inspection of the injury site; and are often the preferred
tool for immobilization in the acute care setting. Disadvantages of
splinting include lack of patient compliance and increased motion at
the injury site. Casting involves circumferential application of plas-
ter or fiberglass. As such, casts provide superior immobilization, but
they are more technically difficult to apply and less forgiving dur-
ing the acute inflammatory stage; they also carry a higher risk of
complications. Compartment syndrome, thermal injuries, pressure

ILLUSTRATION BY bert oppenheim

sores, skin infection and dermatitis, and joint stiffness are possible
complications of splinting and casting. Patient education regarding
swelling, signs of vascular compromise, and recommendations for
follow-up is crucial after cast or splint application. (Am Fam Physi-
cian. 2009;79(1):16-22, 23-24. Copyright © 2009 American Academy
of Family Physicians.)

T
Patient information: he initial approach to casting and and the patient’s functional requirements.
▲

A handout on casting and splinting requires a thorough Splinting is more widely used in primary care
splinting, written by the
authors of this article, is assessment of the skin, neurovas- for acute as well as definitive management
provided on page 23. cular status, soft tissues, and bony (management following the acute phase of
structures to accurately assess and diagnose an injury) of orthopedic injuries. Splints
the injury.1 Once the need for immobiliza- are often used for simple or stable fractures,
tion has been determined, the physician must sprains, tendon injuries, and other soft-tissue
decide whether to apply a splint or a cast. injuries; casting is usually reserved for defini-
tive and/or complex fracture management.
Splinting Versus Casting
Advantages of Splinting
Casts and splints serve to immobilize ortho-
pedic injuries (Table 1).2 They promote heal- Splint use offers many advantages over cast-
ing, maintain bone alignment, diminish pain, ing. Splints are faster and easier to apply.
protect the injury, and help compensate for They may be static (i.e., prevent motion)
surrounding muscular weakness. Improper or dynamic (i.e., functional; assist with
or prolonged application can increase the controlled motion). Because a splint is
risk of complications from immobilization noncircumferential, it allows for the natu-
(Table 2).2,3 Therefore, proper application ral swelling that occurs during the initial
technique and timely follow-up are essential.3 inflammatory phase of the injury. Pressure-
When considering whether to apply a related complications (e.g., skin breakdown,
splint or a cast, the physician must assess the necrosis, compartment syndrome) increase
stage and severity of the injury, the poten- with severe soft-tissue swelling, particularly
tial for instability, the risk of complications, in a contained space such as a circumferential

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 Casting and Splinting

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References

Splinting is the preferred method of fracture immobilization in the C 4

acute care setting.
Casting is the mainstay of treatment for most fractures. C 4
Plaster should be used for most routine splinting applications. C 6
However, when weight or bulk of the cast or the time to bearing
weight is important, a synthetic material chosen principally on the
basis of cost is indicated.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi-

dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information
about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

cast (Table 2).2,3 Therefore, splinting is the plaster is more pliable and has a slower set-
preferred method of immobilization in the ting time than fiberglass, allowing more
acute care setting.4 Furthermore, a splint time to apply and mold the material before it
may be removed more easily than a cast, sets. Materials with slower setting times also
allowing for regular inspection of the injury produce less heat, thus reducing patient dis-
site. Both custom-made and standard “off- comfort and the risk of burns. Fiberglass is
the-shelf” splints are effective.2 a reasonable alternative because the cost has
declined since it was first introduced, it pro-
Disadvantages of Splinting duces less mess, and it is lighter than plaster.
Disadvantages of splinting include lack of Fiberglass is commonly used for nondisplaced
patient compliance and excessive motion at
the injury site. Splints also have limitations
in their usage. Fractures that are unstable or Table 1. Conditions That Benefit from Immobilization
potentially unstable (e.g., fractures requiring
reduction, segmental or spiral fractures, dis- Fractures Inflammatory conditions: arthritis,
Sprains tendinopathy, tenosynovitis
location fractures) may be splinted acutely to
Severe soft-tissue injuries Deep laceration repairs across joints
allow for swelling or to provide stability while
Reduced joint dislocations Tendon lacerations
awaiting definitive care. However, splints
themselves are inappropriate for definitive
note: Listed in order from most common to least common.
care of these types of injuries. Such fractures
Adapted with permission from Chudnofsky CR, Byers S. Splinting techniques. In: Roberts
are likely to require casting and orthopedic JR, Hedges JR, Chanmugam AS, eds. Clinical Procedures in Emergency Medicine. 4th ed.
referral.4 Philadelphia, Pa.: Saunders; 2004:989.

Advantages and Disadvantages

of Casting

Casting is the mainstay of treatment for most Table 2. Complications of Cast or Splint Immobilization
fractures.4 Casts generally provide more
effective immobilization, but require more Compartment syndrome Infection
skill and time to apply and have a higher Ischemia Dermatitis
risk of complications if not applied properly Heat injury Joint stiffness
(Table 2).2,3 Pressure sores and skin breakdown Neurologic injury

Materials and Equipment note: Listed in order from most clinically relevant to least clinically relevant.

Plaster has traditionally been the preferred Information from references 2 and 3.
material for splints.5,6 One advantage is that

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Casting and Splinting
Table 4. Factors That Affect Setting
Times for Casts and Splints

Factors that speed setting times

fractures and severe soft-tissue injuries. Pre- Higher temperature of dipping water
vious literature has demonstrated the ben- Use of fiberglass
efits of using plaster rather than fiberglass Reuse of dipping water
following fracture reduction.6 Table 3 lists Factors that slow setting times
standard materials and equipment used in Cooler temperature of dipping water
splint and cast application.2 Use of plaster
Regardless of the material used, the most
important variable affecting the setting note: Listed in order from most clinically relevant to
least clinically relevant.
time is water temperature (Table 4).7 Cast-
Information from reference 7.
ing materials harden faster with the use of
warm water compared with cold water. The
faster the material sets, the greater the heat
produced, and the greater the risk of signifi-
cant skin burns. Cool water is also recom-
mended when extra time is needed for splint
application.
The dipping water should be kept clean
and fresh. In general, the temperature of
the water should be tepid or slightly warm
for plaster, and cool or room temperature
for fiberglass. These temperatures allow for
a workable setting time and have not been
associated with increased risk of significant
burns. Applying excess material or using an
overly compressive elastic wrap also increases
the risk of excessive heat production. There- Figure 1. Measuring the stockinette. Black
fore, it is best to use only the amount of lines indicate the ends of the intended splint.
Ulnar gutter splint is used to illustrate the
splinting material and compression required procedure. This splint is commonly used to
to stabilize the injury.8 A good rule of thumb treat a “boxer’s fracture” (distal fifth meta-
is that heat is inversely proportional to the carpal fracture), but may also be used to
setting time and directly proportional to the immobilize fractures and serious soft-tissue
number of layers used. injuries of the fourth and fifth fingers and
metacarpals. Alternate splints are chosen for
other injuries.
General Application Procedures
The physician should carefully inspect the cular status before splint or cast application.
involved extremity and document skin Following immobilization, neurovascular
lesions, soft-tissue injuries, and neurovas- status should be rechecked and documented.
The patient’s clothing should also be covered
with sheets to protect it and the surrounding
Table 3. Standard Materials and Equipment area from being soiled by water and plaster
for Splint and Cast Application or fiberglass.

Adhesive tape (to prevent slippage Elastic bandage (for splints) Preparing the Injured Area
of elastic wrap used with splints) Padding To prepare the injured extremity for splint-
Bandage scissors Plaster or fiberglass casting ing, stockinette is measured and applied
Basin of water at room material
temperature (dipping water)
to cover the area and extend about 10 cm
Sheets, underpads (to minimize
Casting gloves (necessary for
beyond each end of the intended splint site
soiling of the patient’s clothing)
fiberglass) (Figures 1 through 3). Later, once the pad-
Stockinette
ding and splint material have been applied,
Information from reference 2. the excess stockinette is folded back over the
edges of the splint to form a smooth, pad-

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 Figure 2. Stockinette application. Stockinette
should extend about 10 cm beyond each
end of the intended splint site. Black lines
beneath the stockinette indicate the ends of
the intended splint.

Figure 4. Stockinette and padding extend

2 to 3 cm beyond the intended edges of the
splint, with extra padding at each end of the
intended splint border.

matic swelling is anticipated and care is

being taken to avoid using any circumferen-
tial materials that are not essential. To create
a splint without stockinette, padding that is
slightly wider and longer than the splint-
ing material should be applied in several
layers directly to the smoothed, wet splint.
Together, the padding and splinting material
are molded to the extremity.
Next, layers of padding are placed over
the stockinette to prevent maceration of the
underlying skin and to accommodate for
swelling. Padding is wrapped circumferen-
tially around the extremity, rolling the mate-
rial from one end of the extremity to the other,
each new layer overlapping the previous layer
by 50 percent. This technique will automati-
Figure 3. Ulnar gutter stockinette, cut and
folded.
cally provide two layers of padding. Extra
layers may be added over the initial layers,
ded edge. Care should be taken to ensure if necessary. The padding should be at least
that the stockinette is not too tight, and two to three layers thick without being con-
that wrinkling over flexion points and bony strictive, and should extend 2 to 3 cm beyond
prominences is minimized by smoothing the intended edges of the splint (Figure 4).
or trimming the stockinette. Generally, a Extra padding is placed at each end of the
stockinette 2 to 3 inches wide is used for the intended splint border, between digits, and
upper extremities and 4 inches wide for the over areas of bony prominence. Promi-
lower extremities. nences at highest risk are the ulnar styloid,
Once a physician is proficient in splint- heel, olecranon, and malleoli. If significant
ing, an acceptable alternative is to create a swelling is anticipated, more padding may
splint without the use of a stockinette. This be used; however, care must be taken not
technique may be particularly useful if dra- to compromise the support provided by the

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Casting and Splinting
Table 5. Guidelines for Proper Cast
and Splint Application

Use appropriate amount and type of padding

splint by using too many layers. Both too Properly pad bony prominences and high-
much and too little padding are associated pressure areas
with potential complications and poor fit of Properly position the extremity before, during,
the splint or cast (Table 5).2,4 and after application of materials
Joints should be placed in their proper Avoid tension and wrinkles on padding,
plaster, and fiberglass
position of function before, during, and after
Avoid excessive molding and indentations
padding is applied to avoid areas of excess
wrinkling and subsequent pressure. In gen- note: Listed in chronologic order.
eral, the wrist is placed in slight extension Information from references 2 and 4.
and ulnar deviation, and the ankle is placed
at 90 degrees of flexion. Padding comes in
several widths. In general, padding 2 inches
wide is used for the hands, 2 to 4 inches for
upper extremities, 3 inches for feet, and 4 to
6 inches for lower extremities.
Prefabricated splints are also available.
They consist of fiberglass, padding, and a
mesh layer, and are easily cut and molded to
the injured extremity. These prefabricated
splints, however, are more expensive and are
not available in all settings.

Splint Preparation

To estimate the length of splint material

needed, the physician should lay the dry splint
next to the area being splinted (Figure 5).
An additional 1 to 2 cm should be added at
Figure 5. Measuring the splinting material.
each end of the splint to allow for shrink-
age that occurs during wetting, molding,
and drying. Ultimately, the splint should be layers necessary to achieve adequate strength
slightly shorter than the padding. should be used.
If using plaster, the physician should mea-
Splint Application
sure and layer the appropriate number of
sheets for the desired splint. If using a roll Dry, layered splint material should be sub-
of fiberglass, the physician should unroll the merged in water until bubbling from the
splint material to the appropriate length to materials stops. The splint is removed and
create the first layer. When the splint edge is excess water squeezed out. Fiberglass will
reached, the next layer should be folded back feel damp; plaster will have a wet, sloppy
on itself to create the subsequent layer. This consistency. The splint is then placed on a
process should be repeated until a splint with hard surface and smoothed to remove any
the appropriate number of layers has been wrinkles and to ensure even wetness of all
created. The thickness of the splint depends layers. With the extremity still in its position
on the patient’s size, the extremity involved, of function, the wet splint is placed over the
and the desired strength of the final product. padding and molded to the contours of the
For an average-size adult, upper extremities extremity using only the palm of the hand
should be splinted with six to 10 sheets of to avoid pressure points produced by the
material, whereas lower extremity injuries fingers. Finally, the stockinette and padding
may require 12 to 15 sheets. Use of more edges are folded back to create a smooth edge
sheets provides more strength, but the splint (Figure 6). The dried splint is secured with
will weigh more, produce more heat, and be an elastic bandage wrapped in a distal to
bulkier. In general, the minimum number of proximal direction (Figure 7).

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 Casting and Splinting

Cast Application
The principles of casting are similar to those
of splinting (Table 5).2,4 Once the extrem-
ity has been prepared with stockinette and
padding and placed in the desired position,
the plaster or fiberglass material is applied.
The casting material is wrapped circumfer-
entially, with each roll overlapping the previ-
ous layer by 50 percent. The physician should
avoid placing excess tension on the plaster or Figure 6. Ulnar gutter splint molded and padding and stockinette
fiberglass because it can create a tight, con- edges folded back.
strictive cast that may damage underlying
skin through pressure, neurovascular com-
promise, or both. Conversely, a cast that is
overly padded or loosely applied can allow
for significant rubbing, friction, and skin
injuries (e.g., abrasions, friction blisters).
Just before the final layer of casting material
is applied, the physician should fold back the
stockinette and padding, and then apply the
final layer (Figure 8), molding the cast while
the materials are still malleable.

Complications of Splinting and Casting

Compartment syndrome is the most seri-
ous complication of casting or splinting. It Figure 7. Elastic bandage applied to secure the splint.
is a condition of increased pressure within
a closed space that compromises blood flow
and tissue perfusion and causes ischemia and
potentially irreversible damage to the soft
tissues within that space. If an immobilized
patient experiences worsening pain, tingling,
numbness, or any sign of vascular compro-
mise such as severe swelling, delayed capil-
lary refill, or dusky appearance of exposed
extremities, an immediate visit to the nearest
emergency department or urgent care office
is indicated for prompt removal of the cast.
Thermal injuries to the skin can occur as
a result of the casting or splinting process.7
Skin breakdown is the most common com-
plication, often caused by focal pressure
from a wrinkled, unpadded, or underpadded
area over a bony prominence or underlying
soft tissue. This can be minimized by ensur-
ing that the padding is adequate and smooth,
without indentations during application.
Bacterial and fungal infections or a pru-
ritic dermatitis can develop beneath a splint
or cast. Infection is more common with an Figure 8. Ulnar gutter cast (shown for com-
open wound, but the moist, warm environ- parison to ulnar gutter splint).

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Casting and Splinting

ment of a splint or cast can be ideal for infec- in Cleveland, Ohio. She completed a family medicine resi-
dency at a Tufts University–affiliated program in Beverly,
tion.9 Finally, some degree of joint stiffness Mass., and a primary care sports medicine fellowship at
is an inevitable complication of immobiliza- Kaiser Permanente, Calif.
tion. With proper application technique and
HOLLY J. BENJAMIN, MD, FAAP, FACSM, is an associate
effective patient education, complications professor of pediatrics and orthopedics at the University
can be minimized. of Chicago (Ill.), where she is also director of the primary
care sports medicine program. Dr. Benjamin received her
Follow-up and Length of medical degree from Northeastern Ohio Universities Col-
lege of Medicine in Rootstown. She completed a pediatrics
Immobilization residency at the University of Chicago, and a sports medi-
Educating patients about cast and splint care cine fellowship at Advocate Lutheran General Hospital in
is crucial. They should receive both verbal Park Ridge, Ill. She serves on the board of directors for
the American Medical Society for Sports Medicine, is part
and written instructions on the importance of the executive committee for the American Academy of
of elevating the injured extremity to decrease Pediatrics Council on Sports Medicine and Fitness, and is a
pain and swelling, and on splint/cast care fellow of the American College of Sports Medicine.
and precautions. They should also refrain CHAD ASPLUND, MAJ, MC, USA, is a clinical faculty
from getting the material wet or pushing member of the Eisenhower Army Medical Center in Fort
objects inside a cast to scratch. It is extremely Gordon, Ga. He received his medical degree from the Uni-
versity of Pittsburgh School of Medicine, and completed
important that patients continually check for
a family medicine residency at DeWitt Army Community
signs of compartment syndrome and report Hospital in Fort Belvoir, Va.
immediately to an urgent or emergent care
Address correspondence to Anne S. Boyd, MD, FAAFP,
facility for removal of the cast or splint at the Lawrenceville Family Health Center, 3937 Butler St.,
first sign of vascular compromise. Ice can be Pittsburgh, PA 15201. Reprints are not available from
applied for 15 to 30 minutes at a time over a the authors.
cast or splint. Strong opioids should be used Author disclosure: Nothing to disclose.
with caution during the first two to three
days after splinting because they can mask
REFERENCES
pain that would otherwise prompt a follow-
up visit.4 1. Reider B, ed. The Orthopaedic Physical Examination.
Philadelphia, Pa.: Saunders; 1999:2-17.
Time to follow-up and length of immobi-
2. Chudnofsky CR, Byers S. Splinting techniques. In: Rob-
lization are extremely variable, depending erts JR, Hedges JR, Chanmugam AS, eds. Clinical Proce-
on the site, type, and stability of the injury dures in Emergency Medicine. 4th ed. Philadelphia, Pa.:
Saunders; 2004:989.
and on patient characteristics (e.g., age,
3. Simon RR, Koenigsknecht SJ, eds. Emergency Ortho-
accessibility, compliance). Most splints and pedics: The Extremities. Norwalk, Conn.: Appleton and
casts require initial follow-up within one to Lange; 1995:3-20.
two weeks after application, and most frac- 4. Eiff MP, Hatch R, Calmbach WL, eds. Fracture Manage-
ture guidelines estimate four to eight weeks ment for Primary Care. 2nd ed. Philadelphia, Pa.: Saun-
ders; 2003:1-39.
for healing. However, all injuries must be
5. Wehbé MA. Plaster uses and misuses. Clin Orthop Relat
assessed, treated, and followed on an indi- Res. 1982;(167):242-249.
vidual basis. 6. Bowker P, Powell ES. A clinical evaluation of plaster-of-
Paris and eight synthetic fracture splinting materials.
The opinions and assertions contained herein are the Injury. 1992;23(1):13-20.
private views of the authors and are not to be construed
7. Yap NF, Fischer S. Burns associated with plaster of Paris.
as official or as reflecting the views of the U.S. Army or
Presented at the Royal Australasian College of Surgeons
the U.S. Army Medical Service at large.
Annual Scientific Congress, Perth 9-13 May 2005.
Abstract no. HS010P. http://www.blackwellpublishing.
com/RACS/abstract.asp?is=20349. Accessed July 16,
The Authors 2007.
ANNE S. BOYD, MD, FAAFP, is a clinical associate pro- 8. Wytch R, Ashcroft GP, Ledingham WM, Wardlaw D,
fessor of family medicine at the University of Pittsburgh Ritchie IK. Modern splinting bandages. J Bone Joint
(Pa.) School of Medicine, and director of the primary care Surg Br. 1991;73(1):88-91.
sports medicine fellowship program at the University of 9. Houang ET, Buckley R, Williams RJ, O’Riordan SM. Out-
Pittsburgh Medical Center St. Margaret. Dr. Boyd received break of plaster-associated Pseudomonas infection.
her medical degree from Case Western Reserve University Lancet. 1981;1(8222):728-729.

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