SAN DIEGO — As many as 93% of splints applied to fractures in children at pediatric emergency departments and urgent care centers may be done incorrectly, according to the results of a new study.

The rates of misapplied splints were "much higher than I anticipated," said Joshua Abzug, MD, director of pediatric orthopedics and assistant professor of orthopedics at the University of Maryland School of Medicine, in Baltimore.

Dr Abzug presented the research here at the American Academy of Pediatrics (AAP) 2014 National Conference and Exhibition.

Mistakes such as insufficient mobilization and application of elastic bandages directly to skin can cause minor complications that impede recovery and even, in rare cases, require surgical interventions. Previous case reports have detailed potential complications, including swelling, skin breakdown, and poor healing, but the researchers wanted to put together a more compelling case.

"Rather than just having anecdotal evidence, we wanted to have real data to show the people providing the splints and say, 'We need to make a change,' " Dr Abzug told Medscape Medical News.

The team studied 225 patients aged 0 to 18 years who were brought to the pediatric orthopedic clinic after having a splint placed at an emergency department or urgent care clinic. The patient or accompanying parent filled out a standardized questionnaire indicating the type of splint, the type of facility where it was placed, the practitioner who performed the splint placement, and the length of time from when the splint was placed to the arrival of the child at the orthopedic clinic.

After examining the splint, the orthopedic surgeon removed it and examined the injury for soft tissue complications. In 31 patients who had undergone fracture reduction, the splint was not removed.

The researchers found high rates of complications and errors, with 93% of splints having been misapplied in some way.

Table. Errors and Complications Related to Splint Application

Error or Complication Incidence, %
All Patients (n = 225)  
   Improper placement 93
   Inappropriate length 50
   Elastic bandage placed against skin 78
Patients With Splint Removal (n = 194)  
   Skin and soft tissue complications 41
   Excessive edema 30
   Pressure points on skin 19
   Pressure points overlying bony prominences 2
   Direct injury to the skin and soft tissue 6

The study did not reveal any major complications, but minor complications are not insignificant, said Dr Azbug. "With stiffness, for example, which is very difficult to quantify, it may take patients longer to get their range of motion back. It may make the recovery longer," he said.

Dr Abzug plans to produce instructional cards and posters with "do's" and "don'ts" that could be displayed in urgent care offices, emergency care clinics, and on splint carts.

The numbers are alarmingly high.

"The numbers are alarmingly high," said Theodore Ganley, MD, sports medicine director at Children's Hospital Philadelphia and an associate professor of orthopedic surgery at the University of Pennsylvania School of Medicine, who attended the presentation.

"Fortunately, kids are resilient. They tolerate splints that aren't perfectly placed, and overall, they respond well to minor skin irritations. If there is a positive, it's that with instruction, those splint placement errors are correctable issues," he told Medscape Medical News.

Dr Ganley suggested that face-to-face communications, along with videos and posters, could help build awareness throughout the healthcare system. "This can help prevent major issues, such as major skin breakdowns," he said.

Dr Abzug and Dr Ganley have reported no relevant financial relationships.

American Academy of Pediatrics (AAP) 2014 National Conference and Exhibition. Abstract 27212. Presented October 11, 2014.


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