Fabricating a Volar Extension Splint for Colles' Fracture

Original Editor - Jess Bell Top Contributors - Jess Bell, Kim Jackson, Ewa Jaraczewska, Admin, Tarina van der Stockt and Chelsea Mclene

Introduction

Distal radius fractures with dorsal angulation (also known as Colles Fractures) are usually the result of a fall on an outstretched hand. In children and young adults, the force required for this sort of fracture is much higher (e.g. a fall off monkey bars or a car accident), whereas, in older adults, distal radius fractures tend to occur following a low-energy trauma (e.g. a fall from a standing height). In younger populations, males are more likely to sustain this fracture. In older populations, it is more common in females. There is also a correlation with osteopenia in older adults.

Many distal radius fractures are managed conservatively, but a number will require surgical fixation. You can read detailed post-operative protocols for Colles’ fractures fixed with open reduction internal fixation (ORIF) here (0-6 weeks post-op) and here (beyond 6 weeks post-op).

Because inadequate management of distal radius fractures can result in chronic wrist pain, reduced mobility, and impact hand function, must treat these fractures appropriately. While a recent review and meta-analysis of surgical treatments found no clinically important differences between various surgical options for a functional outcome one-year post-surgery, the authors of this study noted that:

• Volar plating was associated with fewer complications, particularly for individuals with intraarticular fractures
• Nonbridging external fixation was associated with fewer complications for individuals with extraarticular fractures
• Non-operative treatments may still be preferred for individuals more than 60 years old

Patients with ORIF will need a volar distal orthosis fitted on day one post-surgery. These splints are preferable to a circumferential splint as they are easier to take on and off. As this patient group has had ORIFs to stabilise their fracture, there is no need for them to be fully immobilised. The splints are primarily used for protection (i.e. in case of a fall or a blow to the wrist).

Here we outline a simple method of fabricating this splint:

Required Materials

1. Thermoplastic sheet in basic rectangle template – length is based on the distance from the patient’s MCP joints to around two-thirds of the length of his/her forearm
2. Frying pan
3. Splinting sheers
4. Egg flipper
5. Looped Velcro straps x 3
6. Sticky backed hooks x 3

Method

Figure 1. Thumb hole position on thermoplastic sheet

1. Place the thermoplastic sheet into hot water in the frying pan. This will make it soft and malleable. To avoid burns, please check the temperature before putting the sheet on the patient’s skin.
   
   
2. Once the thermoplastic sheet is softened enough, cut the thumb hole. First, pierce the material with scissors and cut out a small circle. Generally, the thumb hole should be around 3cm from the top of the sheet and 3cm from the side (see Figure 1).
   
   
3. Place the thermoplastic sheet back into the warm water and roll out the thumb hole's edges to ensure it will be comfortable and smooth when worn (see figure 2).
   
   
   

   Figure 2. Rounded edges on volar splint
4. Place the splint on your patient’s hand. Hook the thumb hole around their thumb and mould the plastic around their forearm and through the curvature of their hand. It is best if you sit opposite your patient, with their elbow resting on the table (see figure 3). Remember to check that:
   • The end of the splint is below the MCP crease distally, so the patient can achieve full finger flexion.
   • The area between the thumb and index finger is flat and thin so that the thumb won’t get any pressure areas when moving into abduction
   • The thumb area is large enough to ensure no rubbing on the CMC and to achieve full opposition between the thumb and little finger
   • The patient is in slight wrist extension when fitting the splint – usually 10-15 degrees
     
     
     

     Figure 3. Positioning for fitting volar splint over thumb
5. Once the plastic has dried and hardened (usually very quickly), the splint is ready to be trimmed down to fit the patient. Remember the splint should reach 2/3 of the forearm length, and the sides should be trimmed so that the splint sits at around ¾ depth of the forearm.
   
   
6. Flare the area around the ulnar styloid to avoid any pressure/rubbing in this area.
   
   
   

   Figure 4. Position of 3 velcro straps on volar splint
7. Place the splint back into a frying pan so that you can roll the bottom and top edges to make it smooth on the edges for comfort (see Figure 2).
   
   
8. Add velcro straps to the splint, starting with the most distal strap (which should be the thinnest strap at 2cm wide). This strap should be positioned on a slight diagonal angle (i.e. place it on a downward tilt). For longevity of the splint, try using a heat gun to heat the backing of the hook onto the splint.
   
   
9. Add the middle strap ( 3cm wide) straight across the back of the wrist.
   
   
10. The final strap rests at the proximal end of the splint. This strap should be positioned slightly upward to sit flat when the splint is applied (see Figure 4).
    
    
    

    Figure 5. Volar splint correctly positioned
11. Place the splint on the patient’s arm. Remember to check:
    • The distances at the MCP
    • That the splint clears the CMC joint
    • That the wrist is slightly extended
    • That the straps are firm, without being too tight (see figure 5)
      
      
12. Trim the straps down to fit the patient. Round the edges of the straps and Velcro hooks to stop them from catching on clothing.
    
    
13. Providing a tubigrip or a splint sock worn under the splint is often useful to reduce rubbing/sweating. This will help with comfort and may increase compliance around splint use.

Patient Education

Informed consent

The clinician should explain the procedure to the patient and obtain written or verbal consent. The patient must be willing to partner with the healthcare team in the care plan, including wearing the splint. The explanation given to the patient and caregiver may include, but should not be limited to the following information:

• Reason for choosing this type of splint
• Risk, benefits and possible complications of wearing the splint
• Skin and splint care
• The wearing schedule

Skin Care

• Ensure the skin under the splint is dry
• Check the skin daily for redness, swelling
• Contact your healthcare provider if the redness continues or worsens
• Elevate the splinted extremity to minimise swelling

Splint Care

The following are general suggestions for splint care. However, patients should follow the specific instructions and recommendations from their healthcare team:

• Keep the splint clean and dry
• If the splint gets wet, you can dry it with a hair dryer. Use a "cool" setting.
• Using two sets of hands helps with proper splint application (ask a family member to assist)
• Follow the assigned wear time, but consult with your therapist if the pain is present during the wear time
• The therapist should provide detailed care instructions for custom-made splints
• Hand wipe the splint with gentle soap cleaner when it is soiled or has an odour

Potential Complications

The possible complications of wearing a splint or the consequences of not wearing a splint as recommended must be explained to the patient before the splint is applied. This information should be included in the informed consent and/or written instructions given to the patient or the caregiver. These potential complications include the following:

• Alteration to circulation
• Skin pressure ulcers, especially around bony prominences
• Fingers swelling
• Joint stiffness or contracture
• Wound infections
• Compartment syndrome  
• Decreased patient compliance

Patient Discharge Instructions

You can provide the patient with discharge instructions, which should contain the following information:

Caring for your Splint

You have received a volar extension splint. This splint helps to protect your wrist in case of a fall or direct blow to the wrist.  You must care for the splint and prevent it from being damaged. The damaged splint will no longer be appropriate for wearing. Take good care of your splint. If your splint becomes damaged or loses its shape, you need to contact the clinic as it more likely needs to be replaced.

You have a broken bone in your forearm. The bone was repaired with a procedure called ORIF (open reduction, internal fixation), and the doctor prescribed a splint for you to be worn daily for________days

Splint care

• Wear your splint according to the instructions you received.
• Keep the splint dry at all times. Tape two layers of plastic to cover your splint when you shower or bathe, unless your doctor or therapist said you can take it off while bathing..
• If you need to keep the splint on during hygiene, bathe with your splint, but hold it protected with a plastic bag outside the tub or shower when bathing. Use two layers of plastic closed at the top end with a rubber band to protect the splint from getting wet. Or you can buy a waterproof shield.
• If your splint gets wet, dry it with a hair dryer in the “cool” setting. Do not use the warm or hot setting because you can burn your skin.
• Always keep the splint clean, away from dirt and open flames.
• Wash the Velcro straps and inner cloth sleeve if provided (stockinet), with soapy water and air dry.
• Do not expose your splint to heat, space heaters, or prolonged sunlight. Excessive heat will cause the splint to change shape.
• Do not cut or tear the splint.
• Elevate the part of your body that is in the splint. This helps reduce swelling.

Follow-up care

Make a follow-up appointment with your healthcare provider or as advised.

You need to call your healthcare provider if:

• You experience tingling or numbness in the affected area
• You have severe pain that cannot be relieved with medicine
• The splint feels too tight or too loose
• You observe swelling, coldness, or blue-grey colour in the fingers or toes
• The splint becomes damaged, cracked, or has rough edges that hurt
• You notice pressure sores or red marks that do not go away within 1 hour after removing the splint
• Blisters are present

If you experience any of the above symptoms or have questions related to splint wear and care, please call us at…………………….

Please modify these instructions to meet the needs of your patient and caregiver.

Staff Training

Improper splint fabrication and application may result in adverse outcomes. Staff training and the ability to test their technical competency validly and reliably is critical in reducing negative patient outcomes. A clinician who wants to become competent in splint fabrication should demonstrate the following :

• Technical skill and clinical reasoning to ensure optimal patient outcomes
• Knowledge of the principles of the biomechanics of the splint
• Psychomotor skills
  • Handling of the material
  • Cutting the plastic
  • Securing the Velcro
  • Rolling sharp edges
  • Moulding the splint into the correct position on the patient

Competency-based education is a teaching framework that assesses clinician's skills based on measurable outcomes. To assess technical skills in splint fabrication, a minimum requirement to safely perform this task must be established before the training starts.

Table 1 is an example of competency-based training in splint fabrication.

Skill	Teaching method (discussion, self-study, PowerPoint presentation)	Verification method (Quiz, practice lab, return demonstration)
Indications: Clinician to state and demonstrate independence with various indications for splinting: Objectives, Diagnoses, Risks/Benefits
Precautions/Contraindications: Clinician to state and demonstrate independence with precautions/ contraindications for splints.
Pre-fabrication Considerations: clinician to state and demonstrate independence with pre-fabrication considerations, including: Thermoplastics: types and characteristics Joints to be immobilised How to secure splint in place-strapping vs wrapping Areas at risk for pressure
Procedure: Identify common procedures associated with the type of splint and indications for specific positioning.
Supplies: List necessary supplies
Assess and Document: State components of pre- and post-splint assessment and documentation.
Fabrication: Demonstrate independence with splint fabrication: Anatomy/landmarks of hand/digits Anatomy of the wrist Measure and trace the pattern onto thermoplastic Properties of thermoplastic Positioning of joints before fabrication Cooling of splint Modifications
Communication: Demonstrate independence with all necessary communication components with the patient and RN regarding the splint.
Splint Check: Identify the timeline and components of the splint check.
Documentation: Identify different charges required for splint fabrication vs. splint check and provide support documentation for untimed vs timed charges.
SPLINT LABS: volar extension splint

Table 1. Adapted from: Splinting Competency. Loyola University Medical Center. Inpatient Rehabilitation Services

Summary

1. Clinicians should obtain written or verbal consent.
2. Ensure proper skin care under the splint.
3. Patients should follow their healthcare team's instructions and recommendations regarding the wearing schedule.
4. Patients should receive discharge instructions on how to carry for the splint
5. Staff's competency in splint fabrication must be verified

Additional References

• Parkin D-L. Developing a valid and reliable tool to assess competence in fabricating custom hand orthoses: self versus expert assessment. Master Thesis. School of Allied Health Faculty of Health and Medical Sciences The University of Western Australia, 2019.