Editor’s Spotlight/Take 5: Can Simple Changes in Splinting Technique Reduce Posterior Heel Contact Pressure?

James R. Holmes MDIt has been a very long time since I’ve put a splint on someone’s leg. Perhaps the same is true for you (unless you are a resident or registrar). But if you’re taking general orthopaedic call, there’s a good chance that people—maybe those residents or registrars, or maybe a midlevel professional like a physician assistant or nurse practitioner—are putting splints or casts on patients in your name. And while those individuals act with the best intentions, just as you or I would, sometimes their splints cause harm. I didn’t realize until reading this month’s Editor’s Spotlight/Take 5 article in Clinical Orthopaedics and Related Research® [3] just how common or severe that harm can be. Apparently, splint-induced skin ulcers are the second most common iatrogenic cause of plastic surgery referrals [2]. And although not all of these come from splints or casts, at least 17,000 lawsuits are filed each year because of pressure-related skin ulcers, which makes them one of the top causes of healthcare claims among patients treated in hospitals [1]. Most importantly, I’m pretty sure we’ve all seen a deep skin ulcer caused by a splint, and that we all agree that we never want to see one ever again. For that reason, and with the hope that you’ll share this month’s Spotlight article with the call-takers in your group and with those who apply splints and casts under your supervision (or for your practice), we’re proud to share “Can Simple Changes in Splinting Technique Reduce Posterior Heel Contact Pressure?” [3] This article and the Take 5 interview that follows with its senior author, James R. Holmes MD from the University of Michigan, offer some simple, practical suggestions that will help you and your team avoid this mostly preventable, always upsetting, and often serious complication. Although their study [3] was a biomechanical exploration of contact pressures rather than a clinical one (for obvious reasons), the authors used a common-sense threshold pressure (32 mm Hg, which is the pressure at which dermal arteriole capillaries collapse) as well as splint characteristics associated with unusual skin pressure spikes. They found that floating the heel—putting a pillow under the calf—is a critical step to take, since they found no reasonable amount of padding (they went up to 10 layers) that would keep the skin pressure under 32 mm Hg if the heel was allowed to remain in contact with the bed. They also found a shocking—a mean threefold—increase in skin pressures when the cast padding was bunched rather than evenly applied. The pressure increases measured with bunched padding compared to padding that was evenly applied were frankly frightening (a mean increase of 112 mm Hg [95% CI 46 to 178 mm Hg]). As always, there’s more than meets the eye. Join me to go behind these important discoveries in the Take 5 interview that follows with Dr. Holmes, senior author of “Can Simple Changes in Splinting Technique Reduce Posterior Heel Contact Pressure?” [3]. Take 5 Interview with James R. Holmes MD, senior author of “Can Simple Changes in Splinting Technique Reduce Posterior Heel Contact Pressure?” Seth S. Leopold MD:Congratulations on this simple but very informative study [3]. Let’s cut right to it: You’re putting a splint on a patient with an ankle fracture in the emergency department. How, exactly, are you doing it? James R. Holmes MD: Of course it depends on the specifics of the ankle fracture: Is the injury stable enough so the patient can sit up on the side of the bed and let the leg dangle, or does it require a reduction and therefore an assistant to help me hold the ankle in a reduced position? But in general, ideally, I would slide stockinette over the distal extremity and make a transverse cut in the stockinette at the anterior ankle so it does not bunch up. Then I would take a roll of the more fluffy cast padding and double over nearly the entire roll to a length of 6 to 8 inches, save for the amount needed to wrap the ankle a couple of times. I would put the redundant cast padding “bundle” posteriorly on the heel and use the remaining cast padding to secure it around the ankle. Depending on the size of the limb, I would place at least four more rolls (and sometimes more) circumferentially around the extremity, from toes to tibial tubercle, without wrinkles. It is important to maintain the ankle position during this. For example, if one applies this splint and cast padding with the ankle plantarflexed, and then one dorsiflexes the ankle after applying the plaster, the cast padding in the front of the ankle will bunch up, which can cause a pressure injury (my colleague, Paul Talusan, studied this [4]). I save at least one roll to place over the plaster, making removal a little less dusty. Lastly, as we all learned during our pediatric rotations, I hold the completed splint in place until the plaster is mostly set up and then place it on blankets, not on a hard or vinyl surface, where the heat may be reflected up and/or the plaster may deform if not fully cured. With all the emphasis on cast padding, I think we lose sight of what is equally important, if not more so: the appropriate molding of the plaster. This is obviously paramount when we put on a circumferential plaster cast, but it is also important with splint application. Dr. Leopold:How did your discoveries change how you think about splinting, teach splinting, and/or do splinting in your practice and training program? Dr. Holmes: Our study in this month’s CORR [3] aimed to quantify pressure ulcer risk, and I think it did so reasonably well. We hope this will lead to some uniformity in splinting—a procedure that happens thousands of times every day in this country, and yet we have no “best practice” model to guide clinicians. I think it is best to have a uniform recommendation that accommodates the spectrum of patients we see, because that is easier to implement and maintain. In practice, we try to teach our interns the principles of reduction and splinting during a “boot camp” that precedes the beginning of their internship year. If problems or potential problems with splints are identified in the clinic, we provide real-time feedback. Lastly, when reviewing radiographs, we try to make a point of looking not just at the osseous structures, but the contours of the splint as well. When viewed critically, it is obvious that we can all do a better job with splinting if we are honest with ourselves. Dr. Leopold:To what degree (and how) do your recommendations change—if at all—based on the diagnosis you’re treating, other patient-level factors, and whether it’s a splint, a cast, or a bivalved cast? Dr. Holmes: A clinician must have a good understanding of the level of cooperation he or she can reasonably expect from each patient. The patients we see generally fall into three categories: those with normal sensation, those with normal sensation that is temporarily impaired with a regional anesthetic, and those with impaired sensation from medical diagnoses. Patients without impaired sensation whom you believe to be reliable will usually do well with removable devices, such as bivalved casts or walking boots, as long as they receive very clear instructions about the hazards of these devices, how to do skin checks, and what immediate measures should be taken if they start to feel increased pressure. The importance of seeking immediate medical attention should they develop any problems cannot be stressed enough. We are now preparing a manuscript that looks at posterior heel pressure in removable devices, and even with the appropriate positioning, it appears that these pressures exceed capillary occlusion pressures and therefore put patients at risk for soft tissue injury. If a clinician is leaning toward casting, it is important to consider the skill level of the person who will be applying the cast. The technique of molding a cast is seldom taught these days in the era of internal fixation, which is a shame, because a good, manually applied mold on the tibial crest, arch, and on both sides of the Achilles tendon is critical in applying a safe and comfortable cast. Careful attention to the proximal portion of the cast, particularly around the area of the common peroneal nerve, cannot be overemphasized, either. (This will resonate with anyone who has seen a foot drop as a result of a cast he or she applied.) Interestingly, in my experience, a cast with a good mold in a patient who is reliable and who has normal sensation requires a bit less posterior heel padding. When splinting, the risk of pressure injury is obviously much greater for patients with impaired or absent sensation from a regional block and who are groggy from postoperative anesthesia or analgesics. These patients require a lot more padding to the posterior heel. When I am concerned about a patient’s ability or willingness to follow directions, I often place even more padding in their postoperative splint. I am not sure in such situations whether I am treating that person or whether I’m treating myself (or both), but I sleep better at night. Dr. Leopold:What are the “gotchas” to watch out for when applying splints and casts that might not come right to mind that your study or others like it have tipped you off to? (I liked how you wrote a little about clinical distractions in the Discussion section of theCORR paper that we're talking about here—very practical—feel free to take us a little deeper on that if you like). Dr. Holmes: The first thing to remember is that splint or cast application should not be an afterthought. Too often, we are more concerned with the reduction (if one was performed), the radiographs, or the next pressing, time-sensitive consult. We should think of splint application as a separate procedure that includes stages of preparation, execution, and final evaluation. Too many times, the splinting is delegated to the most junior resident, who asserts and believes he or she is comfortable putting on the splint, but really has not been satisfactorily trained, and more importantly, has not had enough supervised repetitions. The other trap in the emergency department is allowing the ER staff to “slap on a quick splint.” Remember, they don’t have to deal with the consequences of a poorly placed splint and have likely never been trained in proper technique by an orthopaedic surgeon or cast technician. Dr. Leopold: There are two other participants in this drama besides the person applying the splint: the nursing team caring for inpatients with splints and, of course, the patient. I’ve found inpatient care flows very resistant to change, even in the face of compelling safety-related issues. How would you recommend we implement what you learned on inpatient orthopaedic care floors in ways that “stick”? Dr. Holmes: I agree; change management is difficult. Certainly patients who have a regional anesthetic and go home from the emergency department or surgery center get very clear written and verbal instructions from the surgical team, including an explanation of the potential risks and harms associated with splinting and the importance of following our cautions on this topic. But it can be hard to make sure these messages hit home. We need somehow to move these messages from the “important but not urgent” box to the “important and urgent” box. I do not think it is practical or feasible to engage every nursing unit in the hospital, but certainly the ones that frequently care for patients in short-leg splints or casts should be targeted. A simple diagram or photograph of the correct technique could be posted on the patient information board in each patient’s room (some rooms have a whiteboard that lists the patient's nurse, care team, daily schedule for the patient, and other information) Simply positng it is not enough, of course; the nurse needs to emphasize to everyone (including the patient) that the ramifications of getting this wrong can be life-altering. While I do not advocate for dramatic stories or scare tactics, I think it is necessary to give a very clear directive to patients and families that emphasizes the importance of minimizing pressure-related, soft tissue problems, which might require explaining the ramifications of failing to do so in vivid detail. The problem, of course, is that this is one more thing on the checklist that nursing personnel are responsible for. This is why it is important to include the other participants in this drama beyond the two you mentioned: the patient's family, friends, and/or caregivers who may be at the bedside. A candid discussion with the patient and family members, when they are present, is critical to making our messages “stick” after discharge.