Posterior Splint

[5andten]

Throughout residency and into practice I have applied numerous posterior splints. It has always been with orthoglass 4x30 or 5x30. Every once in a while I will get a DTI to posterior heel. Was wondering if anyone had any tips to avoid these or if there are other modalities to splinting that I should check out. All my attendings would say is its part of the risk with splinting. I have tried blue towels on the heel and pulling them out to create space. I also use the big fluffy cotton role around the splint to add padding and still have had a couple. Anyone using plaster instead?

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[Weirdy]

Plaster takes even longer to dry.
Have had this issue only when not padding with enough at heal and ankle.
Or if patient puts weight on it before it thoroughly dries
Prop up calf before they leave the OR to avoid heel resting on the bed
I pull and hold the heel portion out until it is hard enough before leaving OR. N=1, am sure others on here have different tips.

 

[HardRoadPaved]

Have had this issue only when not padding with enough at heal and ankle.

100%. A lot of OR are cutting supply quality and the cheap stretchy cast padding vs cotton tearable padding makes a huge difference.

 

[Sweatshirt]

I usually start with 2 cast rolls, going around the ankle and heel multiple times. ABD pad at heel. 2 more cast rolls, then the posterior splint, ace wraps. After all that make sure you are able to place your fingers between the last cast roll and the splint material. This will allow some extra cushion when they inevitably rest all their weight on the heel. If they are really fat tell them to only prop up pillows behind their calf and totally avoid the heel

 

[Podstar]

I do 3-4 ABDs, 4 cast rolls most times, and a half pound of cotton roll before the splint. Overkill, sure, but I’ll take a big bulky splint over a pressure injury or heel wound any day.

+1 to pulling the heel out/holding space until it drys for extra precaution.

 

[Feli]

Splints post-op are basically just a billing thing where they can use hospital materials to get a decent CPT ( and the ortho or some pods have PAs/resident/fellow to apply them, change them, replace, switch to cast in office, whatever). The splints - or casts - are not very logical or fast or easy when you work by yourself... and for office, the pre-cut orthoglass for splint costs same/more than you get for a splint from many insurance payers (esp when you consider your time). Cast materials + time vs its reimburse is not a ton better... but again, if ASC/hospital materials and "helpers," then many will try for dat $$$.

Their better splint application is in ER (acute ankle, calc, etc fx) where significant edema is expected and pt is sitting and splint/cast dries without any posterior/heel pressure.

If you are set on using splints in OR, do plenty of padding w good cotton Webril, let it dry fully, tell PACU to put pillow up by calf, not under heel. It's generally just not smart as they crack, rub, waste time, etc. It's basically a residents/teachinig thing for more rVU. Foot/ankle surgery (properly performed/educated/pt selection) just doesn't swell THAT much, and cast/boot is much better protection against early WB or a stumble.

...Personally, I just use CAM boots (why would you do elective sx on pts you don't trust?) and occasional bi-valve cast (for major trauma or recons where it'd be detrimental to walk on early and/or I don't know the pt well as they're fresh from ER with major injury). Most of the time, I want to put a basic bandage on, soft Jones, and CAM boot... on to the next case.

 

[deleted1162946]

be excessive with the soft roll and multiple ABD’s. Never had an issue when using multiple ABD’s. Heel and where it ends on the calf are the most important

 

[air bud]

Throughout residency and into practice I have applied numerous posterior splints. It has always been with orthoglass 4x30 or 5x30. Every once in a while I will get a DTI to posterior heel. Was wondering if anyone had any tips to avoid these or if there are other modalities to splinting that I should check out. All my attendings would say is its part of the risk with splinting. I have tried blue towels on the heel and pulling them out to create space. I also use the big fluffy cotton role around the splint to add padding and still have had a couple. Anyone using plaster instead?

Yes, switched to plaster recently. Like 10 sheets of 4x 30. Much more rigid that orthoglass. Never had issues with ulcer with orthoglass though. I always take a 4 inch roll of cast padding, fold on itself about a foot long, that lay on heel and plantar foot longitudinally (with length of foot) then start wrapping. Basically placing padding directly on heel/foot without extra bulk of going circumferentially.

 

[wakaflocka88]

In residency we had a few patients develop thermal burn injuries from plaster around posterior calf. Likely due to dipping it in hot water as plaster is already exothermic.

I only do plaster 5x30 10 thick x2, luke warm water so it sets quicker and 4 ABD pads.

 

[Retrograde_Nail]

just use a trauma roll for your cast padding. It will never happen again.

 

[podourology]

I put 2 folded abdominal pads at posterior heel before final layer of webroll. I also WAWA, so 2 layers of ace.

 

[Hybrocure]

Foot/ankle surgery (properly performed/educated/pt selection)

Stop operating on ortho leftovers.


If they’re too unhealthy for a cam boot they’re too unhealthy for a splint