Ankle and Foot Splinting, Casting, and Taping

CHAPTER 186 Ankle and Foot Splinting, Casting, and Taping



Gregory A. Marolf


Primary care clinicians encounter a wide variety of acute and chronic foot and lower leg injuries that may benefit from immobilization. The value of immobilization as an initial means of therapy has been known for centuries. Treatment of foot and ankle injuries involves an accurate clinical evaluation and, when indicated, radiographic assessment of potential fractures, avulsions, or instability. Casting and cast splinting are commonly used in acute situations and fractures (see Chapter 190, Fracture Care), whereas splinting and taping are probably best used to control chronic instabilities and as adjuncts in rehabilitation. PRICES (protect, rest, ice, compression, elevation, splint) is the mnemonic often utilized when acute immobilization is indicated. It should also be noted that rapid remobilization is an important part of the rehabilitation for most soft tissue injuries to the ankle.



Indications



Soft Tissue Injuries



• Ankle sprains: Treatment options include use of a sugar-tong splint, taping, and braces (stirrup or lace-up type) for support as the patient returns to weight bearing.

• Plantar fasciitis: Immobilization can be achieved with a nocturnal posterior leg splint, which provides a constant stretch to the plantar fascia. (See Chapter 195, Podiatric Procedures, for other treatments, including customized orthotics.)


Fractures



• Tibial or fibular: Stable distal tibial or fibular fractures, including malleolar fractures, can be immobilized with a splint or short-leg walking cast (see Chapter 190, Fracture Care).

• Fifth metatarsal: Immobilize avulsion fractures with a postoperative shoe, posterior splint, or short-leg cast (see Chapter 190, Fracture Care).

• Other: Primary care clinicians may also encounter fractures of the tarsals, or first through fourth metatarsals. When these fractures are nondisplaced and stable, immobilization alone may be appropriate; otherwise, surgical referral may be necessary (see Chapter 190, Fracture Care).


Prophylaxis against Injuries


Ankle taping or bracing may be used as prophylaxis against injury in ankles that need additional stabilization and improved proprioception.



Contraindications



• Early (premature) casting: Casting before maximal swelling has occurred can cause necrosis and compartment syndrome.

• Open wound: Never place a cast over an open wound because of the potential for infection. If the wound is not too large, a window may be cut in the cast to monitor it.

• Unstable fractures: These fractures need surgical repair; splint only until definitive treatment can be provided.


Benefits of Different Types of Immobilization


The type of immobilization used may vary with the location and severity of the injury, patient or clinician preference, and the plan of treatment. The following list of benefits for each option may help when making decisions.



Splinting



• Stability for soft tissue injuries

• Pain relief

• Easily removable to apply ice massage, etc.

• Provides temporary support for patients needing surgery


Casting



• Marked stability

• Significant pain relief

• Immobilization for hard-to-treat soft tissue injuries as well as fractures


Taping



• Supports acutely injured ankles

• Supports chronically weak ankles or a chronically injured plantar fascia

• Enhances proprioception

• Prophylaxis against injury


Equipment



Casting


Figure 186-1 illustrates the materials needed for casting.


• Stockinette: 4-inch stockinette is appropriate for most patients, but 3-inch stockinette may be needed for smaller patients

• Cast padding: 3- or 4-inch rolls (depending on patient size), soft cotton (e.g., Webril) or synthetic (e.g., polyester)

• Synthetic waterproof cast liner (e.g., Gore Procel, Scotchcast Wet or Dry, Delta-Dry, Waterpruf) (optional)

• Cast material: 3- or 4-inch rolls, depending on patient size, plaster or synthetic (e.g., fiberglass)

• Rubber heels (for walking cast, but may not be needed for fiberglass cast)

• Gloves, nonsterile

• Gown and shoe covers for the clinician

• Patient towels or drapes

• Water bucket with tepid water (if using plaster, should have traps in drains)

• Chinese finger traps

• Foot stand (optional)

• Scissors

• Cast cutter

• Cast spreader

• See Chapter 187, Cast Immobilization and Upper Extremity Splinting, if cast removal protective strips (e.g., De-Flex) indicated or desired to protect skin from cast saw during removal

image

Figure 186-1 Materials needed for casting: cast padding, casting material, cast spreader, cast cutter, and stockinette.



Splinting



• Most of foregoing supplies for casting or premade splint material (plaster or synthetic)

• Compression wrap elastic bandage (Ace bandage)


Taping for Ankle



• Skin preparation (benzoin)

• Lubricant (optional)

NOTE: The lubricant may be applied to the skin at sites of potential friction or irritation.


• Underwrap

• image– or 2-inch athletic tape

• Pressure pads or moleskin


Taping for Plantar Fasciitis


Equipment is similar to that used for the McConnell method of taping for patellofemoral knee pain:


• 2-inch dressing retention sheet (skin tape, white)

• image-inch patellofemoral adhesive tape (high-tensile strength tape, brown; some of the original work with McConnell taping was rumored to have used duct tape!)

• Alcohol swabs

• Commercial adhesive remover


Preprocedure Patient Preparation


Obtain verbal or written consent. Possible complications should be explained to the patient. For example, the patient should be aware that there will be a temporary loss of flexibility following immobilization, especially in the foot. In some cases, a partial loss of flexibility can become permanent. Place the patient in a seated or supine position. Some clinicians prefer a prone position with the knee flexed 90 degrees.



Technique



Splinting


Most clinicians have access to premade splinting materials that are fixed or inflatable (e.g., Aircast). However, inexpensive splints can be made from a plaster cast roll and cast padding:


1 Estimate the length of the splint you plan to use.

2 Unroll cast material into layers, making 11 to 13 layers.

3 In a similar fashion, unroll cast padding into layers, making 6 to 8 layers.

4 Unroll a single layer of cast padding for the outside of the splint.

5 The plaster cast material will be placed between the inner and outer layers of cast padding. The inner layers (6 to 8 layers) are placed between the splint and the skin, while the single outer layer of cast padding is placed on the outside of the splint. The latter is used to prevent the Ace bandage from adhering to the plaster.

Generally, when making a splint from casting materials, plaster is used. With this type of splint, the padding will not be wet. The casting material is immersed in water separately. Premade splints may be plaster or fiberglass. With premade materials, the padding will be wet. Premade splint material can also be simulated by rolling a stockinette over the outside of the 11 to 13 layers of cast materials. Fold over the ends of the stockinette and tape them to keep the splint neat. Both the stockinette and the casting materials are then immersed in water together. Both will be wet when applying. Several layers of cast padding are then placed between the patient’s skin and this splint to prevent skin breakdown.


Two types of ankle splints will be discussed: sugar tong and posterior. Application depends on the indication and degree of stabilization desired. The sugar-tong (stirrup) splint may be used in ankle sprains to prevent inversion or eversion.



Sugar-Tong (Stirrup) Splint



1 Measure from the fibular head (at the knee) to the calcaneus, double that measurement, and cut the splint material and padding to size.

2 Wet the splint material and remove excess water by applying gentle pressure across the width of the splint material.

3 Place the padding against the patient’s skin and have the patient or an assistant hold it in place.

4 Apply the splint material against the lateral aspect of the leg, starting just distal to the fibular head (2 fingerbreadths below). Wrap the splint under the heel, and return it up the medial side of the leg to just below the knee (Fig. 186-2). (It is U-shaped like a long sugar tong; the anterior and posterior aspects are open.)

5 Mold the splint material to support the ankle and heel.

6 Place a layer of padding over the splint.

7 Wrap the splint material to hold it in place with an elastic bandage or a roll of cast padding (Fig. 186-3).

image

Figure 186-2 Splint material in the shape of a U (sugar tong). The splint allows for swelling while providing medial and lateral support.


image

Figure 186-3 Finished sugar-tong splint held in place with a compression wrap.



Posterior Splint


The posterior splint may be used with stable tibial or fibular fractures and plantar fasciitis to restrict dorsiflexion or plantar flexion of the foot and ankle complex.


1 Measure from the metatarsal heads to just distal to the popliteal fossa (2 fingerbreaths above), and cut the splint material and padding to size.

2 Wet the splint material and remove excess water.

3 Place the padding against the patient’s skin and have the patient or an assistant hold it in place.

4 Apply the splint material over the padding and against the plantar aspect of the foot and along the posterior aspect of the leg. Extend the splint from the metatarsal heads to just distal to the popliteal fossa (Fig. 186-4).

5 Mold the splint material to support the ankle and heel.

6 Place a layer of padding over the outside of the splint.

7 Wrap the splint material to hold it in place with an elastic bandage or a roll of cast padding (Fig. 186-5).

image

Figure 186-4 Cast material runs along the posterior aspect of the lower leg and the plantar surface, providing immobilization for ankle dorsiflexion and plantar flexion.


image

Figure 186-5 Finished posterior splint held in place with a compression wrap.

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Ankle and Foot Splinting, Casting, and Taping

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