BANDAGING AND SPLINTING FILE

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Supporting and Immobilizing Wounds

Bandages, binders, and splints serve various purposes:

Supporting a wound (e.g. fractured bones)

Immobilizing a wound (e.g. a strained shoulder)

Applying pressure (e.g. elastic bandages on the lower extremities to improve

venous blood flow)

Securing a dressing (e.g. for an extensive abdominal surgical wound)

Retaining warmth (e.g. flannel bandage on a rheumatoid joint)

There are several types of bandages and binders and several ways in which they are

applied. When correctly applied, they promote healing, provide comfort, and can prevent

injury.

BANDAGING

Bandaging is an important part of the case management of many patients. There

are several a situation in which bandaging is indicated. A decision must be made first as

to whether or not a bandage is necessary at all. Determine what is the purpose of applying

bandage is and what is the best material that will address the needs of the patient. It is for

this purpose that a basic knowledge in bandaging is necessary to carry out a quality

patient care.

Bandages

A bandage is a strip of cloth used to wrap some part of the body. Bandages are

available in various widths, most commonly 1.5 to 7.5 cm (0.5 to 3 in). They are usually

supplied in rolls for easy application to a body part.

Many types of materials are used for bandages. Gauze is one of the most

commonly used, because it is light and porous and readily molds to the body. It is also

relatively inexpensive, so it is generally discarded when soiled. Gauze is used to retain

dressings on wounds and to bandage the fingers, hands, toes, and feet. It supports

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dressings and at the same time permits air to circulate; it can be impregnated with

petroleum jelly or other medications for application to wounds.

Elasticized bandages are applied to provide pressure to an area. They are

commonly used as tensor bandages or as partial stockings to provide support and improve

the venous circulation in the legs.

The width of the bandage used depends on the size of the body part to be

bandaged. Padding (e.g. abdominal pads and gauze squares) is frequently used to cover

bony prominences (e.g. the elbow) or to separate skin surfaces (e.g. the fingers).

The bandage has the following purposes:

To limit movement

To apply warmth

To secure a dressing

To hold splints in position

To support parts of the body

To apply pressure

Parts of a Bandage

1. Initial or free end

2. Body or drum

3. Terminal or hidden end

Materials Used in Bandaging

1. Gauze

2. Kling

3. Rubber

4. Flannel

5. Crinoline

6. Muslin

7. Woven Cotton

8. Elastic Adhesive

9. Plastic Adhesive


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INDICATION CONTRAINDICATION

1. Sprain 1. Hampered Circulation

2. Fracture 2. Venostasis

3. Varicose veins 3. Muscle Weakness

4. Cerebral palsy 4. Paresthesia

5. Muscle weakness 5. Numbness

6. Amputation stumps 6. Anesthesia

7. Dislocation 7. Pressure sores

8. Subluxation 8. Blisters

9. Contractures

General Principles of Bandaging

1. Microorganisms flourish in warm, damp and soiled areas.

2. Never apply a wet bandage.

3. Avoid wrinkles and gaps.

4. Never bandage a gap.

5. Pressure exerted upon the body tissues can affect the circulation of the blood.

6. Apply bandage firmly but not too tightly.

7. Excessive and uneven pressure upon body surfaces can interferes with blood

circulation and therefore with the nourishment of the cells in the area.

8. Wrap the bandage in a spiraling pattern rather than in circles.

9. Friction can cause mechanical trauma to the epithelium.

10. Leave the tips of the toes and fingers uncovered when bandaging.

11. The limb should be held in a natural position once the bandage has been applied.

12. Watch for the obvious signs of discomfort by checking the bandage regularly.

Assessment

Inspect and palpate the area for swelling.

Inspect for the presence of and status of wounds (open wounds will require a

dressing before a bandage or binder is applied).

Note the presence of drainage (amount, color, odor, viscosity).


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Inspect and palpate for adequacy of circulation (skin temperature, color and

sensation). Pale or cyanotic skin, cool temperature, tingling and numbness can

indicate impaired circulation.

Ask the client about any pain experienced (location, intensity, onset, quality).

Assess the ability of the client to reapply the bandage or binder when needed.

Assess the capabilities of the client regarding activities of daily living (e.g. to eat,

dress, com hair, bathe) and assess the assistance required during the

convalescence period.

Additional Information about Bandaging

Whenever possible, bandage the part in its normal position, with the joint slightly

flexed to avoid putting strain of on the ligaments and the muscles of the joint.

Pad between skin surfaces and over bony prominences to prevent friction from the

bandage and consequent abrasion of the skin.

Always bandage body parts by working from the distal to the proximal end to aid

the return flow of venous blood.

Bandage with even pressure to prevent interference with blood circulation.

Whenever possible, leave the end of the body part (e. g the toe) exposed so that

you will be able to assess the adequacy of the blood circulation to the extremity.

Cover dressings with bandages at least 5 cm (2 in) beyond the edges of the

dressing to prevent the dressing and wound from becoming contaminated.

Basic Turns for Roller Bandages

Applying bandages to various parts of the body involves one or more of six basic

bandaging turns: circular, spiral, spiral reverse, recurrent, figure eight, and oblique turn.

Circular turns are used to anchor bandages and to terminate them. Circular turns usually

are not applied directly over a wound because of the discomfort the bandage would

cause.

Spiral turns are used to bandage parts of the body that are fairly uniform in

circumference, for example, the upper arm or upper leg. Spiral reverse turns are used to

bandage cylindrical parts of the body that are not uniform in circumference, for example,


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the lower leg or forearm. Recurrent turns are used to cover distal parts of the body, for

example, the end of a finger, the skull, or the stump of an amputation. Figure-eight turns

are used to bandage an elbow, knee, or ankle, because they permit some movement after

application. Oblique turn covers ¼ of the preceding turn.

1. Circular turns

Hold the bandage in your dominant hand, keeping the roll uppermost, and

unroll the bandage about 8 cm (3 in). This length of unrolled bandage

allows good control for placement and tension.

Apply the end of the bandage to the part of the body to be bandaged. Hold

the end down with the thumb of the other hand.

Encircle the body part a few times or as often as needed, making sure that

each layer overlaps one-half to two thirds of the previous layer. This

provides even support to the area.

The bandage should be firm, but not too tight. Ask the client if the

bandage feels comfortable. A tight bandage can interfere with blood

circulation, whereas a loose bandage does not provide adequate protection.

Secure the end of the bandage with tape or a safety pin over an uninjured

area. Pins can cause discomfort when situated over an injured area.

2. Spiral turns

Make two circular turns. Two circular turns anchor the bandage.

Continue spiral turns at about a 30-degree angle, each turn overlapping the

preceding one by two-thirds the width of the bandage.

Terminate the bandage with two circular turns, and secure the end as

described for circular turns.

3. Spiral Reverse turns

Anchor the bandage with two circular turns, and bring the bandage upward at

about a 30-degree angle.


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Place the thumb of your free hand on the upper edge of the bandage. The

thumb will hold the bandage while it is folded on itself.

Unroll the bandage about 15 cm (6 in), and then turn your hand so that the

bandage falls over itself.

Continue the bandage around the limb, overlapping each previous turn by

two-thirds the width of the bandage. Make each bandage turn at the same

position on the limb so that the turns of the bandage will be aligned.

Terminate the bandage with two circular turns, and secure the end as

described for circular turns.

4. Recurrent turns

Anchor the bandage with two circular turns.

Fold the bandage back on itself, and bring it centrally over the distal end to be

bandaged.

Holding it with the other hand, bring the bandage back over the end to the

right of the center bandage but overlapping it by two-thirds the width of the

bandage.

Bring the bandage back on the left side, also overlapping the first turn by two-

thirds the width of the bandage.

Continue this pattern of alternating right and left until the area is covered.

Overlap the preceding turns by two-thirds the bandage with each time.

Terminate the bandage with two circular turns. Secure end appropriately.

5. Figure-eight turns

Anchor the bandage with two circular turns.

Carry the bandage above the joint, around it, and then below it, making a

figure-eight.

Continue above and below the joint, overlapping the previous turn by two-

thirds the width of the bandage.

Terminate the bandage above the joint with two circular turns, and then secure

the end appropriately.


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Requirements for a Successful Bandage

Holds the dressing of splint in place.

Comfortable

Have a neat appearance

It should not come off

It should not be constrictive

It should have a pressure gradient with a gradually diminishing pressure as

bandaging proceeds from distal to proximal portion of the limb.

Binders

A binder is a type of bandage designed for a specific body part; for example, the

triangular binder (sling) fits the arm. Binders are used to support large areas of the body,

such as the abdomen, arm, or chest. Binders can be simple, inexpensive, and

customizable by using plain material. Or, they can be of commercial design which are

often easier to use, more expensive, and slightly less modifiable such as the hook-and-

loop (Velcro) binder.

Triangular Arm Sling

Ask the client to flex the elbow to an 80-degree angle or less, depending on the

purpose. The thumb should be facing upward or inward toward the body. An 80-

degree angle is sufficient to support the forearm, to prevent swelling of the hand,

and to relieve pressure on the shoulder joint (e.g. to support the paralyzed arm of

a stroke client whose shoulder might otherwise become dislocated). A more acute

angle is preferred if there is swelling of the hand.

Place one hand of the unfolded triangular binder over the shoulder of the

uninjured side so that the binder falls down the front of the chest of the client with

the point of the triangle (apex) under the elbow of the uninjured side.

Take the upper corner, and carry it around the neck until it hangs over the

shoulder of the uninjured side.

Bring the lower corner of the binder up over the arm to the shoulder of the injured

side. Using a square knot, secure this corner to the upper corner of at the side of


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the neck on the injured side. A square knot will not slip. Tying the knot at the

side of the neck prevents pressure on the bony prominences of the vertebral

column at the back of the neck.

Make sure wrist is supported, to maintain alignment.

Fold the sling neatly at the elbow, and secure it with safety pins or tape. It may be

folded and fastened at the front.

Remove the sling periodically to inspect the skin for indications of irritation,

especially around the site of the knot.

Straight Abdominal Binder

With the client in a supine position, place the binder smoothly under the body,

with the upper border of the binder at the waist and the lower border at the level

of the gluteal fold. A binder placed over the waist interferes with respiration; one

placed too low interferes with elimination and walking.

Apply padding over the iliac crests if the client is thin.

Bring the ends around the client, overlap them, and secure them with pins or

Velcro. Place the top pin horizontally at the waist to allow for comfort when

moving.

Securing Peritoneal Dressings

Previously, T-binders were used to secure dressings to the peritoneal area. T-

binders have been replaced with sanitary disposable garments that fit like briefs. Placing

an appropriate sized abdominal pad or sanitary napkin in the garment allows the wound

to be protected and drainage to be collected for either males or females.

SPLINTING

In current medical practice splints have been recognized in managing diseases and

injuries of the hand. The proper use of splints is a fundamental part of the treatment and

management of patients with acute or chronic injury of the extremity. Wearing of splints

can influence the performance of purposeful activities, thus, allowing individuals to


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achieve their desired occupational goals. It is therefore believed that knowledge in basic

principles, types, and uses of splints is essential.

Splints

A splint is a rigid flexible appliance utilized to prevent motions of a joint or for

the fixation of displaced movable parts. Orthosis is a permanent device used to replace

or substitute for loss of muscle function.

A splint can be corrugated cardboard, folded newspapers, boards, straight sticks,

or a rolled-up blanket. A splint helps protect the injury until help arrives. The splint

should be long enough to extend beyond the joints on both sides of the fracture.

Classifications of Splint

A. Mechanical Characteristics

1. Static splints – used to provide static support and

immobilizations

2. Dynamic splints – alter the range of passive motion of a

joint or joints by employing traction devices.

B. Source of Power

1. Internally-powered splints – make use of the patient’s

residual muscle power to produce motion of nonfunctional

joints

2. Externally-powered splints – are driven by an external

source.

Splint Application has the following purposes:

1. Prevent deformity

2. Support, protect and immobilize joints

3. Correction of existing deformity

4. Improve independence in activities of daily living


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Splinting Materials

1. No external heat

a. Working temperature is 70 -75 F (21-24 C)

b. Advantages: quick to work with, gives rigid immobilization, and

inexpensive

c. Disadvantages: does not hold up over time and cannot become wet

2. Low temperature thermoplastics

a. Soften in water heated between 135-150 F

b. Advantage: can work with material directly on the skin

c. Disadvantage: may melt in a hot car or if left on hot surface

3. High temperature thermoplastics

a. Advantage: provides strong mobilization

b. Disadvantages: material cannot be formed directly on the patient’s skin

without stockinette, and it does not contour well.

Categories of Thermoplastics

Plastic

Rubber-like

Plastic and rubber-like

Elastic

Flexible

Properties of Splints

1. Conformability

2. Flexibility

3. Durability

4. Rigidity

5. Moisture permeability

6. Finish

7. Color


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Handling Characteristics of Splinting Materials

1. Memory

2. Drape

3. Elasticity

4. Bonding

5. Self-finishing edges

Basic Splint Parts and their Purposes

1. C bar

2. Connector bar

3. Cross bar

4. Cuff or strap

5. Deviation bar

6. Dynamic assist or traction device

7. Finger cuff

8. Fingernail attachment

9. Forearm bar or trough

10. Hypothenar bar

11. Dorsal phalangeal bar or lumbrical bar

12. Metacarpal bar

13. Opponens bar

14. Outrigger

15. Palmar phalangeal bar or finger pan

16. Prop

17. Reinforcement bar

18. Thumb post

19. Wrist bar

Splinting Precautions

1. Alter splint if areas on the skin persist 20 minutes after removal of splint

2. Increasing surface area of splint decreases potential for pressure sores


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3. Arm troughs should be 2/3 length of forearm

4. Trough should be ½ the circumference of the body part.

5. Avoid pressure over bony prominences

6. A pressure point should be bubbled out or enlarged rather than cut of padded

7. Smooth, rolled or rounded edges decreases pressure sores

8. Address moisture due to perspiration, wound drainage to avoid skin breakdown or

infection.

Splinting

Indications:

Fracture

Dislocated joint after reduction

Sprain: torn or stretched ligaments

Strain: torn or stretched muscles or tendons

Postoperative immobilization

Contraindications:

Absolute: none.

Relative: Injuries involving open wounds or infections need easily

removable splints to allow soft tissue care.

Equipment:

Cast padding (soft roll)

Plaster/fiberglass

Lukewarm water

Ace bandages

Disposable gloves

Positioning:

Ankle/foot: 90° angle between foot and leg, neutral eversion/inversion

Knee: 15°–20° flexion


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Shoulder: resting at the side of the body

Elbow: 90° angle between forearm and arm, neutral pronation/supination

Wrist: neutral supination/pronation, 20°–30° wrist extension

Thumb: wrist position as above, thumb in 45° abduction, 30° flexion

Metacarpals, MCP joint, proximal phalanges: wrist position as above, MCP joint

in 90° flexion, DIP and PIP joints in full extension

IP joints, middle/distal phalanx: full extension at IP joints

Techniques in Splinting:

Splint padding

Apply cast padding to entire area to be splinted with 2–3 inches of proximal and

distal overhang.

Padding should be applied evenly in a circular fashion from distal to proximal,

with each turn overlapping by 50% of the next turn to allow at least two layers of

padding in all areas.

Apply extra layers to bony prominences.

Apply padding while limb is in final splint position to prevent bunching of

padding across joint flexion creases.

Fiberglass/plaster

General technique: Immobilize fracture one joint above and one joint below injury.

Prefabricated fiberglass splints can be measured and cut.


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Plaster splints need 10–12 layers of plaster in upper extremities and 12–15 layers

of plaster in lower extremities.

Splints are dipped in room-temperature or lukewarm water.

Excess water is gently squeezed or shaken from the splint.

Splint is applied to the soft roll and never directly onto the skin. The splint is held

in place by an assistant or the patient.

Ace wrap

Wrap Ace bandage around splint with gentle tension.

Ace wrap should never be tight enough to cause venous compression.

Hold extremity in desired position until splint hardens (approximately 5–10

minutes with fiberglass, 10–15 minutes with plaster).


Posterior Elbow Splint

Sugar tong forearm splint

Ulnar gutter splint

Radial gutter splint

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Specific Splints:

1. Posterior elbow splint

Begin 4-inch-wide splint from posterior upper arm, moving across the posterior

elbow.

Extend the splint over the ulnar border of the forearm and hand to just proximal to

the MCP joint.

2. Sugar tong forearm splint

- Use for forearm /wrist injuries.

Begin with 3- to 4-inch-wide splint in the palm of the hand at the level of the

MCP joints.

Extend splint up dorsal aspect of the forearm, around the elbow flexed at 90°,

down the volar aspect of the forearm and hand, to just proximal to the MCP joint.

Be sure that the splint does not limit MCP motion.

3. Ulnar gutter splint

- Used for fourth and fifth metacarpal or phalanx injuries.

Apply 3- to 4-inch-wide slab from ulnar aspect of proximal forearm down along

the ulnar aspect of the small finger.

Fold edges around dorsal and volar aspect of hand and ring/small fingers.

Place the wrist in neutral supination/pronation with 20°–30° extension.

4. Radial gutter splint

- Used for injuries of the second/third metacarpal or fingers.

Apply to radial border as above for ulnar side with a hole cut out to allow motion

of the thumb.

Alternatively, apply two separate 2- to 3-inch-wide slabs to volar and dorsal

aspect of hand and fingers.


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5. Thumb spica splint

Apply sugar tong splint as above.

Add an additional 3-inch-wide slab from upper forearm, along radial border, then

down around thumb.

Thumb IP joint should be included.

6. Long leg splint

- Used for knee and tibia injuries.

Apply 4-inch-wide splint beginning at the medial upper thigh and extending down

the medial knee and ankle.

Continue the splint around the heel and up the lateral side of the ankle and knee to

the lateral upper thigh, forming a U shape.

For additional stability, apply a 6-inch splint from the posterior upper thigh down

to the posterior aspect of the leg and plantar surface of the foot.


Thumb spica splint

Long leg splint

Ankle splint

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7. Ankle splint

- Use for isolated ankle injuries.

Apply 4-inch-wide splint beginning at the proximal border of the upper calf,

extending down the medial calf and ankle, and around the heel and up the lateral

ankle and lateral calf.

For additional stability, apply a 6-inch splint from the posterior upper calf down

the posterior aspect of the lower leg and the plantar surface of the foot.

Complications and Management:

1. Burns

Splints harden by exothermic reaction and can burn underlying skin.

Be sure skin is properly padded.

Never use hot water to moisten splints.

Avoid overly thick splints.

If patient complains of significant heat or pain, remove splint and check the

underlying skin.

If burn occurs, treat with local burn techniques including debridement and topical

Silvadene as necessary.

2. Cast sores

Compression of skin over extended periods can lead to necrosis and breakdown.

Be sure all bony and tendinous prominences are well padded.

Be cautious about applying splints in unconscious patients or patients with

insensate skin.

If patient complains of burning pain or discomfort, remove splint and inspect skin.

If splint is foul-smelling or drainage appears, remove splint immediately and

inspect.

If wound develops, treat with local wound care.

Avoid indenting the splint with finger pressure while it is hardening.


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3. Joint contracture

Long-term immobilization can lead to shortening of ligaments and tendons if

improperly positioned.

Check and re-check position of splint as it hardens.

Avoid immobilization for longer than 3 weeks for shoulder and elbow injuries; 6

to 8 weeks for any other injury.

If contracture develops, begin physical therapy immediately.

Orthopedics consults.


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