Patient Care,Pediatrics,

Clinical Hub,References,Emergency Department Resources,Emergency Department Pediatric Resources

Pediatric ED Splinting Resource

Pediatric ED Splinting Resource - Clinical Hub, References, Emergency Department Resources, Emergency Department Pediatric Resources



Splinting of orthopedic injuries is important to provide protection and comfort for fractures and soft-tissue injuries. Care of nearly all pediatric fractures has rested primarily on the Orthopedic Service with most children having cast placement by an orthopedic resident in the emergency department. While this has been a luxury for the EM service, application of a splint would often be an appropriate approach in the initial management of these injuries.

In addition, PEM splinting offers several advantages pertinent to resident training in an academic center. These include providing emergency medicine and pediatric residents with greater opportunity to gain experience and competence in recognizing and managing pediatric orthopedic injuries (ACGME core requirements for both emergency medicine and pediatrics).

This approach also offers the advantage of sharing the load of care for relatively less severe orthopedic injuries--especially important during busy summer months. By minimizing the over-utilization of our orthopedic resources, this will decrease the work (as these tend to be low-yield educational experiences for their level of training) imposed on the orthopedic resident and allow timelier patient disposition.

Pediatric ED Splint Placement Guideline

The following information is intended as a guideline for the Primary ED management of children with orthopedic injuries amenable to splint placement. Management of the actual patient may require a more individualized approach. When in doubt, consult an Orthopedic resident.

General Inclusion for Primary PEM Management (see List 1 for specific injuries):

Orthopedic injuries and fractures that may be considered stable, where immobilization is primarily to provide comfort and allow for any edema pending orthopedic follow-up for definitive splinting or casting.

General Exclusions for Primary PEM Management:

The exclusions for primary PEM management and splint placement (and therefore require Orthopedic consult/review of films) include any fracture that is considered a(n):

  1. Articular surface fracture
  2. Growth plate fractures
  3. Fracture or dislocation that requires reduction (note that the degree of acceptable angulation varies by type and location of the fracture as well as age of the patient, therefore there is a low threshold for having these x-rays reviewed by Orthopedics).
  4. Unstable fracture as determined by the Orthopedic Service
  5. Any fracture about the hand or carpal bones


  1. Identify injury via appropriate radiographs
  2. Consider primary PEM-placed immobilization for listed injuries below. As noted above, these generally include non- or minimally angulated and/or non-displaced, non-articular, non-growth plate fractures.
  3. Contact Orthopedic Service to review films in order to determine if reduction and/or casting is necessary for all fractures in List 2.These generally include:
    1. Fractures involving the articular surface
    2. Growth plate fractures
    3. Fractures with angulation greater than 5 degrees or ANY displacement
    4. Fractures about the hand or carpal bones
    5. Any fracture with ANY other concerns.
  4. If no reduction deemed necessary and the fracture is considered stable, then PEM service will splint in ED.
  5. The PEM service will then arrange follow-up within a week in the Pediatric Orthopedic clinic.
  6. Send communication to the referral physician’s inbox to aid in follow-up.

List 1: injuries potentially eligible for primary PEM immobilization without Ortho review of films.

Injury TypePrimary PEM Immobilization
Clavicle fracure, non-comminuted Shoulder sling OR sling and swathe
Proximal humerus fracture
Children < 10 years and angulation
Shoulder sling
Elbow injuries: 
  • Non-displaced olecranon fracture
  • Positive posterior fat pad sign
  • Nondisplaced radial neck/head fracture
  • Medial Epicondyle Avulsion, < 5 mm displacement
  • Plaster long arm splint
  • Plaster long arm splint
  • Plaster long arm splint OR sling
  • Plaster long arm splint
Distal radius Buckle fracture Prefabricated volar wrist splint OR
Plaster or fiberglass short arm (volar or sugartong) splint
**Tibia Toddler fracture Plaster long leg splint
**Foot injuries:
  • Metatarsal fracture
  • Phalangeal fracture
  • Plaster or fiberglass short leg splint OR post-op shoe
  • Post-op shoe

**Long leg splint preferable to short leg splints for young children/toddlers to prevent excess movement of the splint

 List 2: Injuries requiring Orthopedic resident review of films (these injuries may be eligible for PEM stabilization at Ortho discretion).

Injury TypePEM Immobilization
Non-displaced Supracondylar Humerus Fracture Plaster long arm splint
Phalangeal buckle fracture Buddy tape with alumofoam splint
Phalangeal shaft fracture, non-angulated, non-articular, no rotation Plaster short arm with outrigger splint
Metacarpal neck (Boxer’s) fracture Ulnar gutter splint
Metacarpal shaft fracture, non-angulated, non-articular, no rotation Ulnar gutter splint OR volar and dorsal plaster slabs
Snuffbox tenderness only, normal films but suspicion for scaphoid injury Prefabricated or plaster or fiberglass thumb spica splint
SH I and II fractures of the distal ulna/radius Prefabricated volar wrist splint OR Plaster or fiberglass short arm (volar or sugartong) splint
**SH I and II type fractures of the distal fibula Plaster or fiberglass short leg splint

**Long leg splint preferable to short leg splints for young children/toddlers to prevent excess movement of the splint