Commercially available splinting materials (e.g., Orthoglass), which incorporate the padding and fiberglass splinting material into a single preparation, are also a good option Although these preparations are designed to provide a sufficient amount of padding by themselves, many practitioners prefer additional cotton padding to minimize the risk of pressure ulcers, especially over bony prominences, such as the malleoli, heel, or elbow, particularly when the splints may be left in place for longer periods of time before follow-up The advantages of these materials are their ease and neatness of application The fiberglass products also appear to be more durable than the plaster splints A relative disadvantage is that these products are not as moldable as plaster to the bends and contours of an extremity It is important to follow the specific manufacturer’s instructions to ensure appropriate application In general, these products are cut to length; moistened with a small amount of water; stretched, smoothed, and molded to the injured extremity; and then covered with an elastic bandage Once the material is applied and secured, maintain the extremity in the proper position until the splint becomes sufficiently rigid This usually occurs more rapidly than with plaster, as soon as 10 minutes from application It is helpful to cut the material slightly longer than necessary and to fold the excess length back on itself to make a smooth comfortable end to the splint This technique is especially helpful at natural flexion areas, such as the palm or toes Remember also that the cut ends of the fiberglass material may become sharp when dry and require either taping of the exposed ends, stretching of the padding material on its application to cover the exposed end, or filing with a nail file once dry to smooth the end of the splint Other Issues Dispense crutches or slings as appropriate to prevent weight bearing or usage that may enhance edema, pain, or cause the splint to break Children are often not capable of using crutches if they are years of age or younger, and even some older children may have difficulty using crutches properly Discharge instructions should include appropriate recommendations for rest, ice, and elevation Discuss signs and symptoms of neurovascular compromise (e.g., compartment syndrome), and recommend that the patient loosen the splint and return to the ED if neurovascular insufficiency is suspected Assist in arrangement of appropriate referral and follow-up specific to each injury Long Arm Posterior Splint Indications Immobilization of elbow and forearm injuries Procedure Ascertain that the injury will be adequately immobilized by a long arm splint ( Fig 130.49A ) Prepare the child by carefully exposing the upper arm, elbow, and forearm The appropriate position for splinting will have the elbow flexed to 90 degrees, the forearm in neutral position, and slight dorsiflexion at the wrist When applying a splint for a supracondylar fracture, position the forearm with slight pronation The length of this splint will extend from the palmar crease of the hand to approximately two-thirds of the distance up the humerus It will run along the ulnar aspect of the forearm and the posterior aspect of the humerus Take care so the splint does not impinge upon the axilla The width should extend semicircularly halfway around the arm Prepare and apply the splint material as described in the “General Splinting” section This splint requires the use of a sling Posterior Splint—Below the Knee Indications Immobilization of ankle sprains and fractures of the foot, ankle, and distal fibula Procedure This splint extends from the ball of the foot to the proximal lower leg at the level of the fibular head ( Fig 130.49B ) Ensure that it does not impinge upon the popliteal fossa when the leg is flexed For metatarsal fractures, the splint is sometimes extended to include the toes The material should be wide enough to support the entire width of the foot The splint will maintain the foot at 90 degrees of dorsiflexion at the ankle and may be most easily applied with the child in the prone position with the leg flexed at the knee Prepare and apply the splint materials as described in the “General Splinting” section Consider additional padding at the malleoli and calcaneus Once the splint is applied, it is often necessary to have someone maintain the foot at 90 degrees while the material hardens Discharge the patient with crutches and warn that this splint does not tolerate weight bearing well, particularly in school-age children or teens Ankle Stirrup (Sugar Tong) Splint Indications Immobilization of injuries to the ankle