be flexed to 90 degrees at the elbow with no rotation of the forearm The hand is dorsiflexed minimally (have the patient hold a small roll of tape or Webril) With the arm positioned as described, measure from the midpalm around the elbow to the knuckles dorsally (add to in to allow for shrinkage) The splinting material should be wide enough to support the arm along the volar and dorsal surfaces but not so wide as to overlap Prepare and apply the materials as described in the “General Splinting” section Ensure sufficient padding is placed over the elbow to prevent pressure ulcers A properly measured splint allows 90 degrees of flexion of the fingers and approaches, but does not cover, the knuckles dorsally An assistant is helpful when applying this splint Ensure the thumb is free to move in all directions Discharge the patient with a sling with the hand slightly above the level of the elbow Thumb Spica Splint Indications Nonrotated, nonangulated, nonarticular fractures of the thumb metacarpal or phalanx Ulnar collateral ligament injuries (gamekeeper’s thumb) Suspected or documented scaphoid fracture Procedure The splint extends in a U-shaped manner along the radial side of the thumb and forearm from the thumbnail to the midforearm ( Fig 130.49H ) The proper splinting position maintains the wrist in slight dorsiflexion, the thumb in some flexion and abduction, and the interphalangeal joint in slight flexion The final position is as though the patient were holding a glass or catching a ball, and will allow apposition of the index finger and thumb Determine the appropriate length of splint material by measuring from the patient’s thumbnail to the midforearm The splint should be wide enough to completely encircle the thumb Prepare and apply the splint materials as described in the “General Splinting” section The Webril should cover the thumb, hand, and forearm Mold the splint so the thumb is maintained in the position previously described A sling is usually unnecessary but may assist in reminding the patient to keep the site elevated Dorsal Extension Finger Splint Indications Nonrotated, nonangulated fractures of the phalanges, not involving greater than 10% of the joint line Immobilization after laceration or tendon repair Sprains of the phalangeal ligaments Note: Mallet and boutonniere fingers require an alternative splinting method Equipment Commercially available foam splints with aluminum backing ½- and 1-in adhesive tape Procedure A dorsal splint is preferred to a volar splint because tactile sensation is maintained, it is more comfortable for the patient, and it is more protective of the injury as the splint lies between the patient and outside surfaces during ambulation The splint extends from the dorsum of the wrist to the end of the finger ( Fig 130.49I ) The appropriate width will be equal to the diameter of the finger Cut the splint to the proper length and place tape on the sharp edges Tape the splint with 1-in tape to the dorsum of the hand and wrist Bend the splint to obtain 50 to 90 degrees of flexion at the metacarpophalangeal joint and 15 to 20 degrees of flexion at the interphalangeal joints Secure the splint of the finger with ½-in tape, making sure not to cover the joint lines REDUCTION OF NURSEMAID’S ELBOW Indications Radial head subluxation (nursemaid’s elbow), which is an injury that probably represents interposition of the annular ligament between the radial head and the capitellum ( Fig 130.50A ) FIGURE 130.50 Reduction of a nursemaid’s elbow (radial head subluxation) Complications Vascular or musculoskeletal damage if the maneuver is performed on a child with a fracture (e.g., supracondylar fracture of the humerus) Procedure Radiographs are not necessary if the suspicion for radial head subluxation is high, but are helpful to be certain that no bony injury exists when the history and examination are equivocal Suspicion for radial head subluxation is based on (i) a history that is suggestive of a mechanism that would lead to radial head subluxation, such as excessive axial traction placed across the elbow joint during a fall while holding hands with an adult ( Fig 130.50 ); (ii) observation of the affected arm, which is generally held at the child’s side, slightly flexed at the elbow and with the forearm in pronation; (iii) absence of point tenderness along the length of the arm and shoulder during examination of the affected arm; (iv) absence of swelling (which could indicate a supracondylar fracture); and (v) tenderness with supination of the forearm An adequate examination requires that the child be comfortable and may entail some distraction It may be useful to have the caregiver palpate the entire arm to assess for tenderness while the medical provider observes from across the room because young children may be frightened and may cry when the medical provider approaches or attempts to touch the child Oral analgesia with acetaminophen or ibuprofen may be also useful Generally, it takes less than 10 to 15 minutes after a successful reduction before the child uses the arm normally Rarely, when a prolonged period has elapsed before reduction, it will take somewhat longer for the child to regain normal function after the maneuver is performed Repeat or try an alternative approach if unsatisfied with the child’s use of the arm Supination and Flexion Approach After explaining the procedure to the parent, have the parent or assistant gently restrain the child in the sitting position As shown in Figure 130.50B , grasp the palm of the child’s hand as if to shake it Encircle the elbow with the other hand placing the thumb over the radial head and annular ligament and position the elbow in some flexion Gently distract the elbow joint and then supinate the palm of the hand ( Fig 130.50C ), and in a continuous motion, flex the elbow bringing the patient’s hand up to their shoulder ( Fig 130.50D ) During the flexion maneuver, a “pop” should be felt with the thumb that overlies the radial head Hyperpronation