Novel Posterior Splinting Technique to Avoid Heel Ulcers - Healio

Novel Posterior Splinting Technique to
Avoid Heel Ulcers
Raymond Y. Hsu, MD; Craig R. Lareau, MD; Christopher T. Born, MD
n tips & techniques
Section Editor: Steven F. Harwin, MD
foot and
SPOTLIGHT ON
ankle
Abstract: Heel ulcers are a costly and preventable complication
of lower-extremity immobilization, but they still occur
with some regularity. A technique using a short leg posterior
splint that suspends the heel away from the splint is described.
This modification completely removes pressure the heel to
prevent decubitus ulcer formation. This technique is simple,
inexpensive, and effective.
The short leg posterior
splint is commonly used
by orthopedic surgeons to immobilize
the foot and ankle
after injury. It can be applied
in multiple settings, including
the outpatient clinic and
emergency department. It is
typically reserved for ankle
sprains and nonoperative foot
and ankle fractures. It is also
useful for operative fractures,
either for temporary preoperative
immobilization or for
postoperative protection of
fracture fixation and soft tissue
management. A short leg
posterior splint does not carry
the risks of compartment syndrome
or malleolar pressure
ulcers associated with more
restrictive immobilizations,
such as circumferential casting
or AO splinting with side gussets.
1 However, decubitus heel
ulcers due to a combination of
pressure and moisture remain
a concern (Figure 1).
Common methods used
to prevent decubitus heel
ulcers include padding the
heel with extra layers of
The authors are from the Department of Orthopaedic Surgery, The
Warren Alpert Medical School of Brown University and Rhode Island
Hospital, Providence, Rhode Island.
Drs Hsu and Lareau have no relevant financial relationships to disclose.
Dr Born is a paid consultant for Stryker.
The authors thank cast technicians Vincent Alexandre, Jason Brown, and
Joe C. Manso for their assistance in developing this technique.
Correspondence should be addressed to: Raymond Y. Hsu, MD,
Department of Orthopaedic Surgery, The Warren Alpert Medical School of
Brown University and Rhode Island Hospital, 593 Eddy St, Providence, RI
02903 (raymond_hsu@brown.edu).
doi: 10.3928/01477447-20121217-03
Webril (Covidien, Mansfield,
Massachusetts) or with Curity
539-inch abdominal pads
(Covidien). 2 A more advanced
and expensive technique using
polyurethane foam cushions
has also been described. 3
Although these practices provide
extra cushion between
the heel and the splint, they do
not completely unload the heel
and make it difficult for moisture
to escape, increasing the
risk of skin breakdown.
The current authors present
a simple method of splinting
that removes pressure from
the heel, allows moisture to
escape, and involves no additional
cost, time, or supplies.
Technique
The patient is positioned
supine with the affected lower
extremity held by an assistant
at the toes and just proximal
to the knee posteriorly, with
the ankle neutral and the knee
in 90º of flexion. Webril is
wrapped circumferentially
with 50% overlap twice to
provide 4 layers of Webril
from the toes to just distal
to the popliteal fossa, taking
care to avoid pressure over the
common peroneal nerve at the
Figure 1: Photograph of a heel ulcer
from a posterior splint placed after
open reduction and internal fixation
of a tibia/fibula fracture.
fibular neck. Extra layers of
Webril padding are placed on
the plantar aspect of the foot
and posterior to the proximal
Achilles tendon. No extra
padding is placed behind the
heel or at the calcaneal attachment
of the Achilles tendon.
When they are approximately
2 cm in diameter, 2 of the
used Webril rolls are saved
and set aside.
Four- or 5-inch Ortho-Glass
(BSN Medical, Inc, Charlotte,
North Carolina) or plaster is
applied posteriorly along the
length of the Webril, ensuring
adequate padding between the
splint material and skin at the
proximal and distal ends.
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n tips & techniques
2A
2C
Figure 2: Photographs showing 2 small rolls of Webril (Covidien, Mansfield, Massachusetts) placed posterior to the
heel between the Webril padding and splint material (A). After an elastic bandage is applied and the splint hardens (B),
the ACE wrap is windowed to allow the 2 small rolls of Webril to be removed (C). The ACE wrap is readjusted back to
its original position (D).
2B
2D
when immobilized and would
benefit from this modification.
4 This splinting technique
is particularly helpful when
heels are at an increased risk
of skin breakdown from moisture.
This includes patients
with pitting edema, serous
drainage from incisions, or
calcaneal traction pin sites.
Although useful for all patients,
this splint is most valuable
in patients at increased risk
of heel complications secondary
to diabetes mellitus, neurologic
disorders, noncompliance,
and draining wounds. In
the authors’ experience with
this splinting modification over
the past year, no heel ulcers
have developed.
When using plaster, extra
caution must be used with
water temperature, padding,
splint thickness, and inadvertent
placement of the extremity
onto insulating material (eg,
plastic-covered hospital pillow)
that may cause a partial- or fullthickness
skin burn. To create a
space to unload the heel, the 2
saved 2-cm rolls of Webril are
inserted deep into the splint
material and superficial to the
Webril posterior to the heel and
the attachment of the Achilles
tendon (Figure 2A).
An elastic bandage is then
wrapped loosely to secure
the splint in standard fashion.
After the splint material has
hardened, the 2 small rolls of
Webril are removed (Figures
2B, C) and the ACE bandage
is adjusted back to its original
position (Figure 2D).
Discussion
To the authors’ knowledge,
this heel suspension short leg
posterior splint has not been
described previously in the
literature. It provides a simple
and inexpensive method
of preventing what can be a
costly complication of lowerextremity
immobilization.
A recent study of 216 patients
with lower-extremity
casts reported a 17.6% rate
of heel pressure ulcers. 4
Although no studies have examined
the financial costs of
heel pressure ulcers from casting,
a significant body of literature
examines the economic
and legal costs of heel ulcers
in general. 5 The cost of treating
a single heel pressure ulcer
is estimated to be between
$2000 and $30,000. 6 These
estimates are for general heel
pressure ulcers and do not account
for the additional costs
in the presence of an operative
fracture, such as delays in fixation
and difficulties with bone
and hardware coverage.
The described splinting
modification removes pressure
from the heel and better
ventilates the most dependent
aspect of the splint without
sacrificing immobilization
strength. Although all patients
are instructed to follow heel
precautions, which involves
avoiding direct pressure over
the heel of the splint, this
splint protects the heel in patients
who are unable or refuse
to comply with these recommendations.
Patients with signs of heel
soreness at splinting have been
shown to be at significantly
increased risk of heel ulcers
References
1. Halanski M, Noonan KJ. Cast
and splint immobilization:
complications. J Am Acad Orthop
Surg. 2008; 16(1):30-40.
2. Hipps HE. Prevention of cast
pressure-sores on the heel.
Southwest Med. 1964; 45:19-
22.
3. Forni C, Loro L, Tremosini M,
et al. Use of polyurethane foam
inside plaster casts to prevent
the onset of heel sores in the
population at risk. A controlled
clinical study. J Clin Nurs.
2011; 20(5-6):675-680.
4. Forni C, Zoli M, Loro L, et al.
Cohort study of the incidence
of heel pressure sores in patients
with leg casts at the Rizzoli
Orthopedic Hospital and
of the associated risk factors
[in Italian]. Assist Inferm Ric.
2009; 28(3):125-130.
5. Lyder CH. Preventing heel
pressure ulcers: economic and
legal implications. Nurs Manage.
2011; 42(11):16-19.
6. Lyman V. Successful heel pressure
ulcer prevention program
in a long-term care setting. J
Wound Ostomy Continence
Nurs. 2009; 36(6):616-621.
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