Case Studies

Journal of Sport Rehabilitation, 1994, 3, 282-291 O 1994 Human Kinetics Publishers, Inc.

A New Protective Soft Splint for Contact Sports

Christopher M. Bouvette, Gerard A. Malanga, William P. Cooney, Michael J. Stuart, and Richard W. Miller

Athletes who sustain metacarpal injuries such as nondisplaced and minimally displaced fractures or metacarpophalangeal dislocation have benefited from the use of a newly developed Plastizote handfwrist orthotic device. This orthosis allows appropriate immobilization as well as early, safe, and effective return to contact sports during the healing process. Three case reports are presented along with applications and methods for fabricating this lightweight splint.

Hand and wrist injuries constitute approximately 20% of all injuries seen in contact sports (13, 14). The importance of good upper extremity function must be stressed to the athlete so that he or she does not continue to play after an injury and thus risk further insult.

The majority of hand and wrist injuries are sprains and strains (3). When a fracture occurs, it is generally a simple fracture with little or no displacement (5, 6). These injuries are usually treated with external immobilization with the use of a splint, brace, or cast. Displaced or unstable fractures may require more aggressive treatment (6, 8, 10, 12). Often, an athlete with a nondisplaced fracture who wishes to return to competition is initially treated with the use of a plaster or fiberglass cast for 4 weeks or more. If the physician is satisfied with the bony bridging and soft tissue healing after this period, use of an orthosis or soft protective playing splint may be considered. The orthosis must immobilize the fracture proximally and distally, and if return to play is a consideration, the device must be rigid enough to protect the fracture but soft enough to allow safe competition (9).

Soft Playing Splints

Opinions vary among national sports committees regarding the safe protection of hand and wrist injuries when immobilization or "casting" is required (15).

C.M. Bouvette and G.A. Malanga are with the Department of Physical Medicine and Rehabilitation, Mayo Clinic and Mayo Foundation. W.P. Cooney and M.J. Stuart are with the Department of Orthopedics, Mayo Clinic and Mayo Foundation. R.W. Miller is with the Prosthetic Laboratories of Rochester. Address correspondence to G.A. Malanga, Mayo Clinic, 200 First St. SW, Rochester, MN 55905.

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Historically, in high school athletics, any substance that is "hard" in its final form, such as plaster, rubber, or fiberglass, has been prohibited regardless of the padding surrounding the material. In recent years, the National Federation of Football Rules Committee has received proposals to make this rule less restrictive and allow the use of new technology and materials so that an injured athlete can participate with the use of a protective splint that contains hard material (15). Although this committee charge has not been approved at the high school level of competition, this controversial issue continues to reappear on the committee's agenda. Currently, several states are experimenting with the use of hard material, properly padded, to immobilize injuries of the forearm, wrist, or hand. Until more data are collected, the committee continues to recommend the current ruling, which allows the high school game umpire or official to determine which protective devices or materials are classified as hard.

One of the more commonly used soft protective playing devices is the RTV-11 silicone rubber splint. Studies have shown that this splint is veIy effective and that it allows adequate healing in more than 90% of athletes (2, 7). The device is composed of silicone and Temper foam, which are molded together over a 3- to 4-hr process requiring a catalyst. Our experience with the fabrication and versatility of this silicone splint has been somewhat disappointing. We found the silicone application to be messy and time-consuming. Silicone is a toxic material in its inert form and must be carefully applied. Ocular damage may result during the application process if this material comes into contact with the eyes. It is also recommended that the RTV-11 application take place in a well- ventilated area to protect against pulmonary imtation. When this splint is used for contact sport purposes, it is suggested that Temper foam be applied over the silicone-impregnated gauze. Temper foam is an open-cell material that is ad- versely affected by the outside temperature. Our orthotists and athletes find that colder temperatures significantly harden Temper foam. In a cold climate, the soft protective playing splint may be converted to a hard playing device. More- over, studies have revealed that once the silicone gauze has dried, it is nonporous and can be worn only for a limited time because of the high potential for skin maceration and breakdown (7). As a result, the patient generally needs two devices to facilitate fracture healing. The silicone protective splint is worn during play, and a bivalved plaster or fiberglass splint is necessary at other times (4).

A Plastizote splint is a reasonable alternative to silicone in many persons. Plastizote is a nontoxic, closed-cell, polyethylene foam that is extremely resilient and durable. It is essentially unaffected by temperature changes. An experienced orthotist can apply this splint in 30 min to 1 hr. It is our experience that once the initial fiberglass or plaster cast has been removed, the Plastizote splint is the only orthosis necessary while the healing process is completed. This protective device may be used for all activities, including competitive contact sports. Grossly, the orthosis is soft, yet it is more rigid than the silicone splint. A piece of Kydex is occasionally used to enhance immobilization and protection at the fracture site. This small piece of thermoplastic material is enveloped in Plastizote. Kydex is a rigid material that does not meet the criterion for use at the high school level of competition, and therefore any use during high school contact play requires approval from game officials. The Plastizote orthosis may be used at the collegiate and professional levels of competition.

284 Bouvefte, Malanga, Cooney, Stuart, and Miller

Case Reports We have successfully treated four handlwrist injuries with a Plastizote orthotic device that was approved as safe for competitive contact sports by high school game officials in our state. Each of the five injuries occurred during high school football play from direct opponent contact to the upper extremity, with secondary components of rotation or metacarpal loading resulting from impact with the playing surface. Radiographs demonstrated three metacarpal fractures (two oblique and one headlneck) and one metacarpophalangeal joint dislocation. The initial treatment included immobilization with a Plastizote splint or cast, rest (no football for at least 3 weeks), and elevation. Once callus formation was present and good fracture alignment was noted, the remaining immobilization was accom- plished with the Plastizote soft, protective handlwrist orthotic device. We report on three of these cases.

In the first case, a 14-year-old football player sustained an injury to the left thumb while being tackled and landing on his extended, palmar-abducted first digit. Radiographs revealed dislocation of the left first metacarpophalangeal joint with lateral displacement of the thumb (Figure 1, A and B). No fractures were identified. The patient subsequently underwent successful closed reduction of the metacarpophalangeal joint and was immobilized with a plaster thumb spica splint. He was instructed not to return to play. After 3 weeks, the cast was removed. There was slight end-point tenderness with ulnar and radial stress applied to the collateral ligaments at the first metacarpophalangeal joint. Minimal swelling was present, and the patient had nearly full range of motion. A Plastizote protective splint was fabricated, and contact competition was resumed. The foot- ball season was completed with no further injury, instability, or tenderness.

In the second case, a 17-year-old high school football player was struck in the right hand by the helmet of another player who was tackling him. Radiographs revealed a nondisplaced, oblique, midshaft fracture of the right third metacarpal

Figure 1 - (A) Initial radio- graph, revealing thumb disioca- tion. (B) Thumb, after reduction.

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Figure 2 - Initial anteroposterior (A) and lateral (B) views of the right hand, demon- strating a nondisplaced, oblique, midshaft fracture of the third metacarpal. (C and D) Repeat films at 6 weeks, revealing adequate healing and good alignment.

bone (Figure 2, A and B). He was placed in a foreann cast and instructed not to return to play. After 3 weeks, the cast was removed, and reevaluation revealed good range of motion and healing of the fracture site. A Plastizote splint was successfully used for the remainder of the football season. Follow-up radiographs demonstrated satisfactory healing and alignment (Figure 2, C and D).

In the third case, an 18-year-old high school football player sustained a right-hand injury of unknown mechanism while being tackled. The team trainer used a finger immobilizer because of concern regarding a fracture and ligamentous injury of the proximal third metacarpophalangeal joint. Evaluation revealed pain and tenderness to palpation along the third metacarpal bone. Radiographs revealed an oblique fracture of the third metacarpal shaft, with minimal posterior displace- ment (Figure 3, A and B). Treatment with ice and a Plastizote splint was imple- mented, and the athlete was instructed not to return to play.

After 3-112 weeks of continuous Plastizote splinting, pain significantly decreased and radiographs revealed callus formation over the fracture site. No significant displacement or angulation was evident. The patient continued to use the protective splint and returned to play. The football season was completed without further injury, and the fracture site healed completely, with minimal angulation (Figure 3, C and D).

Discussion Professional and collegiate athletes may compete with a plaster or fiberglass cast if it is adequately covered with soft material (1 1). High school athletes, however,

286 Bouvette, Malanga, Cooney, Stuart, and Miller

Figure 3 - Anteroposterior (A) and lateral (B) views, showing oblique fracture of the right third metacarpal shaft with minimal posterior displacement. (C and D) Callus formation with adequate alignment demonstrated on repeat radiographs after 3-112 weeks of Plastizote splinting.

are prohibited from using materials that are hard or unyielding, regardless of how well they are protected (1 1). Most players prefer the use of a lightweight substance, and certainly the silicone splint has proved to be an effective device. An athlete who has suffered an injury and wishes to return to play is often treated with plaster or fiberglass casting during practice sessions and a silicone splint during a game. This approach maximizes immobility during times of no contact and minimizes splint weight during contact play; however, it can become time- consuming and expensive.

The Plastizote splint appears to offer at least the same amount of protection as the silicone splint. Although more data are needed, we expect that this method will be used for the treatment of a number of wrist or hand injuries that require closed reduction and subsequent immobilization. The physician may consider the Plastizote orthosis for ulnar collateral ligament sprains; distal radius fractures; ulnar styloid fractures; radial shaft fractures; contusions of the forearm, wrist, and hand; and clinically suspected but radiographically unsupported hand or wrist fractures. It must be noted that only metacarpal fractures and thumb dislocations have been treated with the Plastizote splint at this time.

The following seven steps are required for the fabrication of the Plastizote wristband contact-sport orthosis:

1. Determine appropriate coverage area on hand and measure. 2. Cut pattern out of 114-in. to 112-in. Plastizote (Figure 4). 3. With a stockinet over the hand and forearm, mold warmed (350 OF) Plasti-

zote to the desired position and cool (Figure 5).

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4. If rigid intrinsic protection is required, a Kydex reinforcement can be molded at this time.

5. Bevel Kydex edges and glue onto the Plastizote in the appropriate place for additional protection at the fracture site (Figure 6).

6. Glue and mold a second layer of Plastizote over the first. The Kydex piece is enveloped by the Plastizote sheets (Figures 7 and 8).

7. Trim and add Velcro straps (Figure 9).

The fabrication of this custom splint by an orthotist requires 30 min to 1 hr. In our experience, only one splint is necessary for the duration of the healing process. The orthosis costs approximately $90 to $110 to fabricate. During compe- tition, the splint is wrapped with a 3- or 4-in. Ace bandage. This external wrap provides additional support and keeps the orthosis clean during pIay.

The primary objectives for developing an ideal protective splint for contact play include the following: (a) to protect the injured upper extremity and prevent further injury, (b) to allow the injured athlete to participate safely and effectively, (c) to protect opposing players against injuries from the splint, and (d) to satisfy game officials that these criteria have been met (1). Only continued use and experimentation will determine the effectiveness of this newly deveIoped Plasti- zote playing splint.

Conclusion

A lightweight, soft Plastizote splint appears to be a reasonable alternative to other protective devices for athletes who have suffered metacarpal injuries such

Figure 4 - Pattern cut from Plastizote.

290 Bouvette, Malanga, Cooney, Stuart, and Miller

Figure 9 - Velcro straps added.

as fracture or dislocation. This splint is versatile, inexpensive, and durable, and it can be custom molded and easily applied. It has been well received by Minnesota high school game officials and athletes. In addition, only one splint is necessary throughout the healing process. It is our belief that this splint is a safe and effective closed-reduction treatment for stable metacarpal or carpal injuries and may allow a timely return to competition. A safe return to play is further facilitated by a multidisciplinary approach, which includes the physiatrist, orthopedist, physi- cal therapist, and orthotist. We recommend that game officials be informed of the materials and the indications for their use whenever this contact-sport orthosis is to be introduced in a new state.

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Acknowledgment

We appreciate the assistance of the Prosthetic Laboratories of Rochester, 201 First Ave. SW, Rochester, MN 55902.