Cardboard Splints in Lower Limb Fracture Management
Viability of cardboard splints in the emergency management of lower limb fractures
R. WAHOME¹, D. HARBORNE¹, R. ELLIS¹
- Mbarara University of Science and Technology / Ministry of Health, Department of Emergency Medicine
OPEN ACCESS
PUBLISHED: 31 August 2024
CITATION: WAHOME, R., HARBORNE, D., et al., 2024. Viability of cardboard splints in the emergency management of lower limb fractures. Medical Research Archives, [online] 12(8).
https://doi.org/10.18103/mra.v12i8.5606
COPYRIGHT: © 2024 European Society of Medicine. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
DOI https://doi.org/10.18103/mra.v12i8.5606
ISSN 2375-1924
ABSTRACT
At Mbarara Regional Referral Hospital Uganda, 60% of all admissions are due to severe trauma, 30–35% of which are from tibia/fibular fractures. Emergency splinting of these fractures can be lifesaving and ideally, Plaster of Paris (P.O.P) is the gold standard. Improvised cardboard splints have replaced P.O.P, since they were more readily available and thought to be less expensive to apply especially during the covid 19 pandemic supply chain crisis. While anecdotal evidence exists dating since the First World War, scarce published works exist in measuring the clinical effectiveness of cardboard splints in comparison to P.O.P. The aim of this study was to find out if cardboard can be an effective and cheaper emergency alternative splint to P.O.P especially during the supply chain crises frequent in low resource environments.
A prospective, experimental, cadaveric study was done where 44 open tibia-fibular fractures were splinted with both cardboard and P.O.P. The clinical effectiveness of cardboard and P.O.P splints was found through the measurement of immobilization at a fracture site via the use of 5 angular and 9 linear measurements. Cost comparisons of the splint were also done. Cardboard proved to be the non-inferior splint in 9 of the 14 measures of effectiveness. In the other 4 measures, no statistically significant differences were seen, while P.O.P was superior in 1 measurement. Cardboard proved to be the least expensive splint. During extreme shortages, cardboard could be considered as an emergency material for adequate splinting of lower limb fractures.
Introduction
Trauma accounts for a significant amount of hospital admissions in Africa, with road traffic accidents being a major cause of these accidents (CDC, 2018; Chalya et al., 2012; Chigblo et al., 2017). In Uganda, leg fractures are the commonest long bone fractures (Hsia et al., 2010), with very high complication rates and cost of treatment (Clelland, Chauhan, & Mandari, 2016; Heckman & Sarasohn-Kahn, 1997). At Mbarara Regional Referral Hospital (MRRH), the high incidence of assault and road traffic accidents (specifically motorcycle) make up a significant number of severe cases and hospital emergency admissions (Kisitu et al., 2016; Shikaro, Harborne, & Deus, 2018). With up to 35% of all emergency department visits being due to tibia-fibula fractures (Hsia et al., 2010; Shikaro et al., 2018), these injuries are a source of severe morbidity and mortality and place a significant burden on hospital resources.
As part of emergency treatment of these fractures, splints are the recommended first line modality. These are rigid materials that maintain a body part in a fixed position, but do not encompass the circumference of the whole limb like a cast (Boyd, Benjamin, & Asplund, 2009). These temporary splints reduce bleeding, pain, infections, tissue damage and incidence of other complications (Surgeons, 2018). The recognized gold standard since 1852 remains Plaster of Paris (P.O.P) as is commonly used in most hospitals (Carl R. Chudnofsky; Louis Solomon, 2010). At MRRH, just as in many African hospitals, the government subsidizes healthcare, but the number of patients typically overwhelms the hospital resources necessitating patients to go out-of-pocket and outrightly pay market prices for the medical services required (Biryabarema, 2018; Mawa, 2018). This is a challenge for a large proportion of Ugandans who live below the poverty line and therefore cannot afford P.O.P (Statistics, 2018; Wandera, Kwagala, & Ntozi, 2015). Couple this with the myriad of perennial local supply chain challenges, the COVID-19 pandemic unearthed a more severe crisis in local and international supply (Lugade et al., 2022). While some local manufacturing exists for P.O.P, the majority of the country’s supply was imported, leading to severe product shortages (Chowdhury, Paul, Kaisar, & Moktadir, 2021).
Cardboard has been used as a substitute for P.O.P for the temporary splinting of fractures since the First World War (Core, 2000; Hu et al., 2011). This has since been extensively adopted in the prehospital care of patients as an emergency splinting material easily applicable with household resources (Austin Smith, 2019). It is a robust paper-based material mainly used for packaging and almost universally available both in and out of the hospital (Brouhard & Menna, 2019; Hao & Xie, 2014; Ranganadham, 2024). P.O.P is a gypsum rock that has been ground up and impregnated into cloth which when exposed to water, reforms back into a rock hard material in the shape it has been molded into (Colditz, 2002). When done right, cardboard can be splinted using similar techniques and materials as P.O.P, making them very similar, more-so in resource limited areas (Hu et al., 2011; Langley-Hobbs, Abercromby, & Pead, 1996; W.H.O., 2020).
Measurement of immobilization of splints is done by looking at the splint’s ability to resist deformity, typically first tested in animals (Langley-Hobbs et al., 1996; Louis Solomon, 2010). Due to the challenges of measuring effectiveness of these splints in-vivo (such as worsening deformities, increasing pain or bleeding and the possibility of inflicting permanent damage while performing the proposed measurements), a cadaveric approach was used to circumvent this. The use of angles (degrees) and linear measurements (centimeters) is used to compare the modality of splinting that is most resilient. Certain set-points are used to measure the distance the limb has moved when force is applied, and an angle at the fracture site can also be measured with the help of a goniometer, where the fracture is considered as a pathological joint (Burrows, 1966; Malanga & Mautner, 2017).
While cardboard is considered a waste material in many institutions, P.O.P is costly (Parmar et al., 2014). While the raw material costs may favor cardboard, many experts believed it took longer to splint with cardboard as opposed to P.O.P, therefore negating its advantage (Gocke, Tintinalli, Cline, Ma, & McGraw-Hill Education (Firm), 2015).
Although widely used and unofficially endorsed, minimal published data exists in the use of cardboard as a splinting material, even less when comparing it to the gold standard in-vivo. With patient safety being of paramount importance, studies of effectiveness would preclude safety research. This endeavor therefore sought to find out if cardboard was an effective alternative to P.O.P in terms of effectiveness and costs.
Methods
The study was conducted at the Anatomy and Pathology dissection laboratories where 44 cadaveric limbs suitable for dissection were used, following a pilot study of 10 limbs prior, in a prospective, experimental study design. These were adult unclaimed cadavers without any missing tissue, fractures, or obvious deformity. Cadavers were considered unclaimed after a minimum of 2-week storage, all reasonable methods of tracing were deemed futile and confirmation by local police, judiciary or follow up from local political leaders in local media publications yielded no next of kin or tangible results. Outright donation of bodies was also considered in the study. Cause of death was ascertained from the official mortuary record after confirmation by a pathologist. A steel frame jig was designed to enable accurate and reproducible measurements where 3 different fracture types were created using a hand saw based on the most common fracture patterns. These were all open fractures and a combination of proximal, mid-shaft and distal third fractures in proportion to their prevalence of presentation (Brown, Skaggs, Brady, Tumusiime, & White, 2020; Chigblo et al., 2017; Clelland et al., 2016). Both limbs for every cadaver were used during the study.
Three trained research assistants would then take baseline measurements and follow by randomizing which splint was applied first (but both splinting modalities would be applied on the same leg so as to act as its own control). Each research assistant was responsible for each splinting modality as well as data collection. Five angular and nine linear measurements were recorded after the standard WHO-based splinting protocol was used, using a tape measure and a goniometer (W.H.O., 2020). Both linear and angular measurements were used for better demonstration of the more effective splint. These angles and linear measurements were chosen based on what would be feasible, safe and most dramatically different when measured; others were chosen based on what was considered clinically unacceptable deformities. Standard weights were used to reduce the effects of rigor mortis, compensate for different BMIs, and simulate forces that would occur during patient transport as well as to accentuate the differences between the two splints for clearer outcomes.
This 5 kg standard weight was placed at the toes of the cadaver creating a fulcrum at the fracture and therefore a more clearly defined fracture deformity. An independent observer was available to confirm adequate and correct splinting technique. These splinting materials were standard Government of Uganda supplied P.O.P (10 cm wide) and cardboard boxes of 4 mm thick, double-layered, corrugated, unpainted boxes typically used for packaging IV fluids. Each limb received 10–12 layers of P.O.P covering ½ the circumference of the limb while cardboard was 2 layers thick, covering ¾ of the circumference of the limb (circumference of cardboard was described by the inventor) (Sheldon & Sebastian, 1959).
The fractures once created would be splinted using either P.O.P or dry cardboard and measurements taken. These measurements were meant to show differences in limb reduction, resistance to deformation and resilience of the splint. For effective reduction, the length of the limb was measured pre and post splinting and a better splint would be the one closest to baseline.
Distraction and compressive forces were also used to demonstrate effective resistance against limb lengthening and reduction. For resilience, the angles made at the fracture site would be measured after application of a standard weight as well as measuring the distance from a set point on the jig to the limb. Bigger angles at the fracture site as well as shorter lengths to set points when compared to baseline, would demonstrate worse immobilization. Flexion at the knee and ankle were also used for comparison.
Cost data was collected in terms of resource costs and time. The total amounts of materials needed per splint were costed to the nearest whole item and compared to average cost of items from the Joint Medical Store Uganda (JMS)- a parastatal organization for supplying pharmaceutical items to hospitals. Time was also used. The average time taken to create the splint was measured. This was converted into monetary value by multiplying the time with the most recent salary scale for a medical officer who would typically be applying the splint.
Data was then collected in tables, entered into Epidata Version 3.1, and analyzed using STATA version 12.1 or EXCEL 2013. Variables were expressed using frequencies, means and standard deviations while comparison was done using T-Test and confidence intervals. A power of 80% and an alpha of <0.05 was considered significant.
Ethical Considerations
Express consent was received from the relevant departments including the office of the dean of medicine for Mbarara University of Science and Technology. Further approval was given by Mbarara University of Science and Technology Research Ethics Committee (MUST REC) (ref: MUST-2021-50) and Uganda National Council for Science and Technology (ref: HS1357ES). All cadaveric specimens were handled with dignity and respect as per the code of tissue handling of anatomists.
Results
Table 1 Baseline characteristics of cadavers
| Characteristic | Frequency | Percent |
|---|---|---|
| Male sex | 44 | 100 |
Age in years
| Category | Frequency | Percent |
|---|---|---|
| <25 | 8 | 18 |
| 25-49 | 28 | 64 |
| ≥50 | 8 | 18 |
BMI in Kg/m²
| Category | Frequency | Percent |
|---|---|---|
| <18.5 | 6 | 14 |
| 18.5 to <25 | 24 | 55 |
| >25 | 14 | 31 |
Cause of death
| Category | Frequency | Percent |
|---|---|---|
| Trauma | 16 | 36 |
| Other | 28 | 64 |
Other causes of death*
| Category | Frequency | Percent |
|---|---|---|
| Alcohol intoxication | 2 | 7 |
| Drowning | 4 | 15 |
| Hanging | 6 | 21 |
| Medical illness | 12 | 43 |
| Old age | 2 | 7 |
| Respiratory illness | 2 | 7 |
Duration since death
| Category | Frequency | Percent |
|---|---|---|
| <15 days** | 6 | 14 |
| 15–29 days | 10 | 22 |
| >30 days | 28 | 64 |
Fracture location
| Category | Frequency | Percent |
|---|---|---|
| Proximal 1/3 | 9 | 21 |
| Mid shaft | 12 | 27 |
| Distal 1/3 | 23 | 52 |
Median age = 31 years (IQR 25–42); BMI: Body mass index
- Assessed only among non-trauma cadavers (n=28)
** Duration since death minimum is 12 days
All samples are from 22 cadavers which yielded 44 cadaveric legs/samples.
Table 2 Comparison of cardboard and plaster of Paris measurements (linear limb length)
| Measurement | Cardboard Mean (95% CI) | Plaster of Paris Mean (95% CI) | P value |
|---|---|---|---|
| Average limb length in Cm | 103 (101–104) | 102 (101–104) | 0.2082 |
| Distraction with standard weights in Cm (limb length) | 106 (104–107) | 105 (104–107) | 0.502 |
| Compression with standard weights in Cm (limb length) | 104 (103–105) | 103 (102–105) | 0.520 |
As shown above, the results of what would be considered the efforts of reduction. These show that for both modalities, there would be similar degree of reduction at the fracture site as compared to the other splinting modality as this was being compared to the average limb length.
Table 3 Comparison of cardboard and plaster of Paris measurements (linear measurements)
| Measurement | Cardboard Mean (95% CI) | Plaster of Paris Mean (95% CI) | P value |
|---|---|---|---|
| Maximum knee flexion in Cm | 74 (71–78) | 67 (64–70) | 0.001 |
| Maximum ankle plantarflexion in Cm | 81 (80–83) | 81 (79–83) | 0.702 |
| Fracture lateral rotation with standard weights in Cm | 32 (29–35) | 24 (23–25) | <0.001 |
| Fracture Posterior bending with standard weights in Cm | 55 (52–58) | 43 (41–45) | 0.001 |
| Fracture Valgus deformity with standard weights in Cm | 31 (30–33) | 26 (24–27) | <0.001 |
Referencing above table 3, cardboard was a more resilient splinting material than plaster of Paris in all measurement except for maximum plantarflexion.
For all values above, a higher value signifies a more effective splint.
Table 4 Comparison of plaster of Paris and cardboard measurements (angular measurements)
| Measurement | Cardboard Mean (95% CI) | Plaster of Paris Mean (95% CI) | P value |
|---|---|---|---|
| Maximum knee flexion in degrees | 15 (10–21) | 49 (42–57) | <0.001 |
| Maximum ankle plantarflexion in degrees | 42 (38–47) | 49 (45–53) | 0.001 |
| Maximum ankle lateral rotation in degrees | 38 (33–43) | 39 (36–43) | 0.536 |
| Fracture lateral rotation with standard weights in degrees | 43 (39–48) | 54 (51–58) | 0.001 |
| Fracture posterior bending with standard weights in degrees | 10 (9–12) | 21 (18–23) | <0.001 |
| Fracture valgus deformity with standard weights in degrees | 9 (8–10) | 14 (12–15) | <0.001 |
The above table shows that cardboard was a more resilient splinting material as compared to Plaster of Paris except for in maximum lateral rotation in degrees. For all values above, lower value signifies a more effective splint.
Table 5 Cost Comparisons
| Cost variable | Cardboard Mean (95% CI) | Plaster of Paris Mean (95% CI) | P value |
|---|---|---|---|
| Time in minutes | 5.5 (4.9–6.2) | 5.4 (5.0–5.8) | 0.587 |
| Labor costed in time in UGX | 13,807 (12,197–15,417) | 13,523 (12,444–14,601) | 0.768 |
| Cotton cost in UGX | 3,738 (2,454–3,022) | 3,022 (2,742–3,303) | 0.007 |
| Crepe bandage cost in UGX | 2,920 (2,751–3,090) | 3,475 (3,323–3,626) | <0.001 |
| Total cost in UGX* | 36,645 (35,009–38,281) | 55,199 (54,081–56,318) | <0.001 |
* Includes costs for cotton, Plaster of Paris (18,000/= per splint for Plaster of Paris), labor costs of 75,000/= per hour per doctor for two doctors, other costs amounting to 17,179/= per splint for gowns, gloves, bandages and tape and other sundries.
1 USD = 3563 UGX
Table 5 above shows that time and resource cost being considered, cardboard was significantly cheaper. Although there was no significant difference in the time it took to splint between the two modalities.
Overall, Cardboard was found to be the more resilient of the two splinting materials, and the relatively cheaper option.
Summary
• Fracture reduction after splinting – Limb length was similar when reduction was done with both cardboard and P.O.P, meaning both modalities offered similar tissue reduction.
• Resistance to deformation – Cardboard had more resilient linear and angular measures across multiple parameters meaning cardboard was better at resisting deformation.
• Cost per Splint – Cardboard would cost 18,554 UGX (5.1 USD) cheaper than plaster of Paris per splint and cardboard was the cheaper method of splinting an open tibial-fibula fracture.
• Time needed to splint – Equal time was experienced when using both splinting modalities. Equal time may translate to similar ease of application per splint.
Data was collected for 3 months, and all data was eligible for analysis, and those not normally distributed transformed by multiplying with Log base 10. The cadavers were mainly male, middle aged with normal BMI, who died of non-traumatic causes.
Discussion
Several findings were noted in the study. In terms of demographics’, only men were found in the study. This is comparable to other studies in different countries where cadavers are sourced through unclaimed bodies. This was similar for the age at death as well as cause of death This was also noted as males were more commonly associated with fatal traumatic incidents. Other social factors such as religion, support structure (i.e. children and homelessness are more likely to have women claimed by family and buried appropriately, while men would remain unclaimed (Hunt & Albanese, 2005; Independent, 2020; Kramer, Hutchinson, Brits, & Billings, 2019; Oporia et al., 2018; Srimani, Mazumdar, & Majumdar, 2017). Since anatomists typically screen against trauma patients, those with gross deformities or missing tissue, this value is skewed away from trauma patients. Even with this skew, the number of non-traumatic cases were not disproportionately higher than what is expected cause of mortality as seen in many cadaveric specimens (Noriki et al., 2019; Srimani et al., 2017). As seen in the correlating study, many of the cadaveric samples favor medical illness due to preservation of tissue making them suitable for dissection.
When comparing the linear measurements, it was of note that cardboard splints were able to offer similar fracture reduction as compared to P.O.P. Considering the study used a variety of different fracture locations to increase generalizability, cardboard proved to be a versatile splint. Surprisingly, the degree of immobilization across the different types of fracture sites was similar across the two different splinting materials, but a larger sample may improve on this data. As per the other linear measurements, cardboard proved to be the resilient splint. This was also replicated in angular measurement. Maximum ankle plantarflexion was significant in degrees since a small linear change could result in a larger angular change.
Although no studies have been previously done directly comparing these splinting materials, some mechanical studies have been done separately to investigate this. 12-layer cylindrical pieces of P.O.P were found to withstand about 36.6 N/mm² which would be equivalent to 36.6 kg of force before significant deformation (Langley-Hobbs et al., 1996; Parmar et al., 2014; Vieira et al., 2011). This is compared to similar cylindrical double layer cardboard which could withstand approximately 43.0 N/mm², equivalent to 43 kg of force before deformation. Although the methods of these mechanical study were not the same, they were sufficiently similar for direct comparisons to be made, showing cardboard could be a great splinting modality (Langley-Hobbs et al., 1996; Parmar et al., 2014; Vieira et al., 2011).
Time is a critical factor in the emergency department and the faster things can be done, the better results are achieved for the patient (Carl R. Chudnofsky). Therefore, a splint that takes a shorter time to apply indicates that it is user friendly and versatile. Splinting done by an experienced practitioner takes 3–15 minutes depending on the type of fracture (Anne S. Boyd, 2009), this falls in line with both the times seen in cardboard and Plaster of Paris. Since there was no significant difference in time seen in splinting of both cardboard and Plaster of Paris, it would suggest both are equally versatile and user friendly.
In terms of cost, although the difference between the two splinting modalities appears insignificant (5.1 USD), but when taking the average household expenditure and average income into consideration, the difference is compounded. A cardboard splint would cost an average Ugandan 22% of their monthly income and 39% of their monthly household expenditure (Statistics, 2018). This is in comparison to P.O.P which would cost approximately 33% of monthly income and 57% of monthly household expenditure. This may make P.O.P unattainable to many citizens and thus access to this specific type of healthcare, and thus encouraging the unofficial use of cardboard as the cheaper option.
Limitations
This was a cadaveric study. Although extremely similar, some biomechanics may be different when compared to live patients. It was evident, that no female and pediatric cadavers were available for use in this study. Also, this being a lower limb study, findings may not be directly translatable to other limb or different presentations of fractures. This was also a point assessment and temporal assessment of the effectiveness of the splints was not done to compare its efficiency over time or with wear and tear. We could not account for microscopic pathologies of the limbs not clinically apparent or recorded. We only tested brands of materials typically sourced by and supplied to government hospitals.
Conclusions
Cardboard was not inferior to Plaster of Paris in splinting of various types of open tibia-fibular fractures and would be considered a more resilient splint than Plaster of Paris in many of the parameters used to measure effectiveness of splints. Plaster of Paris and cardboard are both great modalities of splinting leg fractures and both would adequately immobilize a limb if adequate care and technique are employed, with emphasis on open tibia-fibular fractures. Cardboard was also a cheaper alternative to Plaster of Paris for the emergency splinting of open tibia-fibular fractures. While the authors do not advocate for the outright splinting of fractures with cardboard, as an emergency use material such as during supply chain shortages and pre-hospital care, cardboard would be a reasonable material for the splinting of lower limb fractures.
Conflict of Interest:
None
Funding Statement:
None.
Acknowledgements:
None.
References
Anne S. Boyd, H. J. B., Chad Asplund. (2009). Splints and Casts Indications and Methods.pdf. American Academy of Family Physicians, Am Fam Physician. 2009;80(5):491499.
Austin Smith, a. W. D. (2019). SplintER Series: Complications & Discharge Care Plans | Splint Principles 103. academic life in emergency medicine.
Biryabarema, E. (2018). Ugandan hospitals hit by shortages of drugs, other suplies. Reuter’s. Retrieved from
https://www.reuters.com/article/us-uganda-healthcare-idUSKBN1KM4PC
Boyd, A. S., Benjamin, H. J., & Asplund, C. (2009). Principles of casting and splinting. Am Fam Physician, 79(1), 16-22.
Brouhard, R., & Menna, M. (2019). How to Splint a Broken Arm With Cardboard. Retrieved from https://www.verywellhealth.com/splinting-a-broken-arm-4020293
Brown, H. A., Skaggs, J., Brady, C., Tumusiime, V., & White, A. S. (2020). Injury patterns of patients presenting to a non-governmental hospital in Western Uganda. African Journal of Emergency Medicine, 10(3), 118-122. doi:https://doi.org/10.1016/j.afjem.2020.02.001
Burrows, H. J. (1966). Joint Motion: Method of Measuring and Recording. Published by the American Academy of Orthopaedic Surgeons, 1965. Reprinted by the British Orthopaedic Association, 1966. 7¼x4¾ in. Pp. 88, with numerous line drawings. Paper cover. 1966. Edinburgh and London: E. & S. Livingstone Ltd. Price 5s., plus 6d. postage. The Journal of Bone and Joint Surgery. British volume, 48-B(4), 857-857. doi:10.1302/0301-620x.48b4.857
Carl R. Chudnofsky, S. E. B. Roberts: Clinical Procedures in Emergency Medicine, 5th ed, Chapter 50 Splinting.pdf. In Roberts: Clinical Procedures in Emergency Medicine, 5th ed.
CDC. (2018). National Hospital Ambulatory Medical Care Survey 2018. C.D.C. GOV.
Chalya, P. L., Mabula, J. B., Dass, R. M., Mbelenge, N., Ngayomela, I. H., Chandika, A. B., & Gilyoma, J. M. (2012). Injury characteristics and outcome of road traffic crash victims at Bugando Medical Centre in Northwestern Tanzania. Journal of Trauma Management & Outcomes, 6(1), 1. doi:10.1186/1752-2897-6-1
Chigblo, P., Lawson, E., Tidjani, F., Padonou, A., Nezien, C., Goukodadja, O., . . . Akue, A. (2017). Epidemiology of Fractures in a Tropical Country. European Scientific Journal, 13. doi:10.19044/esj .2017.v13n24p416
Chowdhury, P., Paul, S. K., Kaisar, S., & Moktadir, M. A. (2021). COVID-19 pandemic related supply chain studies: A systematic review. Transp Res E Logist Transp Rev, 148, 102271. doi:10.1016/j.tre. 2021.102271
Clelland, S. J., Chauhan, P., & Mandari, F. N. ( 2016). The epidemiology and management of tibia and fibula fractures at Kilimanjaro Christian Medical Centre (KCMC) in Northern Tanzania. The Pan African Medical Journal, 25(51). Retrieved from http://www.panafrican-med-journal.com/content/
Colditz, J. (2002). Plaster of Paris: The forgotten hand splinting material. Journal of hand therapy : official journal of the American Society of Hand Therapists, 15, 144-157. doi:10.1053/hanthe.2002. v15.015014
core, U. m. (2000). Manage musculoskeletal injuries, US MARINE corps field medical training battalion student matterial.
Gocke, T., Tintinalli, J. E., Cline, D., Ma, O. J., & McGraw-Hill Education (Firm). (2015). Posterior Leg Splint [two-dimensional moving image]McGraw-Hill’s AccessMedicine (pp. 1 online resource (1 streaming video file, approximately 2 min. 19 sec). Retrieved from https://ezproxy.lib.monash.edu.au/login?url=https://accessmedicine.mhmedical.com/MultimediaPlayer.aspx?MultimediaID=5481074
Hao, B. C., & Xie, K. B. (2014). [Manipulative reduction and external fixation with cardboard splint for the treatment of calcaneal fractures: a 60-case report]. Zhongguo Gu Shang, 27(7), 545-550.
Heckman, J. D., & Sarasohn-Kahn, J. (1997). The economics of treating tibia fractures. The cost of delayed unions. Bull Hosp Jt Dis, 56(1), 63-72.
Hsia, R. Y., Ozgediz, D., Mutto, M., Jayaraman, S., Kyamanywa, P., & Kobusingye, O. C. (2010). Epidemiology of injuries presenting to the national hospital in Kampala, Uganda: implications for research and policy. International journal of emergency medicine, 3(3), 165-172. doi:10.1007/ s12245-010-0200-1
Hu, Q. D., Jiao, P. Y., Shao, C. S., Zhang, W. G., Zhang, K., & Li, Q. (2011). [Manipulative reduction and external fixation with cardboard for the treatment of distal radial fracture]. Zhongguo Gu Shang, 24(11), 907-909. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22295483
Hunt, D. R., & Albanese, J. (2005). History and demographic composition of the Robert J. Terry anatomical collection. American Journal of Physical Anthropology, 127(4), 406-417. doi:https://doi.org/10.1002/ajpa.20135
Independent, T. (2020). 500 bodies unclaimed from KCCA mortuary annually. The Independent. Retrieved from https://www.independent.co.ug/500-bodies-unclaimed-from-kcca-mortuary-annually/
Kisitu, D. K., Eyler, L. E., Kajja, I., Waiswa, G., Beyeza, T., Feldhaus, I., . . . Dicker, R. A. (2016). A pilot orthopedic trauma registry in Ugandan district hospitals. J Surg Res, 202(2), 481-488. doi:10.1016 /j.jss.2015.12.028
Kramer, B., Hutchinson, E. F., Brits, D. M., & Billings, B. K. (2019). Making the Ethical Transition in South Africa: Acquiring Human Bodies for Training in Anatomy. Anatomical Sciences Education, 12(3), 264-271. doi:https://doi.org/10.1002/ase.1814
Langley-Hobbs, S., Abercromby, R., & Pead, M. (1996). Comparison and assessment of casting materials for use in small animals. The Veterinary record, 139, 258-262. doi:10.1136/vr.139.11.258
Louis solomon, D. w., Selvadurai Nayagam. (2010). Apley’s System of Orthopaedics and Fractures.pdf.
Lugada, E., Komakech, H., Ochola, I., Mwebaze, S., Olowo Oteba, M., & Okidi Ladwar, D. (2022). Health supply chain system in Uganda: current issues, structure, performance, and implications for systems strengthening. J Pharm Policy Pract, 15(1), 14. doi:10.1186/s40545-022-00412-4
Malanga, G. A. M., & Mautner, K. M. (2017). Musculoskeletal physical examination: An Evidence-Based Approach (Vol. Second edition): Elsevier, Inc.
Mawa, M. (2018). Report on the state of regional referral hospitals in Uganda. Retrieved from Uganda:
Noriki, S., Iino, S., Kinoshita, K., Fukazawa, Y., Inai, K., Sakai, T., & Kimura, H. (2019). Pathological analysis of cadavers for educational dissection by using postmortem imaging. Pathol Int, 69(10), 580-600. doi:10.1111/pin.12857
Oporia, F., Kisakye, A. N., Nuwematsiko, R., Bachani, A. M., Isunju, J. B., Halage, A. A., . . . Kobusingye, O. (2018). An analysis of trends and distribution of the burden of road traffic injuries in Uganda, 2011 to 2015: a retrospective study. Pan Afr Med J, 31, 1. doi:10.11604/pamj.2018.31.1.15223
Parmar, A., Tyagi, S. K., Dabas, V., Mistry, J., Jhala, S., Suthar, D., . . . Bhatti, M. (2014). Assessment of the physical and mechanical properties of plaster of Paris bandage cast used as a splinting and casting materials. Veterinary World, 7, 1123-1126. doi:10.14202/vetworld.2014.1123-1126
Ranganadham, m., patel, a. A., srivastava, d. A. K., & solanki, d. M. J. (2024). Characteristics of paper, corrugated paper, fiber board and wood. In D. M. J. S. (ed.) (Ed.). Retrieved from http://ecoursesonline.iasri.res.in/mod/page/view.php?id=6199
Sheldon, D. B., & Sebastian, C. F. (1959). The emergency splinting of fractures with cardboard. West J Surg Obstet Gynecol, 67, 300-302. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/14445766
Shikaro, S., Harborne, D., & Deus, T. (2018). Incidence,patterns of injury and short term outcomes of polytrauma patients admitted in Mbarara regional referral Hospital. pending publication, local research.
Srimani, P., Mazumdar, A., & Majumdar, S. (2017). ANALYSIS OF CADAVER POPULATION: A RETROSPECTIVE STUDY IN A MEDICAL TEACHING INSTITUTION IN WEST BENGAL. International Journal of Anatomy and Research, 5, 3530-3534. doi:10.16965/ijar.2017.106
Statistics, U. B. o. (2018). Uganda National Household Survey 2016-2017. Kampala, Uganda: Government of Uganda
Surgeons, A. C. o. (2018). Advanced trauma and life support (ATLS). In C. o. Trauma (Ed.), (10TH ed., Vol. 10TH EDITION, pp. Chapter 8).
Vieira, G., Barbosa, R., Marcolino, A., Shimano, A., Elui, V., & Fonseca, M. (2011). Influence of the number of layers of paris bandage plasters on the mechanical properties speciments used on orthopedic splints. Revista brasileira de fisioterapia (São Carlos (São Paulo, Brazil)), 15, 380-385. doi:10.1590/S1413-35552011005000018
W.H.O. (2020). Casts and Splints. World Health Organisation.INTERNATIONAL, https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/surgical-care/imeesc-toolkit/best-practice-safety-protocols/casts-and-splints.pdf?sfvrsn=c18eb740_5(Kajiwara Maki, ). Retrieved from https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/surgical-care/imeesc-toolkit/best-practice-safety-protocols/casts-and-splints.pdf?sfvrsn=c18eb740_5
Wandera, S. O., Kwagala, B., & Ntozi, J. (2015). Determinants of access to healthcare by older persons in Uganda: a cross-sectional study. International Journal for Equity in Health, 14(1), 26. doi:10.1186/s12939-015-0157-z