Orthopedic Injuries and Immobilization

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Orthopedic Injuries and Immobilization

• Stanford University
• Division of Emergency Medicine

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History and Physical Exam

• Immediately upon presentation with a dislocation
  or fracture, the neurovascular and circulatory
  status must be checked.
  
• Attempt to ascertain the mechanism of injury.
• - may alert physician to other possibly
  associated
  
• injuries
• as well as provide clues as to the type of injury
  involved
  
• Radiographs should be obtained if fracture OR
  DISLOCATION is suspected
  
• Radiographs should be obtained after reduction
  and IMMOBILIZATION of a fracture or dislocation.

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How do you Describe This?

• Named by where the distal articulating surface
  ends up relative to the proximal articulating
  surface
  
• e.g. Anterior shoulder dislocation
• - Humeral head is anterior to the glenoid fossa

Left Forearm fracture which is Dorsally Displaced
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REDUCING DISLOCATIONS and SUBLUXATIONS

• Three keys to success when attempting reduction
• a. knowledge of anatomy
• b. analgesia and sedation
• c. slow and gentle procedure
• Following reduction, the joint must be splinted
  and proper follow-up is mandatory
  
• After one or two unsuccessful attempts of
  reducing a dislocation (closed reduction), it is
  necessary to reduce under general anesthesia
  (closed) or during surgery (open reduction)

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Finger Dislocation

• Clinical exam to determine nerve and tendon
  function if possible
  
• X-ray to confirm diagnosis
• Anesthetize with a digital block
• Reduce dislocation
• i. Apply traction in line with the distal portion
  of the finger
  
• ii. The deformity should increase slightly just
  prior to joint going back in place
  
• iii. This should be felt as a click
• Take further X-rays if necessary to rule out a
  "chip" fracture
  
• Strap injured finger to adjacent finger
• Warn patient that swelling will persist for
  several months

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Shoulder Dislocation

• Take a past medical history (i.e. has this
  happened before?)
  
• Clinical exam (check for circumflex nerve
  function)
  
• X-ray to rule out possible fracture (i.e. head of
  the humerus)
  
• Several methods for reduction
• Scapular rotation
• Traction/counter traction

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Subluxation of the Radial Head (Nursemaids
Elbow)

• Definition of subluxation a joint disruption in
  which the joint surfaces are maintained in some
  degree of apposition.
  
• Description the radial head slips out from under
  the annular ligament.
  
• i. Generally caused by sudden traction of the
  forearm that extends and pronates the elbow (like
  the motion of pulling a child off the ground by
  his/her wrist).
• ii. Most common in children aging 1 - 4 years
  old, because the lip of the radial head is not
  well formed and may slip out from under the
  annular ligament with more ease.
• iii. Minimal pain if the arm is stationary but
  pain is felt upon flexing or supinating arm,
  (parents often think it is merely a sprain and
  wait 24 - 36 hours before seeking medical help)
• iv. No associated swelling, ecchymosis, or
  neurovascular deficit
  
• Radiography - Normal findings

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Nursemaids Elbow Reduction
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Fracture Types
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Greenstick

• an incomplete fracture in a long bone of a child
  (bones are not yet fully calcified and they break
  like a green stick)

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Open Fracture

• the bone breaks and pierces the overlying skin
  (osteomyelitis are more common)
  
• 4 grades

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Spiral Fracture

• a fracture that spirals part of the length of a
  long bone

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Wrist Fractures
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Scaphoid Fractures

• tenuous blood supply
• high incidence of avascular necrosis in waist and
  proximal fractures
  
• often require bone grafting

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Scaphoid Fractures

• high clinical suspicion even with normal x-ray
• follow up important- repeat x-rays and early
  bone scan in patients with persistent pain
  
• thumb spica with prolonged immobilization

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Introduction

• Evidence of rudimentary splints found as early as
  500 BC.
  
• Used to temporarily immobilize fractures,
  dislocations, and soft tissue injuries.
  
• Circumferential casts abandoned in the ED
• - increased compartment syndrome and other
  complications
  
• - ideal for the ED allow swelling
• splints easier to apply

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Indications for Splinting

• Fractures
• Sprains
• Joint infections
• Tenosynovitis
• Acute arthritis / gout
• Lacerations over joints
• Puncture wounds and animal bites of the hands or
  feet

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Splinting Equipment

• Plaster of Paris
• Made from gypsum - calcium sulfate dihydrate
• Exothermic reaction when wet - recrystallizes
  (can burn patient)
  
• Warm water - faster set, but increases risk of
  burns
  
• Fast drying - 5 - 8 minutes to set
• Extra fast-drying - 2 - 4 minutes to set - less
  time to mold
  
• Can take up to 1 day to cure (reach maximum
  strength)
  
• Upper extremities - use 8-10 layers
• Lower extremities - 12-15 layers, up to 20 if big
  person (increased risk of burn!)
  

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Splinting Equipment

• Ready Made Splinting Material
• Plaster (OCL)
• 10 -20 sheets of plaster with padding and cloth
  cover
  
• Fiberglass (Orthoglass)
• Cure rapidly (20 minutes)
• Less messy
• Stronger, lighter, wicks moisture better
• Less moldable

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Splinting Equipment

• Stockinette
• protects skin, looks nifty (often not necessary)
• cut longer than splint
• 2,3,4,8,10,12-in. widths
• Padding - Webril
• 2-3 layers, more if anticipate lots of swelling
• Extra over elbows, heels
• Be generous over bony prominences
• Always pad between digits when splinting
  hands/feet or when buddy taping
  
• Avoid wrinkles
• Do not tighten - ischemia!
• Avoid circumfrential use
• Ace wraps

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Specific Splints and Orthoses

• Upper Extremity
• Elbow/Forearm
• Long Arm Posterior
• Double Sugar - Tong
• Forearm/Wrist
• Volar Forearm / Cockup
• Sugar - Tong
• Hand/Fingers
• Ulnar Gutter
• Radial Gutter
• Thumb Spica
• Finger Splints

• Lower Extremity
• Knee
• Knee Immobilizer / Bledsoe
• Bulky Jones
• Posterior Knee Splint
• Ankle
• Posterior Ankle
• Stirrup
• Foot
• Hard Shoe

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Long Arm Posterior Splint

• Indications
• Elbow and forearm injuries
• Distal humerus fx
• Both-bone forearm fx
• Unstable proximal radius or ulna fx (sugar-tong
  better)
  
• Doesnt completely eliminate supination /
  pronation -either add an anterior splint or use a
  double sugar-tong if complex or unstable distal
  forearm fx.

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Double Sugar Tong

• Indications
• Elbow and forearm fx - prox/mid/distal radius and
  ulnar fx.
  
• Better for most distal forearm and elbow fx
  because limits flex/extension and pronation /
  supination.
  

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90
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Forearm Volar Splint aka Cockup Splint

• Indications
• Soft tissue hand / wrist injuries - sprain,
  carpal tunnel night splints, etc
  
• Most wrist fx, 2nd -5th metacarpal fx.
• Most add a dorsal splint for increased stability
  - sandwich splint (B).
  
• Not used for distal radius or ulnar fx - can
  still supinate and pronate.
  

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Forearm Sugar Tong

• Indications
• Distal radius and ulnar fx.
• Prevents pronation / supination and immobilizes
  elbow.
  

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Hand Splinting

• The correct position for most hand splints is the
  position of function, a.k.a. the neutral
  position.
  
• This is with the the hand in the beer can
  position (which may have contributed to the
  injury in the first place) wrist slightly
  extended (10-25) with fingers flexed as shown.
• When immobilizing metacarpal neck fractures, the
  MCP joint should be flexed to 90.
  
• Have the patient hold an ace wrap (or a beer can
  if available) until the splint hardens.
  
• For thumb fx, immobilize the thumb as if holding
  a wine glass.

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Radial and Ulnar Gutter

• Indications
• Fractures, phalangeal and metacarpal, and soft
  tissue injuries of the little and ring fingers.

• Indications
• Fractures, phalangeal and metacarpal, and soft
  tissue injuries of index and long fingers.

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Thumb Spica

• Indications
• Scaphoid fx - seen or suspected (check snuffbox
  tenderness)
  
• De Quervain tenosynovitis.
• Notching the plaster (shown) prevents buckling
  when wrapping around thumb.
  
• Wine glass position.

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Finger Splints

• Sprains - dynamic splinting (buddy taping).
• Dorsal/Volar finger splints - phalangeal fx,
  though gutter splints probably better for
  proximal fxs.

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Jones Compression Dressing - aka Bulky Jones

• Procedure
• Stockinette and Webril.
• 1-2 layers of thick cotton padding.
• 6 inch ace wrap.

• Indications
• Short term immobilization of soft tissue and
  ligamentous injuries to the knee or calf.
  
• Allows slight flexion and extension - may add
  posterior knee splint to further immobilize the
  knee.
  

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Posterior Ankle Splint

• Indications
• Distal tibia/fibula fx.
• Reduced dislocations
• Severe sprains
• Tarsal / metatarsal fx
• Use at least 12-15 layers of plaster.
• Adding a coaptation splint (stirrup) to the
  posterior splint eliminates inversion / eversion
  - especially useful for unstable fx and sprains.

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Stirrup Splint

• Indications
• Similiar to posterior splint.
• Less inversion /eversion and actually less
  plantar flexion compared to posterior splint.
  
• Great for ankle sprains.
• 12-15 layers of 4-6 inch plaster.

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Other Orthoses

• Knee Immobilizer
• Semirigid brace, many models
• Fastens with Velcro
• Worn over clothing
• Bledsoe Brace
• Articulated knee brace
• Amount of allowed flexion and extension can be
  adjusted
  
• Used for ligamentous knee injuries and post-op
• AirCast/ Airsplint
• Resembles a stirrup splint with air bladders
• Worn inside shoe
• Hard Shoe
• Used for foot fractures or soft tissue injuries

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Complications

• Burns
• Thermal injury as plaster dries
• Hot water, Increased number of layers, extra
  fast-drying, poor padding - all increase risk
  
• If significant pain - remove splint to cool
• Ischemia
• Reduced risk compared to casting but still a
  possibility
  
• Do not apply Webril and ace wraps tightly
• Instruct to ice and elevate extremity
• Close follow up if high risk for swelling,
  ischemia.
  
• When in doubt, cut it off and look
• Remember - pulses lost late.

• Pressure sores
• Smooth Webril and plaster well
• Infection
• Clean, debride and dress all wounds before splint
  application
  
• Recheck if significant wound or increasing pain

Any complaints of worsening pain - Take the
splint off and look!

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Questions?