Title: Orthopedic Injuries and Immobilization
1Orthopedic Injuries and Immobilization
- Stanford University
- Division of Emergency Medicine
2History 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.
3How 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
4REDUCING 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)
5Finger 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
6Shoulder 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
7Subluxation 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
8Nursemaids Elbow Reduction
9Fracture Types
10Greenstick
- an incomplete fracture in a long bone of a child
(bones are not yet fully calcified and they break
like a green stick)
11Open Fracture
- the bone breaks and pierces the overlying skin
(osteomyelitis are more common) - 4 grades
12Spiral Fracture
- a fracture that spirals part of the length of a
long bone
13Wrist Fractures
14Scaphoid Fractures
- tenuous blood supply
- high incidence of avascular necrosis in waist and
proximal fractures - often require bone grafting
15Scaphoid 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
16Learn How to Splint in 10 Easy Lessons!!!!
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17Introduction
- 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
18Indications for Splinting
- Fractures
- Sprains
- Joint infections
- Tenosynovitis
- Acute arthritis / gout
- Lacerations over joints
- Puncture wounds and animal bites of the hands or
feet
19Splinting 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!)
20Splinting 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
21Splinting 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
22Specific 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
23Long 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.
24Double 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.
10
90
25Forearm 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.
26Forearm Sugar Tong
- Indications
- Distal radius and ulnar fx.
- Prevents pronation / supination and immobilizes
elbow.
27Hand 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.
28Radial 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.
29Thumb 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.
30Finger Splints
- Sprains - dynamic splinting (buddy taping).
- Dorsal/Volar finger splints - phalangeal fx,
though gutter splints probably better for
proximal fxs.
31Jones 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.
32Posterior 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.
33Stirrup 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.
34Other 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
35Complications
- 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!
36Questions?