Musculockeletal Assessment,

Splinting, and Cast Care

Kendra Meyer MPA, PA-C

Injury Assessment

Always start with ABC’s Primary survey

The obvious injury Secondary survey

Catch more subtle musculoskeletal injuries

Injury Assessment Systematic approach

Inspection Palpation

Neurovascular status Sensation Pulses

Injury Assess joints above and below the injury

ROM (range of motion) Active Passive

Don‘t force Strength testing

Injury Assessment

Once ABC’s, primary, and secondary surveys are complete: Stable patients

Splint Unstable patients

Load and go Splint en route

Acronyms

D – deformities C – contusions A – abrasions P – Punctures

B – burns T – tenderness L – lacerations S – swelling

Signs and Symptoms

Pain/tenderness Deformity/angulation Crepitus (grating)

Rice krispies

Swelling Bruising Open fracture Joint locking Neurovascular compromise

Compartment Syndrome

Increase pressure in a closed compartment Occurs with:

Long bone fractures Femur Tibia/fibula Radius/ulna Humerus

Small compartments Foot Hand

Compartment Syndrome

Surgical emergency Compartment needs to be opened to avoid

loss of limb Increased pressure = loss of blood/oxygen

supply = tissue death Can progress quickly

Important to reassess neurovascular status frequently

Compartment Syndrome

Neurovascular compromise Pain Pallor Pulselessness Paresthesias Poikilothermia

Cool sensation Paralysis Puffiness

Edema

Strains

Microscopic muscle tearing Excessive force Stretching Overuse

S/S Hemorrhage Swelling Tenderness Pain with isometric contraction Muscle spasm

Sprains

Injury of ligamentous structures “Rubber band” Twist Possible joint instability

S/S Rapid swelling Pain with ROM testing Decreased ROM Bruising (will likely travel distal to the injury)

Later finding

Sprains I- mild

No loss of joint function Edema 25% fiber involvement Can occur with normal activities

II – moderate Partial tear Weakness in ligament strength

III – complete Pop Joint laxity May require surgical repair Can be as severe as a fracture

Sprain/Strain Treatment

R – rest I – ice C – crutches (other immobilizing devices) C – compression E – elevation

Prevent joint stiffness ROM exercises

Signs & Symptoms of fractures

Pain @ site of injury

Swelling & tenderness

Crepitus Deformity

Loss of function Ecchymosis Paresthesia Distal pulse may

not be present

Fracture Description Break in the continuity of the bone

Orientation of fracture line A. Transverse B. Oblique C. Spiral D. Comminuted E. Segmental F. Torus (buckle)* G. Greenstick*

*kidsEmergency Medicine Sixth Edition

Transverse Fracture

Straight across the bone

Direct trauma

Oblique Fracture

At an angle across the bone

Spiral Fracture

Twisted around the shaft of the bone

Comminuted Fracture

Bone is splintered into more than 3 fragments

Greenstick Fracture

One side of the bone is broken and the other is bent. Mostly seen in children. As long as bone is kept rigid, healing is usually quick

Depressed Fracture

Fragment(s) in driven (seen in fractures of the skull)

Compression Fracture

Bone collapses in on itself (seen in vertebral fractures)

Avulsion Fracture

Fragment of bone pulled off by ligament or tendon attachment

Impacted Fracture

Fragment of one wedged into other bone fragments

Open Fracture

Skin is broken

Fragments of bone will penetrate through skin

Splinting Indications:

Protects injury Decreases pain Facilitates healing Decreases risk of further injury Decreases blood loss in trauma patients Decreases need for narcotics Decreases risk of fat emboli Maintains bony alignment (fractures) Protects the structures around/within:

large lacerations lacerations with tendon injuries

Splinting

Improvised splinting Pillows Blankets Lumber Cardboard Trees Rolled newspaper Umbrella, cane, broom handle

Splinting

Gather equipment Stockinette Webril Plaster/OCL/fiberglass Scissors Warm water Ace wraps Other assist devices

Splinting

Place joint to be immobilized in proper position before applying webril

Add extra padding to bony prominences Upper inner thigh Olecranon Patella Radial styloid Fibular head Ulnar styloid Achilles tendon area Medial/lateral malleoli

Splinting

Procedure N/V checks before and after splinting Remove/cut away clothing from area Cleanse area

Dress any skin injuries as appropriate Avoid pressure on open fractures

Splinting

Apply stockinette Joint position Add webril

2-3 layers 3-4 over bony areas

Wet plaster Apply proper splint Ace wrap into position Allow to set 15 min

Ult takes 24 hours to fully dry Fiberglass quicker

Splinting

D/C instructions ICE AND ELEVATION Splint stress Follow-up is essential

Temporary Home n/v checks

Splinting

The patient complains of increasing symptoms AFTER the splint is placed Loosen Re-check Re-pad Re-splint

Splinting

Complications Ischemia Plaster burns Pressure sores Infection Dermatitis Joint stiffness

Splinting Types of splints

Compression dressing with splint Sling and swathe Volar Thumb spica Ulnar gutter Sugar tong Double splint Long arm posterior splint Jones splint Lower extremity posterior splint AO splint

Application of a Sling & Swathe

o These are used for injuries of arms, elbows and wrists

o Follow the “general rules for splinting” already discussed

o Prepare sling by folding cloth into triangleo Fold injured arm across the chest, position

sling over top of the patient’s chest

Application of a Sling & Swathe

o Extend one point of the triangle behind the elbow on the injured side

o Take bottom point and bring over the patient’s arm. Take it over the top of the injured shoulder

o Draw up the sling so that the patient’s hand is about 4 inches above elbow

Application of a Sling & Swathe

o Tie 2 ends together, make sure the knot does not press against the back of neck

o Make sure fingertips exposedo To make a pocket: twist excess material and

tie a knot in the point

Application of a Sling & Swathe

o Form a swathe from a second piece of material

o Tie it around the chest and injured arm, over the sling.

o Do not place over the patient’s arm of the uninjured side

o Alternateo Sling and ace wrap

Application of an Elastic Wrap

Used to help support Injured muscles, ligaments, & tendons Increase circulation and promote healing

Application of an Elastic Wrap

Start distal on the injured extremity and work the elastic wrap proximal with a ¼ to ½ inch overlap

Wrap firmly, but not so tight that is slows or cuts off circulation

Other Types of Splints

Upper extremity compression dressing with splint

Volar splint Thumb spica splint Ulna gutter splint Sugar Tong splint Double Splint

Sugar tong and posterior

Other Types of Splints

Long arm Posterior splint Bulky Jones splint [w/ or w/o splint] Short leg splint AO splint

Upper Extremity Compression Dressing with Splint

Primarily used for: Temporary immobilization to hand/wrist injuries or

fractures with significant swelling to allow for decrease in swelling before casting

Post-operatively to allow for swelling and temporary immobilization all at once

Volar Splint

Uses: Post-op Basic wrist injuries

Sprains Non-displaced fractures

Apply on the volar aspect of the forearm Wrist slightly cocked back

Thumb Spica

Uses: Injuries to wrist and thumb Scaphoid Thumb fracture Post-op Gamekeeper’s thumb

Beer can hand

Ulnar GutterSplint

Uses: 4th and 5th phalanx and metacarpal fractures

Sugar Tong Splint

Uses: Displaced forearm fractures Elbow fractures Bilateral ankle fractures Displaced unilateral ankle fractures

Double Splint

Primarily used for: Displaced or unstable Colles’ fractures Mid-shaft forearm fractures Elbow fractures Monteggia/Galleazzi fractures/injuries

Long Arm Posterior Splint

Primarily used for: Wrist and elbow injuries/fractures and

distal humerus fractures

Bulky Jones Splint

Primarily used for: Temporary immobilization to foot/ankle

injuries/fractures with significant swelling to allow for decrease in swelling before casting

Short Leg Posterior Splint

Primarily used for: Treat ankle sprains Temporary immobilization of fractures to

the lower extremity

AO Splint

Primarily used for: Treat ankle sprains Temporary immobilization of fractures to

the lower extremity

Casts Types

Short-arm Long-arm Short-leg Long-leg Body cast Spica cast

Complications of Cast

1. Pressure on n/v and bony structures causing necrosis, pressure sores, nerve palsies

2. Compartment syndrome

3. Immobility and confinement in a cast, particularity a body cast, can result in multisystem problems

Application of a Cast

Equipment Underlying considerations Preparatory phase Application phase Follow-up phase

Patient Assessment with Cast

ASSESS:

N/V status for signs of compromise Skin integrity Positioning and potential pressure sites C/V, respiratory, GI for possible complications

of immobility Psychological reaction

Medical Intervention

1. Elevate extremity

2. Avoid resting on hard surface

3. Handle moist cast with palms of hands

4. Turn every 2 hours while cast dries

5. Assess n/ status every hour during the first 24 hours and then as needed

Patient Education

1. Avoid getting cast wet: causes skin breakdown

2. Don’t cover leg cast with plastic or rubber boots: causes condensation and wetting of the cast

3. Avoid weight bearing for 24 hours (plaster)

Patient Education

4. Call healthcare provider if cast cracks/breaks. Instruct try not to fix it

5. Teach how to clean castRemove surface soil with slightly damp cloth

Rub soiled areas with talcum powder

Wipe off residual moisture

Cast Removal

Preparatory Phase

Performance Phase