Orthopedic Injuries and ImmobilizationStanford UniversityDivision of Emergency Medicine

History and Physical ExamImmediately 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 injuriesas well as provide clues as to the type of injury involved Radiographs should be obtained if fracture OR DISLOCATION is suspectedRadiographs should be obtained after reduction and IMMOBILIZATION of a fracture or dislocation.

How do you Describe This?Named by where the distal articulating surface ends up relative to the proximal articulating surfacee.g. Anterior shoulder dislocation - Humeral head is anterior to the glenoid fossa

Left Forearm fracture which is Dorsally Displaced

REDUCING DISLOCATIONS and SUBLUXATIONS Three keys to success when attempting reductiona.knowledge of anatomyb.analgesia and sedationc.slow and gentle procedureFollowing reduction, the joint must be splinted and proper follow-up is mandatoryAfter 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)

Finger DislocationClinical exam to determine nerve and tendon function if possibleX-ray to confirm diagnosisAnesthetize with a digital blockReduce dislocationi.Apply traction in line with the distal portion of the fingerii. The deformity should increase slightly just prior to joint going back in placeiii. This should be felt as a clickTake further X-rays if necessary to rule out a "chip" fractureStrap injured finger to adjacent fingerWarn patient that swelling will persist for several months

Shoulder DislocationTake 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 reductionScapular rotationTraction/counter traction

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 deficitRadiography - Normal findings

Nursemaids Elbow Reduction

Fracture Types

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

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

Spiral Fracturea fracture that spirals part of the length of a long bone

Wrist Fractures

Scaphoid Fracturestenuous blood supplyhigh incidence of avascular necrosis in waist and proximal fracturesoften require bone grafting

Scaphoid Fractureshigh clinical suspicion even with normal x-rayfollow up important - repeat x-rays and early bone scan in patients with persistent painthumb spica with prolonged immobilization

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IntroductionEvidence 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 swellingsplints easier to apply

Indications for SplintingFracturesSprainsJoint infectionsTenosynovitisAcute arthritis / goutLacerations over jointsPuncture wounds and animal bites of the hands or feet

Splinting Equipment

Plaster of ParisMade from gypsum - calcium sulfate dihydrateExothermic reaction when wet - recrystallizes (can burn patient)Warm water - faster set, but increases risk of burnsFast drying - 5 - 8 minutes to setExtra fast-drying - 2 - 4 minutes to set - less time to moldCan take up to 1 day to cure (reach maximum strength)Upper extremities - use 8-10 layersLower extremities - 12-15 layers, up to 20 if big person (increased risk of burn!)

Splinting Equipment

Ready Made Splinting MaterialPlaster (OCL)10 -20 sheets of plaster with padding and cloth cover Fiberglass (Orthoglass)Cure rapidly (20 minutes)Less messyStronger, lighter, wicks moisture betterLess moldable

Splinting EquipmentStockinette protects skin, looks nifty (often not necessary)cut longer than splint2,3,4,8,10,12-in. widthsPadding - Webril2-3 layers, more if anticipate lots of swellingExtra over elbows, heelsBe generous over bony prominencesAlways pad between digits when splinting hands/feet or when buddy tapingAvoid wrinklesDo not tighten - ischemia!Avoid circumfrential useAce wraps

Specific Splints and OrthosesUpper ExtremityElbow/ForearmLong Arm PosteriorDouble Sugar - TongForearm/WristVolar Forearm / CockupSugar - TongHand/FingersUlnar GutterRadial GutterThumb SpicaFinger SplintsLower ExtremityKneeKnee Immobilizer / BledsoeBulky JonesPosterior Knee SplintAnklePosterior AnkleStirrupFoot Hard Shoe

Long Arm Posterior SplintIndicationsElbow and forearm injuries:Distal humerus fxBoth-bone forearm fxUnstable 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.

Double Sugar TongIndicationsElbow 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.

1090

Forearm Volar Splint aka Cockup SplintIndicationsSoft tissue hand / wrist injuries - sprain, carpal tunnel night splints, etcMost 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.

Forearm Sugar TongIndicationsDistal radius and ulnar fx.Prevents pronation / supination and immobilizes elbow.

Hand SplintingThe 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.

Radial and Ulnar GutterIndicationsFractures, phalangeal and metacarpal, and soft tissue injuries of the little and ring fingers.IndicationsFractures, phalangeal and metacarpal, and soft tissue injuries of index and long fingers.

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

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

Jones Compression Dressing - aka Bulky JonesIndicationsShort 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.

ProcedureStockinette and Webril.1-2 layers of thick cotton padding.6 inch ace wrap.

Posterior Ankle SplintIndicationsDistal tibia/fibula fx.Reduced dislocationsSevere sprainsTarsal / metatarsal fxUse 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.

Stirrup SplintIndicationsSimiliar 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.

Other OrthosesKnee ImmobilizerSemirigid brace, many modelsFastens with VelcroWorn over clothingBledsoe BraceArticulated knee braceAmount of allowed flexion and extension can be adjustedUsed for ligamentous knee injuries and post-opAirCast/ AirsplintResembles a stirrup splint with air bladdersWorn inside shoeHard ShoeUsed for foot fractures or soft tissue injuries

ComplicationsBurnsThermal injury as plaster driesHot water, Increased number of layers, extra fast-drying, poor padding - all increase riskIf significant pain - remove splint to coolIschemiaReduced risk compared to casting but still a possibilityDo not apply Webril and ace wraps tightlyInstruct to ice and elevate extremityClose follow up if high risk for swelling, ischemia.When in doubt, cut it off and lookRemember - pulses lost late. Pressure soresSmooth Webril and plaster wellInfectionClean, debride and dress all wounds before splint applicationRecheck if significant wound or increasing pain

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

Questions?