Presentation on theme: "Orthopedic Injuries and Immobilization"— Presentation transcript:
1 Orthopedic Injuries and Immobilization Stanford UniversityDivision of Emergency Medicine
2 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 associatedinjuriesas well as provide clues as to the type of injury involvedRadiographs should be obtained if fracture OR DISLOCATION is suspectedRadiographs should be obtained after reduction and IMMOBILIZATION of a fracture or dislocation.
3 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 fossaLeft Forearm fracture which is Dorsally Displaced
4 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)
5 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
6 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
7 Subluxation of the Radial Head (Nursemaid’s 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 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 hours before seeking medical help)iv. No associated swelling, ecchymosis, or neurovascular deficitRadiography - Normal findings
14 Scaphoid Fractures tenuous blood supply high incidence of avascular necrosis in waist and proximal fracturesoften require bone grafting
15 Scaphoid Fractures high clinical suspicion even with normal x-ray follow up important - repeat x-rays and early bone scan in patients with persistent painthumb spica with prolonged immobilization
16 Learn How to Splint in 10 Easy Lessons!!!! As Seen On TV!!Hey Kids,Learn How to Splint in 10 Easy Lessons!!!!Amaze Your Friends !!!WOW !!!Be the First on your Block !!!
17 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 swellingsplints easier to apply
18 Indications for Splinting FracturesSprainsJoint infectionsTenosynovitisAcute arthritis / goutLacerations over jointsPuncture wounds and animal bites of the hands or feet
19 Splinting Equipment Plaster of Paris Made from gypsum - calcium sulfate dihydrateExothermic reaction when wet - recrystallizes (can burn patient)Warm water - faster set, but increases risk of burnsFast drying minutes to setExtra fast-drying minutes to set - less time to moldCan take up to 1 day to cure (reach maximum strength)Upper extremities - use 8-10 layersLower extremities layers, up to 20 if big person (increased risk of burn!)
20 Splinting Equipment Ready Made Splinting Material Plaster (OCL) sheets of plaster with padding and cloth coverFiberglass (Orthoglass)Cure rapidly (20 minutes)Less messyStronger, lighter, wicks moisture betterLess moldable
21 Splinting Equipment Stockinette 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
22 Specific Splints and Orthoses Upper ExtremityElbow/ForearmLong Arm PosteriorDouble Sugar - TongForearm/WristVolar Forearm / CockupSugar - TongHand/FingersUlnar GutterRadial GutterThumb SpicaFinger SplintsLower ExtremityKneeKnee Immobilizer / BledsoeBulky JonesPosterior Knee SplintAnklePosterior AnkleStirrupFootHard Shoe
23 Long Arm Posterior Splint IndicationsElbow and forearm injuries:Distal humerus fxBoth-bone forearm fxUnstable proximal radius or ulna fx (sugar-tong better)Doesn’t completely eliminate supination / pronation -either add an anterior splint or use a double sugar-tong if complex or unstable distal forearm fx.
24 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.1090
25 Forearm Volar Splint aka ‘Cockup’ Splint IndicationsSoft 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.
26 Forearm Sugar Tong Indications Distal radius and ulnar fx.Prevents pronation / supination and immobilizes elbow.
27 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.
28 Radial and Ulnar Gutter IndicationsFractures, 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.
29 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.
31 Jones Compression Dressing - aka Bulky Jones ProcedureStockinette and Webril.1-2 layers of thick cotton padding.6 inch ace wrap.IndicationsShort 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.
32 Posterior Ankle Splint IndicationsDistal tibia/fibula fx.Reduced dislocationsSevere sprainsTarsal / metatarsal fxUse at least layers of plaster.Adding a coaptation splint (stirrup) to the posterior splint eliminates inversion / eversion - especially useful for unstable fx and sprains.
33 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.
34 Other Orthoses Knee Immobilizer Semirigid brace, many models Fastens 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
35 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 painAny complaints of worsening pain - Take the splint off and look!