Orthopedic Injuries and Immobilization Stanford University Division of Emergency Medicine

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.

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

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)

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

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

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 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

Nursemaid’s Elbow Reduction

Fracture Types

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

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

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

Wrist Fractures

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

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

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

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!)

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

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

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

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) Doesn’t completely eliminate supination / pronation -either add an anterior splint or use a double sugar-tong if complex or unstable distal forearm fx.

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. 10 90

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.

Forearm Sugar Tong Indications Distal radius and ulnar fx. Prevents pronation / supination and immobilizes elbow.

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.

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.

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.

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

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.

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.

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.

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

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!

Questions?