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The exciting world ofSuture, Splinting, and

Casting

John ShaffHand Surgery

Christopher DavisRadiology

Provide multiple clinical pearls and review key clinical skills utilized in urgent care injury assessment and treatment.

Teach techniques and provide hands on practice of the following skill areas: suturing, splinting, and casting emphasizing clinical “tricks of the trade.”

Utilize memory tools, discussions, and hands on techniques to reinforce the protocols learned.

Objectives

Prepare the patient Feel the notch

Relax Take your time

The “One Stick” Block

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Volume: 2-4 cc Lidocaine – PLAIN

How deep?: Subcutaneously. Inject just on top of the tendon sheath and the infiltrate the digital nerves.

Effectiveness: Just as good as multiple sticks

Pain Level: About the same

Satisfaction: Patients – Same

Providers - Better

The “One Stick” Block

The “One Stick” Block

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LacerationsEventually all bleeding stops… one way or another

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Dogs: 5% infection risk - tear wounds.Treatment – Amox/Clav. 875mg BID, pain control, and

wound irrigation. These can be much worse due to other damage (fractures, vascular injury, deep muscle tears).

No. 1 Bacteria is Pasteurella canis

No. 2 is Staph. aureus

Cats: 80% infection rate - puncture wound.Treatment – Amox/Clav. 875mg BID,

pain control, and wound irrigation.

No. 1 Bacteria is Pasteurella multiocida

No. 2 is Staph. aureus

Animal Bites

Ah, yes… when the dog bites

Lacerations Over SinusesFinger probe technique – Listen for eggshells

Lip Laceration - “Million dollar laceration”

What is the imaging Gold Standard for facial injury?

Blunt Trauma

“Cheek just puffed out after I sneezed”

Facial Injuries

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Watch the edges

Running/Simple

Three Layers

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Severe Contamination

Suturing

Shapes:Cutting – Reverse & Conventional

Good for most skin & nailsTapered – Deep tissue and fascia

Curvature:

Types of Needles

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Nonabsorbable:Silk, NYLON, Polypropylene, Polyester fiber,

Polybutester, and Coated Polybutester

Natural Absorbable:Collagen, Plain surgical gut, Fast-absorbing

surgical gut, and Chromic surgical gut

Synthetic Absorbable:Polyglactin 910 (VICRYL), Polycaprolate

Poliglecaprone 25 (Monocryl), Polysorb,and Polydioxanone (PDSII)

Types of Sutures

Sutures:

Only needles needed – PS-2 and P-3.

Only suture needed – 6-0, 5-0, 4-0 Nylon

and 4-0 Vicryl, that’s it.

Anesthesia tips –Be nice and take your time:

Hold the syringe to warm the lidocaine.

Add 1cc bicarb for every 9cc of 1% lidocaine.Use 2% or 0.5% bupivacaine for larger or

complex lacerations.

Bottom Line

Suturing Do’s:Cut off rings

Assess neurovascular status PRIOR to anesthesia

Infuse lidocaine inside the wound edges

Irrigate – A LOT! (towels)

Approach at a 90 degree angle to the skin

Brief use of finger tourniquet – “Squeeze trick”

Listen and feel for clicking when looking for FB

Tag the corners first, EXCEPT in a thin flap

Use the “Over – Under” method

Reset your needle while holding the suture!

Tips for Suturing

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Suturing Dont’s:Perform a closure only if you are comfortable

Don’t rush the anesthesia infusion

Remember to pucker up the edges.

Loose closure only of contaminated wounds

Loose closure of the fascia layer

If it looks bad now, it will look worse later.

External staples on the scalp works fine

Don’t forget to close the galea layer.

No internal sutures in the hand-EVER!

Tips for Suturing

WOUND LOCATION TIMING OF REMOVAL (DAYS)

Face Three to five

Scalp Seven to 10

Arms Seven to 10

Trunk 10 to 14

Legs 10 to 14

Hands or feet 10 to 14

Palms or soles 14 to 21

Timing of suture and staple removal

Basic Rules:1) ICE – Not necessary

2) Gentle Compression – first hour or two

3) Elevate – first 24 hours for extremities

4) Pool Rule – No Water, especially lakes!

Wound Care Rules:1) Antibiotic Rule – Always if contaminated

2) Sensation Rule – Check often, fingers & toes

3) Smother Rule – Only a gloss coat of topical

4) Dressing Rule – Change it daily, after shower

Patient Education

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Splinting

Preparing (Helpful Hints):Choose the right material size – 2”, 3”, 4”

Need: Splint roll, ACE Wrap, water, & towel

Peel and cut back

REALLY dry it out

Applying (Do’s and Don’ts):DO Place in position of comfort… Usually

DO Roll back the ends and move ends

DON’T squeeze the corners – Ankles & Elbows

DON’T stretch the ACE, just roll it

90 Degrees at the ankle – a MUST!*

Tips for Splinting

Upper Extremity:Volar or Short Arm

Ulnar Gutter

Thumb Spika

Sugar Tong

Long Arm/Hanging Long Arm

Types of Splints

Lower Extremity:Short LegLong LegCadillac – (Short leg and sugar tong combo)

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Basic Rules:1) ICE, ICE, Baby!... - But gently

2) Elevate, Elevate, Elevate - ABOVE the heart

3) ACE RE-Wrap Rule - DON’T STRECH IT!

4) Weight Baring - There is no weight baring

Crutch Training Rules:1) Pink Flamingo Rule – draw the bad leg up

2) Lead Off Rule - Crutch first, foot second

3) Stairs Rule – NO up or down stairs, ever!

4) Backwards Rule – There is no backwards

Patient Education

Short Arm Splint

Thumb Spica Splint

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Sugar Tong Splint

Short Leg Splint

Long Leg Splint

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Assessment (NOM)First- Neurovascular

Second – Open versus Closed

Third – Mechanism of Injury

Description (TOAD)T ype – Spiral, transverse, comminutedO pen vs. ClosedA ngulation – Degrees of angulationD isplacement – Percentage

Fractures

Six Most Commonly Missed Fractures

Hand – Assume that it is fractured

Scaphoid – “Snuff Box” tenderness

Radial Head – Positive Posterior Fat Pad

Cervical – PANDA Neck Criteria

Calcaneous – Bohler’s Angle/Assess Spine

Salter-Harris – Most Common is Type II of the wrist (50%)

Fractures

Distal Radius

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Distal Radius Humerus

Supracondylar Fx

Second Metacarpal

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Boxer’s Fractures

Radius and Ulna

Spiral Tib/Fib

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Dislocation and Fracture

Casting

Upper Extremity:

Short Arm

Thumb Spika

Clam Shoveler – Boxer’s Fracture

Long Arm/Hanging Long Arm

Types of Casting

Lower Extremity:1. Short Leg2. Long Leg – slight bend at knee3. Cylinder

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Short Arm Cast

Thumb Spica Cast

Long Arm Cast

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Short Leg Cast

Long Leg Cast

Preparing (Helpful Hints):Choose the right material size – 3” or 4”

Need: Cast roll, stockinet, cast padding, water

REALLY shake off the water

Applying (Do’s and Don’ts):DO over extend the stocking

DO Roll back the ends, AFTER one pass

DON’T over pad, even distribution of padding

DON’T Pinch (Fingers and toes)

Extra PAD on the heel– a MUST!

Tips for Casting

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Basic Rules:1) ICE, ICE, Mayby... – Not as important

2) Elevate, Elevate, Elevate – first two weeks

3) Pool Rule – No Water, especially lakes!

4) Weight Baring – It depends

Cast Care Rules:1) Itching Rule – NOTHING goes in the cast!

2) Wiggle Rule – Keep wiggling fingers and toes

3) Swelling Rule – Split cast If swelling continues

4) CRPS Rule – REMOVE cast if present!

Patient Education

Bates, Barbara, A Guide to Physical Examination and History Taking, Fifth Edition, J.B. Lippincott Company, Philadelphia, PA, 1991.

Cannon B, Chan L, Rowlinson JS, Baker M, Clancy M (2010). Digital anaesthesia: one injection or two? Emergency medicine journal: EMJ, 27 (7), 533-6 PMID.

Gilbert, David, N., et. al., The Sanford Guide to Antimicrobial Therapy 2010, 40th

Edition, Antimicrobial Therapy, Inc., Sperryville, VA, 2010.

Jauch, Edward C, et. al., Acute Management of Stroke, MedScape Online,

Jul 10, 2012.

Lai, Stephen Y, et. al., Sutures and Needles, Medscape Online, June 3, 2013.

Kirkcaldy, Robert, New Treatment Guidelines for Gonorrhea: Antibiotic Change, Online CDC Expert Commentary, 08/13/2012.

Purvis, John, M. Engaging with Younger Patients, AAOS Now, May 2009.

Sarwark, John F., Put Pediatric Patients and Parents in the Picture, AAOS Bulletin, April 2004.

Staff author, Diseases Characterized by Urethritis and Cervicitis, CDC Report, April 12, 2007

Staff author, Joint dislocation, Wikipedia, 18 March 2012.

REFERENCES