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Orthopedic Injuries and
Immobilization
Stanford University
Division of Emergency Medicine
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History and Physical Exam Immediately upon presentation with a dislocation or
fracture, the neurovascular and circulatory statusmust be checked.
Attempt to ascertain the mechanism of injury.
- may alert physician to other possibly associatedinjuries
- as well as provide clues as to the type of injuryinvolved
Radiographs should be obtained if fracture OR
DISLOCATION is suspected Radiographs should be obtained after reduction and
IMMOBILIZATION of a fracture or dislocation.
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How do you Describe This?
Named by where the
distal articulating
surface ends up relative
to the proximalarticulating surface
e.g. Anterior shoulder
dislocation
- Humeral head is anteriorto the glenoid fossa
Left Forearm fracture which is Dorsally Displaced
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REDUCING DISLOCATIONS
and SUBLUXATIONS
Three keys to success when attempting reduction
a. knowledge of anatomy
b. analgesia and sedationc. slow and gentle procedure
Following reduction, the joint must be splinted andproper follow-up is mandatory
After one or two unsuccessful attempts of reducing adislocation (closed reduction), it is necessary toreduce under general anesthesia (closed) or duringsurgery (open reduction)
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Finger Dislocation Clinical exam to determine
nerve and tendon function ifpossible
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 increaseslightly just prior to joint goingback in place
iii. This should be felt as a click
Take further X-rays ifnecessary to rule out a "chip"fracture
Strap injured finger to adjacentfinger
Warn patient that swelling willpersist for several months
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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 possiblefracture (i.e. head of thehumerus)
Several methods for reduction
- Scapular rotation
- Traction/counter traction
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Subluxation of the Radial Head
(Nursemaids Elbow)Definition of subluxation = a joint disruption in
which the joint surfaces are maintainedin some degree of apposition.
Description: the radial head slips out fromunder the annular ligament.
i. Generally caused by sudden traction of theforearm that extends and pronates theelbow (like the motion of pulling a childoff the ground by his/her wrist).
ii. Most common in children aging 1 - 4 yearsold, because the lip of the radial head isnot well formed and may slip out fromunder the annular ligament with moreease.
iii. Minimal pain if the arm is stationary butpain is felt upon flexing or supinatingarm, (parents often think it is merely asprain and wait 24 - 36 hours beforeseeking medical help)
iv. No associated swelling, ecchymosis, orneurovascular deficit
Radiography - Normal findings
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Nursemaids Elbow Reduction
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Fracture Types
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Greenstick an incomplete
fracture in a long
bone of a child
(bones are not yetfully calcified and
they break like a
green stick)
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Open Fracture
the bone breaks and
pierces the overlying
skin (osteomyelitis
are more common)
4 grades
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Spiral Fracture
a fracture that
spirals part of the
length of a longbone
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Wrist Fractures
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Scaphoid Fractures
tenuous blood
supply
high incidence ofavascular necrosis
in waist and
proximal fractures
often require bone
grafting
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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 withprolonged
immobilization
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Learn How to Splint in
10 Easy Lessons!!!!
Hey Kids,As Seen OnTV!!
Amaze Your
Friends !!!
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your Block !!!
WOW !!!
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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 EDallow swelling- splints easier to apply
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Indications for Splinting
Fractures
Sprains
Joint infections Tenosynovitis
Acute arthritis / gout
Lacerations over joints Puncture wounds and animal
bites of the hands or feet
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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 tomold
Can take up to 1 day to cure (reach maximum
strength)
Upper extremities - use 8-10layers
Lower extremities - 12-15layers, up to 20 if bigperson (increased risk of burn!)
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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
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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
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Specific Splints and OrthosesUpper 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
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Long Arm Posterior Splint
Indications Elbow and forearm injuries:
Distal humerus fx
Both-bone forearm fx
Unstable proximal radius orulna fx (sugar-tong better)
Doesnt completely eliminatesupination / pronation -eitheradd an anterior splint or use
a double sugar-tong ifcomplex or unstable distalforearm fx.
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Double Sugar Tong
Indications
Elbow and forearm fx -
prox/mid/distal radius andulnar fx.
Better for most distal
forearm and elbow fx
because limits
flex/extension and
pronation / supination.
10
90
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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.
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Forearm Sugar Tong
Indications
Distal radius and
ulnar fx.
Prevents pronation /supination andimmobilizes elbow.
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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 tothe 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 flexedto 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.
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Radial and Ulnar Gutter
Indications
Fractures, phalangeal andmetacarpal, and soft tissue
injuries of the little and ring
fingers.
Indications
Fractures, phalangeal andmetacarpal, and soft tissue
injuries of index and long
fingers.
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Thumb Spica Indications
Scaphoid fx - seen orsuspected (check snuffboxtenderness)
De Quervain tenosynovitis. Notching the plaster (shown)
prevents buckling whenwrapping around thumb.
Wine glass position.
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Finger Splints
Sprains - dynamic
splinting (buddy
taping). Dorsal/Volar finger
splints - phalangeal
fx, though gutter
splints probably
better for proximal
fxs.
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Jones Compression Dressing
- aka Bulky Jones Indications
Short term immobilization
of soft tissue andligamentous injuries to the
knee or calf.
Allows slight flexion and
extension - may add posterior
knee splint to furtherimmobilize the knee.
Procedure Stockinette and
Webril.
1-2 layers of thickcotton padding.
6 inch ace wrap.
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Posterior Ankle Splint
Indications Distal tibia/fibula fx.
Reduced dislocations
Severe sprains Tarsal / metatarsal fx
Use at least 12-15 layers ofplaster.
Adding a coaptation splint(stirrup) to the posterior splinteliminates inversion /eversion - especially usefulfor unstable fx and sprains.
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Stirrup Splint
Indications
Similiar to posterior splint.
Less inversion /eversionand actually less plantar
flexion compared to
posterior splint.
Great for ankle sprains.
12-15 layers of 4-6 inch
plaster.
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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
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Complications Burns
Thermal injury as plaster dries
Hot water, Increased number oflayers, extra fast-drying, poorpadding - all increase risk
If significant pain - remove splint
to cool Ischemia
Reduced risk compared tocasting but still a possibility
Do not apply Webril and acewraps tightly
Instruct to ice and elevateextremity
Close follow up if high risk forswelling, 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 splintapplication
Recheck if significant wound orincreasing pain
Any complaints of
worsening pain -Take the splint off
and look!
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Questions?