casting/splinting Flashcards
most reliable sign of a fracture?
pain!!!
types of fracture
oblique = simple strait across bone
comminuted = several pieces
spiral = spirals around the bone
compound = bone exits the skin- “open fracture”
avulsed = where tendon is attaching to bone gets pulled off
greenstick = no complete break, just a disruption of the architecture (“like a greenstick on tree”)
tendon vs. ligament
tendons attach mm. to bone
ligaments bine bone to bone
open fracture
= “compound fracture”
Definition: a fracture that has communicated with the outside environment.
Two ways:
High velocity trauma or missile injury
Spikes of bone pierce the skin
ALWAYS REQUIRES surgical consult
Do not get fooled by the size of the injury, whether a prick or larger wound, must get a surgical consult and intervention.
somtimes the bone goes back in after the penetration
SALTER HARRIS classification
note: growth plate is b/w epiphysis (top) and metaphysis (bottom)
I: fracture where growth plate separates or slips
II: just through metaphysis (** most common ** )
III: through epiphysis
IV: through epiphysis and metaphysis
V: growth plate crushed b/w epiphysis / metaphysis
(worst! only 1%)
S = slipped A = above L = lower T= through R = rammed and ruined
as number goes up, its worse
- in 3-5, have disruption of the growth plate –> results in deformation of growth
THE HIGHER THE SALTER NUMBER THE POORER THE PROGNOSIS FOR RECOVERY.
THE MORE SERIOUS FRACTURES CAN LOOK BENIGN
FRACTURE REDUCTIONS MUST BE PERFECT FOR BEST RESULTS
pain in snuff box
over the scaphoid - may need internal fixation, largest problem is avascular necrosis in this area of the hand
Colle’s fracture
Fracture of the distal radius with dorsal displacement, with or without ulnar involvement.
“Dinner fork” deformity - tip of radius displaces upward
***Falling on an outstretched hand.
Associated fracture of the ulnar styloid process >60% of the time.
tx: external reduction, then casting (usually closed reduction, external fixation)
most commonly broken bone?
clavicle
Tri-malleolar fracture
Involves: calcaneus being jammed up
- Lateral malleolus (edge of fibula)
- Medial malleolus (edge of tibia)
- Posterior tibia
Landing flat on the heal from significant
height.
Very unstable fracture.
Treatment: Surgery (ORIF) - open reduction internal fixation
fracture complications
Local:
- Vascular injury causing hemorrhage, internal or external
- Visceral injury causing damage to structures such as the brain, lung or bladder
- Damage to surrounding tissue, blood vessels, nerves or skin
- Hemarthrosis: fracture through joint capsule
- Compartment syndrome (or Volkmann’s ischemia)
- Wound Infection - more common for open fractures
Systemic:
- Fat embolism – long bone/pelvic fractures
- Shock
- Thromboembolism (pulmonary or venous)
- Exacerbation of underlying diseases such as diabetes or coronary artery disease (CAD)
- Pneumonia
Late fracture complications
Local:
- Delayed union: bone isn’t healing in way that it should (should heal between 6-8 weeks)
- Nonunion : ends don’t heal
- Mal-union : healed crooked
- Joint stiffness
- Contractures
- **Myositis ossificans – calcifications and bony masses can form in muscle; esp. if there was a lot of bleeding
- Avascular necrosis (worry about hip joint)
- Algodystrophy (or Sudeck’s atrophy) – RDS or Regional pain syndrome
- Osteomyelitis - infection in bone
- Growth disturbance or deformity – children’s growth plates
Systemic
- Gangrene, tetanus, septicemia
- Fear of mobilising
- Osteoarthritis
compartment syndromes
The pressure inside the facial compartment exceeds the blood pressure
= medical emergency!!!!
Causes compromise of the circulation to the soft tissue, ischemia and necrosis.
Irreversible damage can occur in 8 hours.
Conditions associated with compartment syndromes:
- Soft tissue injuries
- Soft tissue injury with fracture
- Exercised induced
- Crush injury
- Prolonged tourniquet application
- Electrical injury
- Burns
- Animal bites
MUST ALWAYS CHECK NEUROVASCULAR STATUS DISTAL TO THE INJURY!!!! KNOW THIS!!!!
Stryker 295: tool that can measure the pressure in the facial compartment
tx: fasciotomy - open up the wound and relieve the pressure
fracture blisters
- Tense vesicles or bullae that arise on markedly swollen skin directly over a fracture.
- Tibia, ankle and elbow.
- Arise in 24-48 hours post injury, early as 6 hours.
-Two types:
Clear fluid filled
Blood filled
- Caused by separation of the dermis from the epidermis.
- Can result in increased infection rate- the blister can fill with infection
-Treatment: Benign neglect Debridement Aspiration Surgical delay
malalignment
will straighten itself out in kids if less than 15 degrees
ankle sprains
= ligamental tear
commonly caused by inversion (foot turns in on the outside) - causes lateral tear
eversion = causes inward rotation, and medial tears
grading of ankle sprains
Grade I
- Mild sprain, mild pain, little swelling, and joint stiffness may be apparent without laxity (loosening)
Usually affects the anterior talofibular ligament
Minimum or no loss of function
Can return to activity within a few days of the injury (with a brace or taping)
Grade II
Moderate to severe pain, swelling, and joint stiffness are present
Partial tear of the lateral ligament(s)
Moderate loss of function with difficulty on toe raises and walking
Takes up to 2-3 months before regaining close to full strength and stability in the joint
Grade III
Severe pain may be present initially, followed by little or no pain due to total disruption of the nerve fibers
Swelling may be profuse and joint becomes stiff some hours after the injury
Complete rupture of the ligaments of the lateral complex (severe laxity)
Usually requires some form of immobilization lasting several weeks
Complete loss of function (functional disability) and necessity for crutches
Usually managed conservatively with rehabilitation exercises, but a small percentage may require surgery
Recovery can be as long as 4 months
tx: RICE, rest, ice, compression, elevate
- immobilization if grade III or higher
when to immobilize?
fractures, sprains, severe soft tissue injuries, reduced joint dislocations, inflammatory conditions, deep laceration across joints, tendon lacerations
long arm cast
prevention of flexion, extension, pronation, supination
benefits of a cast
BETTER IMMOBILIZATION IN FIXED POSITION
LESS MOVEMENT AND THE FRACTURE SITE
LASTS FOR WEEKS TO MONTHS
CAN’T BE REMOVED BY THE PATIENT
hazards of casting:
- compartment syndrome, ischemia, pressure sores, infection, dermatitis, joint stiffness
Benefits of splint
FASTER AND CHEAPER
CAN BE ADAPTED FROM SURROUNDING MATERIAL
NOT AS LIKELY TO CAUSE PRESSURE PROBLEMS
CAN BE REMOVED BY THE PATIENT
way to wrap a splint/cast
always start distal to proximal!!! will prevent the swelling
joint injections
indications for soft tissue: Bursitis Tendonitis Trigger points Ganglion cysts Neuroma Entrapment syndromes Fasciitis
joint conditions indications: Effusion Crystalloid arthropathies Synovitis Inflammatory arthritis Advanced osteoarthritis
Contraindications: Local cellulitis - infected skin!! Acute fracture Tendinous sites at high risk for rupture Drug allergy Septic arthritis – for therapeutic injection, not aspiration
Relative CI’s:
Minimal relief after 2 previous injections
Underlying coagulopathy / anticoagulation therapy
Uncontrolled diabetes
Surrounding joint osteoporosis
Anatomically inaccessible joint
