EM Ortho 3: Generalities part 3 (UE)

Question 1

Instances where orthopedic consultation should be done

Answer 1

1. Compartment syndrome
2. Irreducible fractures / dislocations
3. Open fractures

*Orthopedists differ in their preferred approach to the timing of surgery in many cases

Question 2

reasons why closed reduction cannot be accomplished

Answer 2

1. interposition of soft tissues within the joint
2. presence of an associated fracture

orthopedic consultation should be sought in such cases; timely reduction, which sometimes can be achieved only surgically, may help minimize the complications and shorten the duration of pain

Question 3

remarks regarding cases with circulatory compromise

Answer 3

even if circulation has been restored by the EP through correction of deformity, the orthopedist may wish to investigate the integrity of the involved vessels and should at least be contacted to discuss the case

Question 4

examples of open fractures that may just be irrigated in the ED and referred for follow up

Answer 4

open fracture of the phalanges

Question 5

when is immobilization indicated?

Answer 5

-for fractures
-for dislocated joints that have been reduced

when a joint becomes dislocated, the ligaments that had provided its stability are disrupted, and the joint is susceptible to redislocation until healing has occurred

Question 6

remarks on plaster of Paris

Answer 6

-calcium sulfate
-makes use of exothermic reations, meaning they liberate heat
-use RT water; if steam is visible, the water is certainly too hot

Question 7

how to immobilize the elbow effectively?

Answer 7

the splint should begin distal to the wrist and extend high up the lateral arm, almost to the level of the humeral neck

Question 8

how to immobilize the ankle effectively

Answer 8

the splint should extend from beneath the metatarsal heads to the proximal calf

Question 9

remarks on thickness of non-prepadded plaster

Answer 9

the splint should be at least 12 layers thick for an adult

even more layers should be used for children, who typically remain as active as possible and have little regard for protecting the dressing

Question 10

frequently overlooked step in preparing the plaster splint

Answer 10

after submersion, laying of the plaster on a flat surface and massaging the layers into one another so that they fuse together

this creates a strong dressing that is solid on cross-section

a splint whose separate layers are still visible on cross-section is much weaker

Question 11

remarks when applying gauze bandage on the splint

Answer 11

the assistant should use the palms, rather than the fingertips, when holding the splint in place and when holding the joint in a particular position

Question 12

indications for shoulder immobilizer

Answer 12

fractures of the shoulder girdle
-clavicle
-well-positioned humeral neck fractures
reduced shoulder dislocation
acromioclavicular separations*

Question 13

instances when an arm sling may be used alone

Answer 13

nondisplaced fracture of the radial head

Question 14

remarks on the long-arm gutter splint

Answer 14

the most common error associated with fashioning this dressing is insufficient length
- if the splint is not carried far enough above the elbow, it will not exert enough leverage to prevent motion of that joint

Question 15

indications for long-arm gutter splint

Answer 15

useful for injuries about the elbow, including
- displaced radial head fracture
- supracondylar humeral fracture
- reduced dislocation of the elbow

Question 16

remarks on sugar-tong splint

Answer 16

prevents motion of the wrist and elbow, including pronation-supination

appropriate for fractures about the wrist or distal forearm
-some orthopedists use it as a definitive dressing after reduction of wrist fractures

Question 17

remarks on fractures of the wrist

Answer 17

generally, fractures about the wrist are immobilized in neutral position

Colles’ fractures may sometimes be immobilized in palmar flexion after reduction

Question 18

uses of short-arm gutter splint

Answer 18

fractures of the proximal phalanx of the ring or little finger
fractures of the 4th or 5th metacarpal
(including the common “boxer’s fracture” - fracture of the 5th metacarpal neck)

Question 19

uses of thumb spica splint

Answer 19

scaphoid fracture
fracture of the thumb metacarpal or proximal phalanx

Question 20

remarks on thumb spica splint

Answer 20

neutral position of wrist
- avoids reproducing the position of injury in the case of scaphoid fracture, which is typcally caused by forced dorsiflextion

OK sign
- preserves thumb-to-index pinch funxtion