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Patient Evaluation > Joint Aspiration and Injection 
Bursal Aspiration and Injection
 Casting and Splinting > Flashcards

Joint Aspiration and Injection 
Bursal Aspiration and Injection
 Casting and Splinting Flashcards

1
Q

Joint Aspiration dx ?

A

Obtain synovial fluid for analysis

**arthrocentesis **

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2
Q

Joint Aspiration therapeutic ?

A

Relieves discomfort of painful effusion

Allows for more accurate joint exam

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3
Q

Joint Aspiration is a invasive procedure so what is important ?

A

Sterile technique is mandatory!

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4
Q

Joint Aspiration: Each joint has _____________ and sites for needle placement

A

specific landmarks

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5
Q

Joint Aspiration what can increase guidance ?

A

US

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6
Q

Joint Aspiration Significant amount of fluid can ?

A

accumulate in the knee

be prepared with proper equipment

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7
Q

Joint Aspiration Indication ?

A

Painful effusion – traumatic or rheumatic

Articular inflammation of unknown cause:

Viscosity
Crystal examination
Cell count
Bacterial culture
Gram stain
PCR studies
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8
Q

Joint Aspiration contraindication ?

A

Needle must go through infected skin:

  • Cellulitis, burn, infected subcut tissue, impetigo
  • Can seed joint with bacteria

After total arthroplasty
-Unless done by orthopedic specialist

Hemarthrosis in a patient with hemophilia or on anticoagulants

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9
Q

Joint Aspiration potential complications ?

A

Bleeding

Infection

Pain

Intra-articular injury

Reaccumulation of fluid

Injury to vascular or neural structures

Allergic reaction

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10
Q

Bursal Aspiration potential complications ?

A

Infection

Pain

Chronic recurrence

Chronic drainage via a sinus tract

Acute recurrent swelling

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11
Q

Patient Preparation – Knee Aspiration ?

A

Obtain informed consent

May uncover joint instability

Will briefly sting

May need additional tx

  • Immobilization
  • Antibiotic/antiinflammatory meds
  • Hospitalization
  • Referral to specialist
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12
Q

Materials Needed ?

A

Tray table

Sterile drapes

Sterile gloves

Povidone-iodine solution

1% lidocaine

Sterile 1” 25-G needle and sterile 5-10 mL syringe

Sterile 1 ½” 18-G needle

Three sterile 20-30 mL syringes

Sterile hemostat - squeeze tip of needle so it is not
dripping

Vacutainer tubes as indicated

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13
Q

Crystals tube/contianer ?

A

Red- or green-top, 0.5 mL

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14
Q

RA latex

A

Red top, 0.5 mL

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15
Q

Total protein

A

Red-top, 0.5 mL

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16
Q

Glucose

A

Red- or gray-top, 0.5 mL

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17
Q

Mucin clot

A

Red-top, 0.5 mL

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18
Q

Cell count

A

Purple-top, 1 mL

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19
Q

Routine culture

A

0.5 mL, Send in syringe

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20
Q

Gram stain

A

0.5 mL, Send in syringe

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21
Q

TB culture

A

0.5 mL, Send in syringe

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22
Q

Fungal culture

A

0.5 mL, Send in syringe

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23
Q

Vacutainer Tubes ?

A

tubes needed for what you want to check for ( know what u want to test for so you have the appropriate tubes available )

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24
Q

Procedure ?

A

Position patient appropriately

Perform 10 minute scrub

Drape area, if desired

Prepare a sterile field

Don sterile gloves

Draw up lidocaine
5 mL or 10 mL syringe

Anesthetize the skin

ID landmarks for needle placement

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25
Q

Procedure, cont’d 1 ?

A

Advance the needle

Aspirate for blood

Note resistance of joint capsule

Withdraw needle while injecting lidocaine

Attach 18 G to 20 or 30 mL syringe

Introduce into anesthetized track
Keep gentle pressure on plunger while advancing

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26
Q

Procedure, cont’d 2 ?

A

Enter joint space
-Briefly painful for patient

Aspirate synovial fluid
-When syringe is full, put hemostat on needle hub. Remove syringe and replace with an empty one. Put pressure above knee joint to empty SPP. Continue until joint space is empty.

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27
Q

Procedure, cont’d 3 ?

A

Once empty, intra-articular med can be administered (lido/depomedrol)

Withdraw needle

Apply direct pressure with a sterile dressing for several minutes

Apply sterile dressing
Label specimens and send

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28
Q

Follow-up Instructions ?

A

Advise patients to avoid use of joint for at least one day, longer if traumatic effusion

Contact office if sudden reaccumulation of fluid or signs of infection

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29
Q

Knee Joint Aspiration, knee mainly ________ ? for what ?

A

extended

To narrow retropatellar space

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30
Q

Bursitis: Numerous ______ around joints

A

bursae

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31
Q

Bursitis: May accumulate fluid, usually due to ?

A

inflammation from external mechanical irritation

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32
Q

Bursitis: Intrabursal scar tissue ?

A

Feels like small nodules

Can develop early

Can cause pain

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33
Q

Bursal Aspiration reduces and relieves what ?

A

Relieves discomfort

Reduces restriction of movement

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34
Q

Bursal Aspiration decreases risk of ?

A

Chronicity

Spontaneous drainage

Infection of stagnant bursal fluid

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35
Q

Bursal Aspiration – Patient Prep ?

A

Informed consent - Risk of infection, bleeding, reaction to anesthesia, ongoing pain, fluid may reaccumulate

Procedure takes 5-10 min after a 10 minute scrub

Bee sting sensation from lidocaine, lasts <30 sec

After care – rest and protect, possible ATB or anti-inflammatory meds

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36
Q

Bursal Aspiration - Procedure ?

A

Position patient

Prepare sterile field

Perform 10 minute scrub

Don sterile gloves, drape area

Draw up 1 mL lidocaine, administer with 25-27 G
needle

Administer lido under the skin

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37
Q

Bursal Aspiration - Procedure cont’d ?

A

Switch to 18 G and a larger syringe

Aspirate slowly until bursa is flat

Apply direct pressure over puncture site

Dress joint with adhesive bandage and elastic compression wrap

Lab and send specimen

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38
Q

Splint facts ?

A

Rigid

Encases only part of the circumference ( wrapped with ace bandage )

Must be secured

Less protection but allows for swelling

May be all that is needed for soft tissue injury

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39
Q

Cast facts ?

A

Rigid

Encases the circumference of the extremity

Applied after acute swelling has subsided

Better for fracture stabilization

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40
Q

Patient Assessment: Examine ?

A

Skin

Neurovascular status – 5 Ps

Soft tissues

Bony structures

5P’s: pain, pulse, pallor, paresthesia, paralysis

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41
Q

Indications for Casts and Splints ?

A

Simple, acute nondisplaced fractures

Reduced joint dislocations

Soft tissue injuries

  • Severe strains/sprains
  • Tendon lacerations
  • Deep lacerations across joints

Some congenital deformities

Foot and ankle ulcers

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42
Q

Cast vs. Splint: Splint ?

A

More often used in primary care

During acute swelling phase

Simple or stable fxs

Sprains

Tendon injuries

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43
Q

Cast vs. Splint: Casts ?

A

Definitive and/or complex fx management

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44
Q

Splint Advantages ?

A

Faster and easier to apply

Can be static or dynamic

Allows for swelling

Less pressure-related complications

More easily removed

Allows for regular inspection

45
Q

Splint Disadvantages

A

Lack of patient compliance

Excessive motion at injury site

Inappropriate for definitive care of :

Unstable fxs
Displaced fxs
Segmental fxs
Spiral fxs
Dislocation fxs
46
Q

Contraindications to Casting ?

A

During the acute injury phase (3-4 days)

If cast will cover soft tissue infection

If cast will cover an open wound

47
Q

Cast - Potential Complications:

A

Compartment Syndrome

Cast Dermatitis

Pressure Sores

Nerve Injuries

DVT

48
Q

Cast - Potential Complications: Compartment Syndrome ?

A

Most serious complication

Pain that increases over time

Pain is out of proportion

Pain is worse with passive motion

Normal pressure 5-10 mm Hg, ischemia once +30

Can result in irreversible damage

Bivalve the cast, cut padding and stockinet

**can cause irreversible damage **

49
Q

Cast - Potential Complications: Cast Dermatitis ?

A

Most common complication

Moisture, maceration, pruritus

50
Q

Cast - Potential Complications: Pressure Sores ?

A

Inadequate padding or finger indentations

no padding in bony surfaces

51
Q

Cast - Potential Complications: Nerve Injuries

?

A

Especially ulnar and common peroneal

compression over nerve

52
Q

Cast - Potential Complications: DVT ?

A

↓ ambulation, ↑ immobilization

53
Q

Cast -Expected Outcomes ?

A

Decreased swelling, pain

Fracture alignment

Joint stiffness

Muscle atrophy

  • Weigh risks
  • Immobilize only what is needed, for as short a time as possible
54
Q

Cast Length: In theory ?

A

to encompass joint proximal and distal to fx

55
Q

Cast Length: Not often done if length of limb ________ to injury is long enough ?

A

proximal

Ex: wrist fx and short arm cast

56
Q

Fiberglass vs. Plaster: Fiberglass ?

A

Lighter

More durable

Does not soften if gets wet

Dries and hardens faster

Less messy

releases more heat

57
Q

Fiberglass vs. Plaster: Plaster ?

A

Easier to mold

Slower setting time

Emits less heat as it cures

“Wicks” underlying wound drainage

Easily washed off

Cheaper

58
Q

Cast/Splint Materials: Stockinet ?

A

Stretchable, tube-shaped

2”, 2.5”, 3”, 4”, 5” and 6”

Barrier to itchy cast padding

Helps provide comfortable cast border at ends

**stocking keeps it from being itching **

59
Q

Cast/Splint Materials: cast padding ?

A

2”, 3”, 4”, 5”

Protects skin and bony prominences

Provides some compression

Cotton (webril) or synthetic:
-Cotton – plaster casts
tears easily
-Synthetic – fiberglass casts

**after socket then yu put on the cast padding **

60
Q

Cast/Splint Materials: Cast tape ?

A

2”, 3”, 4”, 6”

Smaller widths on distal parts

61
Q

Cast/Splint Materials: Basin or Bucket ?

A

Cool or room temp water - fiberglass

Tepid or slightly warm water- plaster

Deep enough to fully immerse roll

62
Q

Splint Materials: Fiberglass or plaster has ______ layers

A

multiple

63
Q

Splint Materials: Prefabricated available ??

A

Cut to fit from a roll

Not well-padded

64
Q

Splint Materials: others ?

A

+/- Stockinet

Padding

Bucket of water

Elastic bandage (Ace) or 
Coban to secure
65
Q

Patient Preparation –Cast/Splint ?

A

Explain procedure to patient

Patient in position of function

Position after closed reduction
-Position to retain the reduction

66
Q

Patient in position of function: Short arm ?

A

flex elbow to 90, thumb up, wrist in slight extension, fingers slightly curled (“holding a can of Coke”)

67
Q

Patient in position of function: Short LEG ?

A

ankle at 90°, knee flexed

If dorsiflexed – trouble walking

If plantar flexed – contraction of Achilles

Apply with patient prone or use a toe stand
-to far dorsiflex or to much plantar flex so it is important to keep it at 90

68
Q

Splint Procedure

A

Lay dry splint next to area being splinted

Add 1-2 cms to allow for shrinkage

Measure and layer appropriate number of layers

Submerge in water until bubbling stops

Squeeze out excess water

Lay on hard surface and smooth out wrinkles

Apply damp splint onto padding and mold using palms

Fold back stockinet and padding to cover edges

Secure with Ace or Coban, wrapping distally to proximally

69
Q

Splint Procedure: Measure and layer appropriate number of layers
, thickness depends on ?

A

Patient’s size

Extremity involved

Average 6-10 layers for UE’s, 12-15 for LE’s

70
Q

Splint Types ?

A

Ulnar gutter

Posterior mold
-Arm or leg

Sugar tong
-Arm or leg

Thumb Spica

Volar wrist

71
Q

Ulnar Gutter Splint ?

A

From tip of little finger to just distal to elbow

For fxs of 4th and 5th phalanges and MCP’s

Maintain proper position

Coban or Ace to secure

72
Q

Ulnar Gutter Splint is for what fx’s ?

A

For fxs of 4th and 5th phalanges and MCP’s

73
Q

Short Leg Posterior Mold Splint ?

A

Initial immobilization of severe ankle sprains and fxs of distal leg, ankle, foot

Pad malleoli, metatarsal pad area, head of 5th metatarsal and heel

Remove as much water as possible before applying so water does not pool at heel

Maintain proper position

Coban or Ace to secure

74
Q

Short Leg Posterior Mold Splint are for what fractures ?

A

Initial immobilization of severe ankle sprains and fxs of distal leg, ankle, foot

75
Q

Lower Leg Sugar Tong Splint - 
(“Stirrup”) Splint ?

A

Applied to medial and lateral sides of leg

Gives mediolateral support and allows full ROM of toes and knee

Alternative to posterior mold

Pad bony prominences and heel

Maintain proper position

Coban or Ace to secure

76
Q

Cast Materials ?

A

Bandage scissors

Stockinet

Cast padding

Cast tape

Bucket of water

Gloves, if fiberglass cast

77
Q

Materials: apron and gloves - plaster is ______ .

A

messy

78
Q

Materials: apron and gloves - fiberglass is ?

A

sticky and stains

79
Q

Materials: what are the bandage scissors for ?

A

Trim padding and cast materials

80
Q

Procedure: Choose appropriate width stockinet: ____ for arms ?

A

2-3”

81
Q

Procedure: Choose appropriate width stockinet: ____ for legs ?

A

4”

82
Q

Procedure: Choose appropriate width stockinet: Cut length with _________ so it can be folded over cast material

A

4” of excess at each end

Smooth out or cut to remove wrinkles

Cut hole for thumb in arm cast

83
Q

Procedure: Choose appropriate width padding: start at narrow end of ?

A

extremity

84
Q

Procedure: Choose appropriate width padding: keep patient in?

A

proper position

85
Q

Procedure: Choose appropriate width padding: keep roll in __________ contact

A

continuous

86
Q

Procedure: Choose appropriate width padding: overlap by ___ (2 layers)

A

50%

Two layers is sufficient

87
Q

Procedure: Choose appropriate width padding: __ beyond end of cast

A

2”

88
Q

Procedure: Choose appropriate width padding: others ?

A

2 extra layers at ends

Additional padding over bony prominences (tear small sections)

Not too much, not too little

89
Q

Procedure: other cont’d ?

A

Don apron and gloves

Select appropriate width cast tape

Immerse material

  • Plaster until “sloppy wet”
  • Fiberglass for 10 sec, squeeze once gently to remove excess water
90
Q

Procedure: Apply tape ?

A

Roll on, oriented to have continuous contact

Start at narrow end of extremity

Overlap by 50%

Fold or tuck as needed to avoid bunching

Span length of planned cast with each roll

Start and finish 1-2” inside padding border

91
Q

Procedure: Apply tape - extra thickness where ?

A

volar wrist, plantar surface if foot for strength

92
Q

Procedure: Apply tape - twist ___ or accordion fold between thumb-index web space ?

A

360

fold it to make it narrower ( accordian)

93
Q

Procedure: cast tape ?

A

Before applying final layer, roll down stockinet and padding at each end

4-6 layers of plaster or 3-4 layers of fiberglass for non-weight bearing cast

Mold each layer gently but firmly, use palms not fingers (wet gloves)

Ensure proper position is maintained

94
Q

Short Arm Cast Extends from ________________ to olecranon process to just proximal to MCPs.

A

2 fingerbreadths distal

Cut hole in stockinet for thumb

Rotate material 360 between thumb-index webspace

95
Q

Short Arm Cast Allows for full ?

A

elbow flexion

full ROM of MCPs

full thumb to index pinch

96
Q

Short Leg Cast Extends from ?

A

tibial tubercle to just proximal to MTPs

97
Q

Short Leg Cast Allow for full ?

A

knee flexion and full ROM of MTPs

98
Q

Short Leg Cast: Do not ___ ____ with extra circumferential wraps, _________

A

pad heel

use torn strips

99
Q

Short Leg Cast: Reinforce plantar surface with ?

A

extra layers if it’s a walking cast

100
Q

Short Leg Cast: no weights bearing until ?

A

hardening

101
Q

How long does it take a fiber glass short leg cast to harden ?

A

1-2 hours

102
Q

How long does it take a plaster short leg cast to harden ?

A

4-6 hours

103
Q

Evaluation After Casting ?

A

Assess patient and cast/splint before discharging

Cast/splint extends to proper boundaries without interfering with ROM

Check for finger indentations and sharp edges – cut, trim or repad as necessary

Check neurovascular status distally

104
Q

Cast Aftercare: Sling ?

A

For elevation and support

Remove 3-4 times a day for ROM elbow, shoulder

105
Q

Cast Aftercare ?

A

Sling

Cast shoe

Crutches/walker

Do not get cast wet!

  • Plastic cover in shower
  • Hairdryer may be used
106
Q

Cast Aftercare con’d ?

A

Do not insert objects!

F/U visit variable, usually 1-2 weeks

Fxs need 4-8 weeks to heal

Call if numbness, tingling, weakness, skin discolorations or increased pain

107
Q

Cast Removal ?

A

Oscillating blade

Cast saw cuts cast material, not padding, stockinet or skin

Do not saw over bony prominences

Press blade onto cast at 90° to cast

Stabilize cutter with your thumb

Make overlapping half moon cuts

108
Q

Cast Removal cont’d ?

A

Feel give, lift up and out, don’t drag along

Move to adjacent spot

If blade becomes hot, shut off and wait

Cut down two sides

Spread fiberglass/plaster apart with cast spreaders

Cut padding and stockinet with scissors

Supportive half can be left in place as a splint until x-ray taken

109
Q

Cast Window ?

A

Occasionally done

In existing cast or in a new cast

Provides access for wound care or to remove FB

½ - 1”

Patient Evaluation (29 decks)

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