Joint Aspiration and Injection Bursal Aspiration and Injection Casting and Splinting Flashcards
Joint Aspiration dx ?
Obtain synovial fluid for analysis
**arthrocentesis **
Joint Aspiration therapeutic ?
Relieves discomfort of painful effusion
Allows for more accurate joint exam
Joint Aspiration is a invasive procedure so what is important ?
Sterile technique is mandatory!
Joint Aspiration: Each joint has _____________ and sites for needle placement
specific landmarks
Joint Aspiration what can increase guidance ?
US
Joint Aspiration Significant amount of fluid can ?
accumulate in the knee
be prepared with proper equipment
Joint Aspiration Indication ?
Painful effusion – traumatic or rheumatic
Articular inflammation of unknown cause:
Viscosity Crystal examination Cell count Bacterial culture Gram stain PCR studies
Joint Aspiration contraindication ?
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
Joint Aspiration potential complications ?
Bleeding
Infection
Pain
Intra-articular injury
Reaccumulation of fluid
Injury to vascular or neural structures
Allergic reaction
Bursal Aspiration potential complications ?
Infection
Pain
Chronic recurrence
Chronic drainage via a sinus tract
Acute recurrent swelling
Patient Preparation – Knee Aspiration ?
Obtain informed consent
May uncover joint instability
Will briefly sting
May need additional tx
- Immobilization
- Antibiotic/antiinflammatory meds
- Hospitalization
- Referral to specialist
Materials Needed ?
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
Crystals tube/contianer ?
Red- or green-top, 0.5 mL
RA latex
Red top, 0.5 mL
Total protein
Red-top, 0.5 mL
Glucose
Red- or gray-top, 0.5 mL
Mucin clot
Red-top, 0.5 mL
Cell count
Purple-top, 1 mL
Routine culture
0.5 mL, Send in syringe
Gram stain
0.5 mL, Send in syringe
TB culture
0.5 mL, Send in syringe
Fungal culture
0.5 mL, Send in syringe
Vacutainer Tubes ?
tubes needed for what you want to check for ( know what u want to test for so you have the appropriate tubes available )
Procedure ?
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
Procedure, cont’d 1 ?
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
Procedure, cont’d 2 ?
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.
Procedure, cont’d 3 ?
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
Follow-up Instructions ?
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
Knee Joint Aspiration, knee mainly ________ ? for what ?
extended
To narrow retropatellar space
Bursitis: Numerous ______ around joints
bursae
Bursitis: May accumulate fluid, usually due to ?
inflammation from external mechanical irritation
Bursitis: Intrabursal scar tissue ?
Feels like small nodules
Can develop early
Can cause pain
Bursal Aspiration reduces and relieves what ?
Relieves discomfort
Reduces restriction of movement
Bursal Aspiration decreases risk of ?
Chronicity
Spontaneous drainage
Infection of stagnant bursal fluid
Bursal Aspiration – Patient Prep ?
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
Bursal Aspiration - Procedure ?
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
Bursal Aspiration - Procedure cont’d ?
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
Splint facts ?
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
Cast facts ?
Rigid
Encases the circumference of the extremity
Applied after acute swelling has subsided
Better for fracture stabilization
Patient Assessment: Examine ?
Skin
Neurovascular status – 5 Ps
Soft tissues
Bony structures
5P’s: pain, pulse, pallor, paresthesia, paralysis
Indications for Casts and Splints ?
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
Cast vs. Splint: Splint ?
More often used in primary care
During acute swelling phase
Simple or stable fxs
Sprains
Tendon injuries
Cast vs. Splint: Casts ?
Definitive and/or complex fx management
Splint Advantages ?
Faster and easier to apply
Can be static or dynamic
Allows for swelling
Less pressure-related complications
More easily removed
Allows for regular inspection
Splint Disadvantages
Lack of patient compliance
Excessive motion at injury site
Inappropriate for definitive care of :
Unstable fxs Displaced fxs Segmental fxs Spiral fxs Dislocation fxs
Contraindications to Casting ?
During the acute injury phase (3-4 days)
If cast will cover soft tissue infection
If cast will cover an open wound
Cast - Potential Complications:
Compartment Syndrome
Cast Dermatitis
Pressure Sores
Nerve Injuries
DVT
Cast - Potential Complications: Compartment Syndrome ?
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 **
Cast - Potential Complications: Cast Dermatitis ?
Most common complication
Moisture, maceration, pruritus
Cast - Potential Complications: Pressure Sores ?
Inadequate padding or finger indentations
no padding in bony surfaces
Cast - Potential Complications: Nerve Injuries
?
Especially ulnar and common peroneal
compression over nerve
Cast - Potential Complications: DVT ?
↓ ambulation, ↑ immobilization
Cast -Expected Outcomes ?
Decreased swelling, pain
Fracture alignment
Joint stiffness
Muscle atrophy
- Weigh risks
- Immobilize only what is needed, for as short a time as possible
Cast Length: In theory ?
to encompass joint proximal and distal to fx
Cast Length: Not often done if length of limb ________ to injury is long enough ?
proximal
Ex: wrist fx and short arm cast
Fiberglass vs. Plaster: Fiberglass ?
Lighter
More durable
Does not soften if gets wet
Dries and hardens faster
Less messy
releases more heat
Fiberglass vs. Plaster: Plaster ?
Easier to mold
Slower setting time
Emits less heat as it cures
“Wicks” underlying wound drainage
Easily washed off
Cheaper
Cast/Splint Materials: Stockinet ?
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 **
Cast/Splint Materials: cast padding ?
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 **
Cast/Splint Materials: Cast tape ?
2”, 3”, 4”, 6”
Smaller widths on distal parts
Cast/Splint Materials: Basin or Bucket ?
Cool or room temp water - fiberglass
Tepid or slightly warm water- plaster
Deep enough to fully immerse roll
Splint Materials: Fiberglass or plaster has ______ layers
multiple
Splint Materials: Prefabricated available ??
Cut to fit from a roll
Not well-padded
Splint Materials: others ?
+/- Stockinet
Padding
Bucket of water
Elastic bandage (Ace) or Coban to secure
Patient Preparation –Cast/Splint ?
Explain procedure to patient
Patient in position of function
Position after closed reduction
-Position to retain the reduction
Patient in position of function: Short arm ?
flex elbow to 90, thumb up, wrist in slight extension, fingers slightly curled (“holding a can of Coke”)
Patient in position of function: Short LEG ?
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
Splint Procedure
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
Splint Procedure: Measure and layer appropriate number of layers
, thickness depends on ?
Patient’s size
Extremity involved
Average 6-10 layers for UE’s, 12-15 for LE’s
Splint Types ?
Ulnar gutter
Posterior mold
-Arm or leg
Sugar tong
-Arm or leg
Thumb Spica
Volar wrist
Ulnar Gutter Splint ?
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
Ulnar Gutter Splint is for what fx’s ?
For fxs of 4th and 5th phalanges and MCP’s
Short Leg Posterior Mold Splint ?
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
Short Leg Posterior Mold Splint are for what fractures ?
Initial immobilization of severe ankle sprains and fxs of distal leg, ankle, foot
Lower Leg Sugar Tong Splint - (“Stirrup”) Splint ?
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
Cast Materials ?
Bandage scissors
Stockinet
Cast padding
Cast tape
Bucket of water
Gloves, if fiberglass cast
Materials: apron and gloves - plaster is ______ .
messy
Materials: apron and gloves - fiberglass is ?
sticky and stains
Materials: what are the bandage scissors for ?
Trim padding and cast materials
Procedure: Choose appropriate width stockinet: ____ for arms ?
2-3”
Procedure: Choose appropriate width stockinet: ____ for legs ?
4”
Procedure: Choose appropriate width stockinet: Cut length with _________ so it can be folded over cast material
4” of excess at each end
Smooth out or cut to remove wrinkles
Cut hole for thumb in arm cast
Procedure: Choose appropriate width padding: start at narrow end of ?
extremity
Procedure: Choose appropriate width padding: keep patient in?
proper position
Procedure: Choose appropriate width padding: keep roll in __________ contact
continuous
Procedure: Choose appropriate width padding: overlap by ___ (2 layers)
50%
Two layers is sufficient
Procedure: Choose appropriate width padding: __ beyond end of cast
2”
Procedure: Choose appropriate width padding: others ?
2 extra layers at ends
Additional padding over bony prominences (tear small sections)
Not too much, not too little
Procedure: other cont’d ?
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
Procedure: Apply tape ?
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
Procedure: Apply tape - extra thickness where ?
volar wrist, plantar surface if foot for strength
Procedure: Apply tape - twist ___ or accordion fold between thumb-index web space ?
360
fold it to make it narrower ( accordian)
Procedure: cast tape ?
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
Short Arm Cast Extends from ________________ to olecranon process to just proximal to MCPs.
2 fingerbreadths distal
Cut hole in stockinet for thumb
Rotate material 360 between thumb-index webspace
Short Arm Cast Allows for full ?
elbow flexion
full ROM of MCPs
full thumb to index pinch
Short Leg Cast Extends from ?
tibial tubercle to just proximal to MTPs
Short Leg Cast Allow for full ?
knee flexion and full ROM of MTPs
Short Leg Cast: Do not ___ ____ with extra circumferential wraps, _________
pad heel
use torn strips
Short Leg Cast: Reinforce plantar surface with ?
extra layers if it’s a walking cast
Short Leg Cast: no weights bearing until ?
hardening
How long does it take a fiber glass short leg cast to harden ?
1-2 hours
How long does it take a plaster short leg cast to harden ?
4-6 hours
Evaluation After Casting ?
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
Cast Aftercare: Sling ?
For elevation and support
Remove 3-4 times a day for ROM elbow, shoulder
Cast Aftercare ?
Sling
Cast shoe
Crutches/walker
Do not get cast wet!
- Plastic cover in shower
- Hairdryer may be used
Cast Aftercare con’d ?
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
Cast Removal ?
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
Cast Removal cont’d ?
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
Cast Window ?
Occasionally done
In existing cast or in a new cast
Provides access for wound care or to remove FB
½ - 1”
