Orthopedic Injuries and Immobilization COPY

Question 1

History and Physical

1. Immediately upon presentation with a dislocation or fracture, what must be checked?
2. Attempt to ascertain the mechanism of injury.- How will this help? 2
3. Radiographs should be obtained if what is suspected?
4. Radiographs should be obtained after what?

Answer 1

1. the neurovascular and circulatory status

2.

• may alert physician to other possibly associated injuries
• as well as provide clues as to the type of injury involved
  3. fracture OR DISLOCATION
  4. reduction and IMMOBILIZATION of a fracture or dislocation.

Question 2

1. How do you Describe This?
2. How are fractures named how?

Answer 2

1. Left Forearm fracture which is Dorsally Displaced
2. Named by where the distal articulating surface ends up relative to the proximal articulating surface
   e. g. Anterior shoulder dislocation
   - Humeral head is anterior to the glenoid fossa

Question 3

REDUCING DISLOCATIONS and SUBLUXATIONS

Three keys to success when attempting reduction?

3

Answer 3

1. knowledge of anatomy
2. analgesia and sedation
3. slow and gentle procedure

Question 4

REDUCING DISLOCATIONS and SUBLUXATIONS

1. Following reduction, what should you do?
2. After one or two unsuccessful attempts of reducing a dislocation (closed reduction) what should you do?

Answer 4

1. the joint must be splinted and proper follow-up is mandatory
2. it is necessary to reduce under general anesthesia (closed) or during surgery (open reduction)

Question 5

Finger Dislocation

1. Clinical exam to determine what? 2
2. Imaging?
3. Analgesic?
4. How would you reduce the dislocation? 3
5. Why would we take further xrays?
6. Strap finger where?
7. Warn pt about what?

Answer 5

1. Clinical exam to determine nerve and tendon function if possible
2. X-ray to confirm diagnosis
3. Anesthetize with a digital block
4. Reduce dislocation
   i. Apply traction in line with the distal portion of the finger
   ii. The deformity should increase slightly just prior to joint going back in place
   iii. This should be felt as a click
5. Take further X-rays if necessary to rule out a “chip” fracture
6. Strap injured finger to adjacent finger
7. Warn patient that swelling will persist for several months

Question 6

Shoulder Dislocation

1. Important question to ask on Hx?
2. Clinical exam? Which nerve?
3. Xray to rule out? Which ones? 2
4. Methods for reduction? 2

Answer 6

1. Take a past medical history
   - (i.e. has this happened before?)
2. Clinical exam (check for nerve function) Axillary
3. X-ray to rule out possible fracture
   - head of the humerus,
   - bony Bankart
4. Several methods for reduction
   - Scapular rotation
   - Traction/counter traction

Question 7

Describe the following types of fractions:

1. Closed?
2. Open?
3. Multiple?
4. Comminuted?
5. Greenstick?
6. Spiral?

Answer 7

Question 8

What is a greenstick fracture?

Answer 8

an incomplete fracture in a long bone of a child (bones are not yet fully calcified and they break like a green stick)

Question 9

1. What is an open fracture?
2. What is more common in this?
3. How many grades?

Answer 9

1. the bone breaks and pierces the overlying skin
2. (osteomyelitis are more common)
3. 4 grades

Question 10

Spiral Fracture is what?

Answer 10

1. a fracture that spirals part of the length of a long bone

Question 11

WRIST FRACTURES

1. What is Smith’s fracture?
2. Colles’ fracture?
3. What nerve do you have to worry about?

Answer 11

3. Median nerve- indication for fixing it would would to save it

Collies is a dorsal displaced fragment

Question 12

Scaphoid Fractures characteristics? 3

Answer 12

1. tenuous blood supply
2. high incidence of avascular necrosis in waist and proximal fractures
3. often require bone grafting

Cast for at least 6 weeks, immobilization for 10

Question 13

Scaphoid Fractures

1. Why is follow up important?
2. Tx?

Answer 13

1. follow up important
   - repeat x-rays and early bone scan vs MRI in patients with persistent pain
2. thumb spica with prolonged immobilization

Question 14

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

why? 3

Answer 14

1. increased compartment syndrome and other complications
2. ideal for the ED – allow swelling
3. splints easier to apply

Question 15

Function of splints?

6

Answer 15

1. To immobilize orthopedic injuries
2. To promote healing
3. Maintain bone alignment
4. Diminish pain
5. Protect injury
6. Help compensate for surrounding muscular weakness

Question 16

Indications for Splinting

8

Answer 16

1. Fractures
2. Sprains
3. Joint infections
4. Tenosynovitis
5. Acute arthritis / gout
6. Lacerations over joints
7. Puncture wounds and animal bites of the hands or feet
8. Infection

Question 17

Splinting Vs Casting

5 factors

Answer 17

1. Assess the stage and severity of injury
2. Potential for instability
3. Risk of complications
4. Patient’s functional requirements
5. Casting for definitive and/or complex

Question 18

Splints for what? 4

Answer 18

1. simple and stable fractures,
2. sprains,
3. tendon injuries,
4. other soft tissue injuries

Question 19

Splinting custom made or “off-the-shelf”

1. Advanatge? 4
2. Disadvantage? 2

Answer 19

ADVANTAGE

1. Faster and easier
2. Static or dynamic
3. Pressure related complications are less like skin breakdown, necrosis, compartment syndrome
4. Easy removal

DISADVANTAGE

1. Lack of patient compliance and excessive motion at injury site
2. Not for unstable or potentially unstable fractures like segmental or spiral or dislocated fractures

Question 20

Casting

1. Advantages? 2
2. Disadvnatges? 3

Answer 20

1. ADVANTAGES
   - Mainstay of Tx for most fractures
   - More effective immobilization
2. DISADVANTAGES
   - Require more skills
   - More time to apply
   - Higher risk of complications

Question 21

Splinting Equipment

Plaster of Paris

1. Made from what?
2. ___________ reaction when wet - recrystallizes (can burn patient)
3. Warm water - pros and cons?
4. Fast drying - how long to set?
5. Extra fast-drying - how long to set and mold?
6. Can take up to how long to cure (reach maximum strength)?
7. Upper extremities - how many layers?
8. Lower extremities - layers’?

Answer 21

1. gypsum - calcium sulfate dihydrate
2. Exothermic
3. faster set, but increases risk of burns
4. 5 - 8 minutes to set
5. 2 - 4 minutes to set - less time to mold
6. 1 day
7. use 8-10 layers
8. 12-15 layers, up to 20 if big person (increased risk of burn!)

Question 22

Splinting Material

Ready Made Splinting Material

1. Composed of?
2. How many sheets?
3. Also can use Fiberglass (Orthoglass)
   - Cures how fast?
4. Advantage? 4
5. Disadvantage?

Answer 22

1. Plaster (OCL)
2. 10 -20 sheets of plaster with padding and cloth cover
3. Cure rapidly (20 minutes)

4.

• Less messy
• Stronger,
• lighter,
• wicks moisture better
  5. Less moldable

Question 23

Stockinette

1. ADvanatges? 2
2. Cuts how compared to splints?

Padding- Webril

1. Layers?
2. Extra over where?
3. What should you do between digits?
4. Avoid what?
5. Do not tighten why?

Answer 23

Stockinette

1. protects skin, looks nifty (often not necessary)
2. cut longer than splint
   - 2,3,4,8,10,12-in. widths

Padding - Webril

1. 2-3 layers, more if anticipate lots of swelling

2.

• Extra over elbows, heels
• Be generous over bony prominences
  3. Always pad between digits when splinting hands/feet or when buddy taping

4.

• Avoid wrinkles
• Avoid circumferential use
  5. Do not tighten - ischemia!

Ace wraps

Question 24

Specific Splints and Orthoses

Upper Extremity

1. Elbow/Forearm? 2
2. Forearm/Wrist? 2
3. Hand/Fingers? 4

Lower Extremity

1. Knee? 3
2. Ankle? 2
3. Foot? 1

Answer 24

Upper Extremity

1. Elbow/Forearm
   - Long Arm Posterior
   - Double Sugar - Tong
2. Forearm/Wrist
   - Volar Forearm / Cockup
   - Sugar - Tong
3. Hand/Fingers
   - Ulnar Gutter
   - Radial Gutter
   - Thumb Spica
   - Finger Splints

Lower Extremity

1. Knee
   - Knee Immobilizer / Bledsoe
   - Bulky Jones
   - Posterior Knee Splint
2. Ankle
   - Posterior Ankle
   - Stirrup
3. Foot
   - Hard Shoe

Question 25

Long Arm Posterior Splint Indications: 4

Answer 25

Indications 1. Elbow and forearm injuries: 2. Distal humerus fx 3. Both-bone forearm fx 4. Unstable proximal radius or ulna fx (sugar-tong better) Doesn’t completely eliminate supination / pronation -either add an anterior splint or use a double sugar-tong if complex or unstable distal forearm fx.

Question 26

Double Sugar Tong Indications?

Answer 26

1. Elbow and forearm fx - prox/mid/distal radius and ulnar fx. 2. Better for most distal forearm and elbow fx because limits flex/extension and pronation / supination.

Question 27

Forearm Volar Splint aka ‘Cockup’ Splint Indications? 4

Answer 27

1. Soft tissue hand / wrist injuries - sprain, carpal tunnel night splints, etc 2. Most wrist fx, 2nd -3rd metacarpal fx. 3. Most add a dorsal splint for increased stability - ‘sandwich splint’ (B). 4. Not used for distal radius or ulnar fx - can still supinate and pronate.

Question 28

Forearm Sugar Tong Indications? Prevents what?

Answer 28

Indications 1. Distal radius and ulnar fx. 2. Prevents - pronation / supination and immobilizes elbow.

Question 29

Hand Splinting ## Footnote 1. The correct position for most hand splints is what? 2. This is with the the hand in the “beer can” position (which may have contributed to the injury in the first place). Which is? 3. When immobilizing metacarpal neck fractures, boxers fx, the MCP joint should be what? 4. Have the patient hold a what? 5. For thumb fx, immobilize how?

Answer 29

1. the position of function, a.k.a. the neutral position. 2. wrist slightly extended (10-25°) with fingers flexed as shown. 3. flexed to 90°. 4. ace wrap (or a beer can if available) until the splint hardens. 5. the thumb as if holding a wine glass.

Question 30

Radial and Ulnar Gutter Indications? 2

Answer 30

Indications - Fractures, phalangeal and metacarpal, and soft tissue injuries of the little and ring fingers. - Fractures, phalangeal and metacarpal, and soft tissue injuries of index and long fingers.

Question 31

Thumb Spica 1. Indications? 3 2. What helps prevent buckling? 3. Postion?

Answer 31

1. Indications - Scaphoid fx - seen or suspected (check snuffbox tenderness) - De Quervain tenosynovitis - Base of 1st Metacrapal fracture “Bennett's” or proxiximal phalanx fracture thumb. 2. Notching the plaster (shown) prevents buckling when wrapping around thumb. 3. Wine glass position.

Question 32

1. When would you use dynamic splinting? 2. Dorsal/Volar finger splints are used when?

Answer 32

1. Sprains - dynamic splinting (buddy taping). 2. Dorsal/Volar finger splints - - phalangeal fx, though gutter splints probably better for proximal fxs.

Question 33

Jones Compression Dressing - aka Bulky Jones 1. Indications? 2. Allows what? 3. Procedure? 3

Answer 33

1. Indications - Short term immobilization of soft tissue and ligamentous injuries to the knee or calf. 2. Allows slight flexion and extension - may add posterior knee splint to further immobilize the knee. 3. Procedure - Stockinette and Webril. - 1-2 layers of thick cotton padding. - 6 inch ace wrap.

Question 34

Posterior Ankle Splint 1. Indications? 4 2. Layers? 3. Adding what can eliminate inversion/eversion especially useful for unstable fx and sprains?

Answer 34

1. Indications - Distal tibia/fibula fx. - Reduced dislocations - Severe sprains - Tarsal / metatarsal fx 2. Use at least 12-15 layers of plaster. 3. Adding a coaptation splint (stirrup) to the posterior splint eliminates inversion / eversion - especially useful for unstable fx and sprains.

Question 35

Stirrup Splint 1. Similar to what? 2. Describe its allowed movements? 3. Indication? 4. Layers?

Answer 35

1. Similiar to posterior splint. 2. Less inversion /eversion and actually less plantar flexion compared to posterior splint. 3. Great for ankle sprains. 4. 12-15 layers of 4-6 inch plaster.

Question 36

Other Orthoses 4

Answer 36

1. Knee Immobilizer 2. Bledsoe Brace 3. AirCast/ Airsplint 4. Hard Shoe

Question 37

Knee Immobilizer 1. What is it? 2. Worn where? Bledsoe Brace 1. What is it? 2. Talk about allowed flexion and extension. 3. Used for? AirCast/ Airsplint 1. Resembles what? 2. Worn where? Hard Shoe 1. Used for? 2

Answer 37

Knee Immobilizer 1. Semirigid brace, many models/Fastens with Velcro 2. Worn over clothing Bledsoe Brace 1. Articulated knee brace 2. Amount of allowed flexion and extension can be adjusted 3. Used for ligamentous knee injuries and post-op AirCast/ Airsplint 1. Resembles a stirrup splint with air bladders 2. Worn inside shoe Hard Shoe 1. Used for - foot fractures or - soft tissue injuries

Question 38

Casting Pearls Remember these 11

Answer 38

1. First, do no harm, be gentle 2. Immobilize in position of function 3. Skin clean and dry 4. Do not immobilize unnecessarily 5. Plenty of stockinette 6. Pad bony prominences 7. Apply casting tape with roll-up in “candy cane” fashion 8. Remember “curing time” 9. Mold appropriately 10. Take home instructions 11. When in doubt- Remove

Question 39

Contraindications to casting/splinting 3

Answer 39

1. Early (premature casting): Casting before maximal swelling has occurred can cause necrosis and possibly compartment syndrome 2. Open wound: never place a cast over an open wound as potential for infection 3. Unstable fractures: need surgical repair

Question 40

Complications of cast or splint? 8

Answer 40

Question 41

Complications 1. Burns? 3 2. Ischemia? 6 3. Pressure sores? 1 4. Infection? 2

Answer 41

1. Burns - Thermal injury as plaster dries - Hot water, Increased number of layers, extra fast-drying, poor padding - all increase risk - If significant pain - remove splint to cool 2. Ischemia - Reduced risk compared to casting but still a possibility - Do not apply Webril and ace wraps tightly - Instruct to ice and elevate extremity - Close follow up if high risk for swelling, ischemia. - When in doubt, cut it off and look - Remember - pulses lost late. 3. Pressure sores - Smooth Webril and plaster well 4. Infection - Clean, debride and dress all wounds before splint application - Recheck if significant wound or increasing pain

Question 42

Any complaints of worsening pain with splint/cast, what should we do?

Answer 42

Take the splint off and look!

Question 43

Patient instructions/education? 8

Answer 43

1. Elevate the limb 2. Check circulation 3. Watch for increased swelling 4. Check mobility distally 5. Protect skin from rough edges 6. Keep cast dry 7. Do not remove the cast 8. Do not put anything inside the cast

Question 44

Return to ER or a physician if… 7

Answer 44

1. Pain 2. Skin color changes 3. Sensation changes 4. Inability to move fingers 5. Bad odor or staining 6. Too tight or too loose 7. Foreign objects in cast