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OITE > Orthopedic Injuries and Immobilization COPY > Flashcards

Orthopedic Injuries and Immobilization COPY Flashcards

1
Q

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?
A
  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.
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2
Q
  1. How do you Describe This?
  2. How are fractures named how?
A
  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
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3
Q

REDUCING DISLOCATIONS and SUBLUXATIONS

Three keys to success when attempting reduction?

3

A
  1. knowledge of anatomy
  2. analgesia and sedation
  3. slow and gentle procedure
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4
Q

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?
A
  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)
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5
Q

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?
A
  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
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6
Q

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
A
  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
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7
Q

Describe the following types of fractions:

  1. Closed?
  2. Open?
  3. Multiple?
  4. Comminuted?
  5. Greenstick?
  6. Spiral?
A
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8
Q

What is a greenstick fracture?

A

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

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9
Q
  1. What is an open fracture?
  2. What is more common in this?
  3. How many grades?
A
  1. the bone breaks and pierces the overlying skin
  2. (osteomyelitis are more common)
  3. 4 grades
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10
Q

Spiral Fracture is what?

A
  1. a fracture that spirals part of the length of a long bone
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11
Q

WRIST FRACTURES

  1. What is Smith’s fracture?
  2. Colles’ fracture?
  3. What nerve do you have to worry about?
A
  1. Median nerve- indication for fixing it would would to save it

Collies is a dorsal displaced fragment

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12
Q

Scaphoid Fractures characteristics? 3

A
  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

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13
Q

Scaphoid Fractures

  1. Why is follow up important?
  2. Tx?
A
  1. follow up important
    - repeat x-rays and early bone scan vs MRI in patients with persistent pain
  2. thumb spica with prolonged immobilization
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14
Q

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

A
  1. increased compartment syndrome and other complications
  2. ideal for the ED – allow swelling
  3. splints easier to apply
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15
Q

Function of splints?

6

A
  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
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16
Q

Indications for Splinting

8

A
  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
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17
Q

Splinting Vs Casting

5 factors

A
  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
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18
Q

Splints for what? 4

A
  1. simple and stable fractures,
  2. sprains,
  3. tendon injuries,
  4. other soft tissue injuries
19
Q

Splinting custom made or “off-the-shelf”

  1. Advanatge? 4
  2. Disadvantage? 2
A

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
20
Q

Casting

  1. Advantages? 2
  2. Disadvnatges? 3
A
  1. ADVANTAGES
    - Mainstay of Tx for most fractures
    - More effective immobilization
  2. DISADVANTAGES
    - Require more skills
    - More time to apply
    - Higher risk of complications
21
Q

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’?
A
  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!)
22
Q

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?
A
  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
23
Q

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?
A

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

24
Q

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
A

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
25
Q

Long Arm Posterior Splint

Indications: 4

A

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.

26
Q

Double Sugar Tong

Indications?

A
  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.
27
Q

Forearm Volar Splint aka ‘Cockup’ Splint

Indications? 4

A
  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.
28
Q

Forearm Sugar Tong

Indications?

Prevents what?

A

Indications

  1. Distal radius and ulnar fx.
  2. Prevents
    - pronation / supination and immobilizes elbow.
29
Q

Hand Splinting

  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?
A
  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.
30
Q

Radial and Ulnar Gutter

Indications? 2

A

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.
31
Q

Thumb Spica

  1. Indications? 3
  2. What helps prevent buckling?
  3. Postion?
A
  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.
32
Q
  1. When would you use dynamic splinting?
  2. Dorsal/Volar finger splints are used when?
A
  1. Sprains - dynamic splinting (buddy taping).
  2. Dorsal/Volar finger splints -
    - phalangeal fx, though gutter splints probably better for proximal fxs.
33
Q

Jones Compression Dressing - aka Bulky Jones

  1. Indications?
  2. Allows what?
  3. Procedure? 3
A
  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.
34
Q

Posterior Ankle Splint

  1. Indications? 4
  2. Layers?
  3. Adding what can eliminate inversion/eversion especially useful for unstable fx and sprains?
A
  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.
35
Q

Stirrup Splint

  1. Similar to what?
  2. Describe its allowed movements?
  3. Indication?
  4. Layers?
A
  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.
36
Q

Other Orthoses 4

A
  1. Knee Immobilizer
  2. Bledsoe Brace
  3. AirCast/ Airsplint
  4. Hard Shoe
37
Q

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
A

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
38
Q

Casting Pearls

Remember these

11

A
  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
39
Q

Contraindications to casting/splinting

3

A
  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
40
Q

Complications of cast or splint?

8

A
41
Q

Complications

  1. Burns? 3
  2. Ischemia? 6
  3. Pressure sores? 1
  4. Infection? 2
A
  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
42
Q

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

A

Take the splint off and look!

43
Q

Patient instructions/education?

8

A
  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
44
Q

Return to ER or a physician if…

7

A
  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

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