X-rays and Splinting Flashcards
Volar Wrist Splint
- Restricts wrist flexion and extension
- For wrist sprains, stable wrist fractures
- Splint to MCP level, fingers free
Sugar tong
- Restricts elbow motion, wrist flexion/extension as well as pronation/supination
- Forearm fractures
Thumb Spica
- Any thumb sprain or fracture
- Thumb metacarpal fracture
- Acute scaphoid fracture
Coaptation
What nerve should be monitored during eval + application of this for this type of fracture?
- Humerus fractures
- Radial nerve
Long arm
- Distal humerus fractures
- Proximal radius fractures
- Olecranon fractures
- Splint elbow at 90 degrees
- Elbow dislocation
- Maintain wrist in neutral position
Ulnar gutter
- Boxer’s fracture
- Ulnar metacarpal injuries
- Splint MCP joints at 90 degrees, intrinsic plus position
- MP collateral ligament length
Stirrup and posterior short leg splint
- Ankle fractures, dislocations
- Ankle sprains
- Splint ankle at 90 degrees
- Achilles tendon injury
- Calcaneus and talus fractures
AP vs PA x-rays
- AP = anterior-posterior
- PA = posterior-anterior
- PA film – in pt back (smaller cardiac view)
- AP film – heart appears larger
- Direction the beam travels through chest to plate
- Know which one you’d order and why. Which organs are closer to AP vs PA
Radiodensity x-ray
More dense structures will be lighter and less dense will be darker
Four indications for lateral chest x-ray
- To localize lesion seen on frontal CXR
- To clarify lobar collapse/consolidation
- To explore a retrosternal or retrocardiac shadow
- To confirm presence of fluid in one of the fissures
Always L lateral view (beam enters on R, plate positioned to pt’s L side)
L lower lobe more visible in this view
ABCDE method for CXR
- Airways
- Bones
- Cardiac silhouette mediastinum
- Diaphragm and gastric bubble visible
- Everything else (lines, tubes, drains, EKG sticker)
ABCDE abnormalities - position causes
- Position of the patient
- Rotation off plate
- Mediastinum off center
- Clavicles rotated
- Do not place supine - want 90 degrees or upright d/t gravity
ABCDE method: A (what to look for)
Common abnormalities
- See trachea in line, lung fields clear and symmetrical
- See bifurcation
- White lines = lung markings all the way out to edge
- black lines = defining lines of lobes
- Blood vessels of hilum noted
Abnormalities: lung consolidation (PNA); tension PTX (look for medial sternal shift); COVID PNA; cancer masses
ABCDE method: B (what to look for?)
Common abnormalities
- Clavicles equal and intact? How many ribs when at full lung capacity? (8-9 good)
- Ribs and Shoulders intact?
Abnormalities: seeing all 10 ribs, clavicles not equal
ABCDE method: C (what to look for?)
Common abnormalities
- L/R vent?
- Atrium central line?
- Width of heart should be as long as ribs (not less or more)
- Mediastinum central and noted w/aortic arch
- Cardiac size ok? CTR
Abnormalities: cardiomegaly
Cardiac Size on CXR
- Measured in relation to the total thoracic width - the Cardio-Thoracic Ratio (CTR)
- CTR = Cardiac width : thoracic width
- Cardiac size is measured by drawing vertical parallel lines down the most lateral points on each side of the heart, and measuring between them.
- Thoracic width is measured by drawing vertical parallel lines down the inner aspect of the widest points of the rib cage, and measuring between them.
ABCDE method: D (what to look for?) and E
- Rounded at bottom w/BL sharp costophrenic angles
- Intact BL
- Air noted at bottom of left side
- No air on bottom right
- E: write down what you see (bullets, leads, tubes, etc)
Abnormalities: blunted CPAs → COPD (w/flat diaphragm); air presence in diagphragm (fluid); diaphragm
E (foreign bodies, leads, etc)
Imaging for muscular or soft tissue injuries
Clinical exam
MRI imaging
Imaging for bony injuries
Clinical exam
X-ray imaging
Occasionally CT imaging - tibial plateau fracture
Systematic view of ortho xrays
What to check?
- Correct patient, side, most recent (date/same day)
- 2 views (AP/lateral)
- Can get 3 views
- Joint above and joint below site of injury or 2 adjacent (I.e.: compare two hips)
Rationale for Splinting and purpose
- Prevents further blood loss and injury
-
Can restore or maintain perfusion
- Kinked extremity = perfusion
- Splint ASAP
- Lengthen extremity before splinting
- Relieves pain
- Important during evaluation
- Do not delay
Reasons scaphoid fracture is a DO NOT MISS condition?
- Fractured → only vascularized in one end → will die if not immobilized → thumb will be useless
Cause, classic symptoms, of scaphoid fracture
Imaging? Type of splint?
- FOOSH (fall on outstretched hand) w/pain in wrist and hand
- Snuff box tenderness (suspect fracture)
- CT, MRI, Bone scan
- Thumb spica → holds thumb in extended position
- Refer to hand consult
Colle’s Fracture
what, MOI, imaging
- Fracture of distal radius, sometimes w/fracture of distal ulna or ulnar styloid → dorsal angulation of bone fragment
- Most are stable but can be unstable if articular surface involved
- MOI: FOOSH
- Imaging: X-ray
Colle’s fracture
Treatment
- Varies based on stability and deformity
- Stable or non-angulated → volar splint
-
Unstable or angulated → closed reduction (align bones)
- Hematoma block (lidocaine) → traction/ counter-traction
- THEN volar or sugar tong
- Most require surgery
- Can use chinese trap finger mechanism
Ottawa Ankle Rules
- Ankle X-ray series only required if there is any pain in malleolar zone and…
- Bone tenderness at posterior edge or tip of lateral malleolus
- “ ” medial malleolus
- Inability to bear weight both immediately and in ED for four steps
Bimalleolar fracture + treatment
- NOT STABLE
- Need surgery and splinting
- Posterior and sugar tong splint
- Help immobilize ankle in two planes of movement
Pilon fracture + treatment
- Fractured tibia at base near ankle
- EXTREMELY UNSTABLE b/c cannot bear weight
- Can make it worse
- Fracture will continue up tibia if bearing weight → can make it worse if putting weight on it
Trimalleolar fracture
- WORSE CASE SCENARIO
- dislocation of tibial-talor joint & bilmalleolar fracture
- Fracture can move around
Masionneuve Fracture + treatment
- DO NOT MISS
- Proximal fibular fracture accompanying any kind of ankle fracture
- Rotational forces transmitted up to knee (ankle inversion)
- Palpate proximal fibula in any ankle injury (image whole) - palpate 5th metatarsal AND up by knee
- Treatment: long-leg posterior splint → ortho referral
- strict non-weight bearing
5th metatarsal fracture
- Important to palpate 5th MT in ankle injury assessment
- Hard to see on x-ray films - low threshold to view
- Treatment: posterior splint or JONES dressing
No foot film necessary if no pain on palpation
