- bone breaks and pierces overlying skin (osteomyelitis is more common) - 4 grades

- spirals part of length of long bone

Casting and Splinting Flashcards by Emily Hendrickson

1st step in assessing fx/dislocation?

assess neuromuscular and circulatory status
attempt to ascertain MOI, this may alert physicain to other possibly assoc injuries
as well as provide clues as to type of injury involved
Radiographs should be obtained if fx or dislocation is suspected
these should be obtained after reduction and immobilization of fx or dislocation

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Steps of reducing finger dislocation?

exam to determine nerve and tendon fxn if possible
xray to confirm dx
anesthetize w/ digital block
reduce dislocation: apply traction in line w/ distal portion of finger, deformity should increase slightly just prior to jt going back in place, should be felt as a click
take further XRs if necessay to rule out chip fx
strap injured finger to adjacent finger, warn pt that swelling will persist for several months

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Steps for shoulder dislocation tx?

take past medical hx (has this happened b/f?)
clinical exam (nerve fxn)
XR to r/o possible fx (head of humerus)
several methods for reduction:
scapular rotation
traction/counter traction

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What is a greenstick fx?

incomplete fx in long bone of chid (bones aren’t calcified yet)

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What is an open fx?

bone breaks and pierces overlying skin (osteomyelitis is more common)
4 grades

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Spiral fx?

spirals part of length of long bone

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Describe diff b/t smith and colle’s fx?

smith: falling on flexed hand, radius moves volarly
colles: FOOSH - radius moves dorsally and head of radius moves volarly
in both cases: worry about median nerve

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What are we concerned about w/ scaphoid fx? Dx? Tx?

tenuous blood supply, has high incidence of AVN in waist and proximal fx, often reqr bone grafting
dx: high clinicla suspicion even w/ normal XR
f/u impt: repeat XR and early bone scan in pts w/ persistent pain
thumb spica w/ prolonged immobilization

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Why were circumferential casts abandoned in ED?

increased compartment syndrome and other complications
splints are ideal for ED: allows for swelling
splints easier to apply

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Why are splints used?

to immobilize ortho injuries
to promote healing
maintain bone alignment
diminish pain
protect injury
help compensate for surrounding muscular weakness

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What are the indications for splinting?

fx
sprains
jt infections
tenosynovitis
acute arthritis/gout
lacerations over jts
puncture wounds and animal bites of hands or ft

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Conditions that benefit from immobilization?

fx
sprain
severe soft tissue injuries
reduced jt dislocations
inflammatory conidtions: arthritis, tendinopathy, tenosynovitis
deep laceration repairs across jts
tendon lacerations

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Deciding on splinting vs casting?

assess stage and severity of injury
potential for instability
risk for complications
pt’s fxnl requirements
splints for:
1. simple and stable fx
2. sprains
3. tendon injuries
4. other soft tissue injuries
casting for definitive and/or complex fx management - can put buckle fx in cast (doesn’t swell up)

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Advantages and disadvantages of splinting?

advantage:

faster and easier
static or dynamic
pressure related complications less likely: skin breakdown, necrosis, compartment syndrome
easy removal

disadvantage:

lack of pt compliance, and excessive motion at injury site
not for unstable or potentially unstable fx like segmental or spiral or dislocated fx

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Advantages and disadvantages of casting?

advantages:

mainstay for tx for most fx
more effective immobilization

disadvantages:

reqr more skills
more time to apply
higher risk of complications (swelling, pressure sores)

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How many layers of plaster of paris do you use for splinting?

UE: use 8-10 layers
LE: 12-15 layers, up to 20 if big person (but increased risk of burn)
can take up to 1 day to cure
exothermic rxn when wet: recrystallizes (can burn pt)

Specific splints and orthoses used?

UE:
- elbow/forearm:
long arm posterior
double sugartong
- forearm/wrist:
volar forearm/cockup
sugartong
- hands/fingers:
ulnar gutter
radial gutter
thumb spica
finger splints

LE:
- knee:
knee imobilizer/bledsoe
 bulky jones
post knee splint 
- ankle: post ankle, stirrup
- foot: hard shoe (not used for jone's fx - needs ski boot (immobilize peroneals)

Indications for long arm posterior splint?

elbow and forearm fx:

distal humerus fx
both bone forearm fx
unstable proximal radius or ulna fx (sugar-tong better)
doesn’t completely eliminate supination/pronation so either add on anterior spint or use a double sugar tong if complex or unstable distal forearm fx

Indications for double sugar-tong?

elbow and forearm fx: prox/mid/distal radius and ulnar fx

- better for most distal foreamr and elbow fx b/c limits flex/extension and pronation/supination

Indications for forearm volar spint aka cockup splint?

soft tissue hand/wrist injuries- sprain, carpal tunnel night splints, etc
most wrist fx, 2nd-5th metacarpal fx
most add a dorsal splint for increased stability: sandwich splint
not used for distal radius or ulnar fx (still can supinate and pronate) - need to use posterior splint/sugartong in this case

Use of forearm sugar tong?

distal radius and ulnar fx

- prevents pronation/supination and immobilizes elbow

Correct position for splinting?

most hand splints: neutral position or position of fxn
hand in beer position (wrist slightly extended/ fingers flexed)
if immobilizing metacarpal neck fx: MCP jt should be flexed to 90 degrees
for thumb fx: immobilize thumb as if holding a wine glass

Indications for ulnar and radial gutter?

ulnar:
fx, phalangeal and metacarpal and soft tissue injuries of little and ring fingers
radial:
fx, phalangeal and metacarpal, and soft tissue injuries of index and long fingers

Indications for thumb spica?

scaphoid fx: seen or suspected (check for snuffbux tenderness)
De quervain tenosynovitis
notching plaster prevents buckling when wrapping around thumb, wine glass position

Indications for finger splints?

- sprains: dynamic splinting (buddy tapping) | - dorsal/volar finger splints - phalangeal fx, though gutter splints probably better for proximal fx

Jones compression dressing (aka Bulky Jones) indications and procedure?

- short term immobilization of soft tissues and ligamentous injuries to knee or calf - allows slight flexion and extension - may add posterior knee splint to further immobolize the knee (post op tibial fx, olecranon bursitis) - procedure: stockinette and webril 1-2 layers of thick cotton padding, 6 inch ace wrap

Indications for posterior ankle splint?

- distal tibia/fibula fx - reduced dislocations - severe sprains - tarsal/metatarsal fx - use at least 12-15 layers of plaster - adding a coaptation splint (stirrup) to posterior splint eliminates inversion/eversion especially useful for unstable fx and sprains

Indications for stirrup splint?

- similar to post splint ( distal tibia/fibular fx, tarsal/metatarsal fx, severe sprains, dislocations) - less inversion/eversion and actually less plantar flexion compared to posterior splint (still allows for dorsiflexion) - great for ankle sprains - 12-15 layers of 4-6 inch plaster

What is a bledose brace?

- articulated knee brace - amt of allowed flexion and extension can be adjusted - used for ligamentous knee injuries and post-op

When is a hard shoe used?

- for foot fx and soft tissue injuries (except jones)

CI to casting?

- early (premature casting): casting b/f maximal swelling has occurred can cause necrosis and possibly compartment syndrome - open wound: never place cast over an open wound as potential for infection - unstable fx: need surgical repair

Complications of casts or splints?

- compartment syndrome - ischemia (reduced risk for splinting, don't apply webril and ace tightly, instruct to ice and elevate) - heat injury (thermal injury as plaster dries, hot water, increased number of layers, extra fast drying, poor padding all increase risks) - pressure sores or skin breakdown (smooth webril and plaster well) - infection (clean, debride and dress all wounds b/f splint, recheck if sig wound or increasing pain) - dermatitis - jt stiffness - neuro injury ** any complaints of worsening pain: take splint off and look!

What instructions should you give to your pt?

- elevate limb - check circulation - watch for increased swelling - check mobility distally - protect skin from rough edges - keep cast dry - don't remove cast - don't put anything inside cast

When should you tell pt to return to ER or physician?

- pain - skin color changes - sensation changes - inability to move fingers - bad odor or staining - too tight or too loose - foreign objects in cast