Casting and splinting of sprains and fx - SRS Flashcards by Stephen Schaffner

Identify

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What is the most reliable sign of a fx?

Pain

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What is the most important thing to ascertain when doing PE on a patient with a fracture?

Neurovascular status, compromise here can be very bad.

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What is an open fracture?

•: a fracture that has communicated with the outside environment.

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What are the typical MOA for an open fx? 2

High velocity trauma or missile injury
Spikes of bone pierce the skin

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What must you absolutely do with a compound fx regardless of the size?

Must get a surgical consult

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What kind of fx is this?

What class?

What is the ballpark age of this patient?

Epiphyseal fracture - salter harris class IV

Child - d/t presence of growth plates

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Identify

Salter harris class I - “slipped”

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Salter Harris Class?

V - Rammed and Ruined

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Salter HArris Class?

II - Above, fracture of bone but not plate

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Salter harris clasS?

III - Lower, plate but not bone

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Salter Harris Class?

IV - Through, both of them

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Salter harris class?

I - slipped. Transverse fx through the growth plate or physis

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Salter class?

Salter type III - •FRACTURE THROUGH THE GROWTH PATE AND EPIPHYSIS SPARING THE METAPHYSIS

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What is this clasS?

Salter II - •FRACTURE THROUGH THE METAPHYSIS SPAREING THE EPIPHYSIS

Most common

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Salter class?

Salter type V - •COMPRESSION FRACTURE OF THE GROWTH PLATE

Rare

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Class?

Salter IV - Extend through all three elements Growth plate, epiphysis and metaphysis

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Your patient falls on their hand and has these findings. What is the dx?

All looks normal…

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LAter the patient returns and you see these results. What now?

Scaphoid fracture - occult in the beginning, but now visible because of the calcifications

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What is the biggest danger of an occult scaphoid fx?

Avascular necrosis of the proximal bone

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If a patient presents with a “dinner fork” deformity, what is that?

What is broken?

What is displaced?

COLLES’ FRACTURES

•Fracture of the distal radius with dorsal displacement, with or without ulnar involvement.

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What causes a colle’s fracture?

What may also be involved?

Falling on outstretched hand

60% of the time there is an associated fracture of the ulnar styloid process

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Fracture type?

Colles’

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Fracture type?

Colles’

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What does a tri-malleolar fracture involve?

1. Lateral malleolus 2. Medial malleolus 3. Posterior tibia

MOA for a tri-malleolar fracture?

Landing flat on the heel from significant height.

What is the treatment for a tri-malleolar fracture?

Open reduction and internal fixation (surgery)

What is the worst fracture complication in general?

Ischemic contractures/injuries

What are some of the early/local complications with fractures? 2 emphasized

**_-Vascular injury causing hemorrhage, internal or external_** - Visceral injury causing damage to structures such as the brain, lung or bladder - Damage to surrounding tissue, blood vessels, muscle, nerves or skin - Hemarthrosis **_-Compartment syndrome (or Volkmann's ischemia)_** -Wound Infection - more common for open fractures

What are some early/systemic fracture complications? 2 emphasized

**_-Fat embolism – long bone / pelvic fractures from bone marrow_** -Shock – extensive bleeding **_-Thromboembolism (pulmonary or venous)_** - Exacerbation of underlying diseases such as diabetes or coronary artery disease (CAD) - Pneumonia

What are some late/local fracture complications? 4 that you should get in particular

* Delayed union * Nonunion * Mal-union * Joint stiffness * Contractures **_•Myositis ossificans – calcifications and bony masses can form in muscle_** **_•Avascular necrosis – loss of blood supply_** **_•Algodystrophy (or Sudeck's atrophy) – RSD or Regional pain syndrome_** **_•Osteomyelitis - infection_** •Growth disturbance or deformity – children’s growth plates

What are some systemic/late complications? 4 emphasized

* **_Gangrene,_** * **_tetanus,_** * **_septicemia_** * Fear of mobilizing * **_Osteoarthritis_**

Compartment syndrome should be considered a?

Medical emergency

What happens in compartment syndrome?

* The pressure inside the fascial compartment exceeds the blood (arterial) pressure. * Causes compromise of the circulation to the soft tissue, ischemia and necrosis.

At what time point can irreversible damage arise d/t compartment syndromes?

8 hours

What are some conditions associated with compartment syndromes?

* Soft tissue injuries * Soft tissue injury with fracture * Exercised induced * Crush injury * Prolonged tourniquet application * Electrical injury * Burns * Animal bites

How is compartment syndrome treated?

Fasciotomy

What is a stryker 295 device used for?

Measuring compartment pressures

What is shown here?

Fracture blisters

Describe fracture blisters.

-Tense vesicles or bullae that arise on markedly swollen skin directly over a fracture.

Fracture blisters may arise as two types, what are they?

Clear fluid filled Blood filled

What causes fracture blisters (other than the obvious)?

Seperation of dermis from epidermis

What are four treatment options for fracture blisters?

Benign neglect Debridement Aspiration Surgical delay

Comment on these findings. In kids this might straighet out if the angle is less than?

Malalignment of fractures ## Footnote WILL STRAIGHTEN IN KIDS IF ANGLE LESS THAN 15 DEGREES

Indetify

Top to bottom - Inversion, Eversion, High ankle sprain

Sprain grade? ## Footnote Moderate to severe pain, swelling, and joint stiffness are present Partial tear of the lateral ligament(s) Moderate loss of function with difficulty on toe raises and walking Takes up to 2-3 months before regaining close to full strength and stability in the joint

Sprain grade? ## Footnote Severe pain may be present initially, followed by little or no pain due to total disruption of the nerve fibers Swelling may be profuse and joint becomes stiff some hours after the injury Complete rupture of the ligaments of the lateral complex (severe laxity) Usually requires some form of immobilization lasting several weeks Complete loss of function (functional disability) and necessity for crutches Usually managed conservatively with rehabilitation exercises, but a small percentage may require surgery Recovery can be as long as 4 months

III

Sprain grade? ## Footnote Mild sprain, mild pain, little swelling, and joint stiffness may be apparent without laxity (loosening) Usually affects the anterior talofibular ligament Minimum or no loss of function Can return to activity within a few days of the injury (with a brace or taping)

Treatment for acute sprains?

* R= REST * I= ICE * C= COMPRESSION * E= ELEVATE NOTE: MAY NEED IMMOBILIZATION WITH GRADE III SPRAINS

What are the benefits of a cast?

* BETTER IMMOBILIZATION IN FIXED POSITION * LESS MOVEMENT AT THE FRACTURE SITE * LASTS FOR WEEKS TO MONTHS * CAN’T BE REMOVED BY THE PATIENT

What are the benefits of a splint?

* FASTER AND CHEAPER * CAN BE ADAPTED FROM SURROUNDING MATERIAL * NOT AS LIKELY TO CAUSE PRESSURE PROBLEMS * CAN BE REMOVED BY THE PATIENT

What are some complications of casting that must be considered?

Compartment syndrome ishemia heat injury pressure sores and skin breakdown infection dermatitis joint stiffness neurologic injury

Identify each of these splint types

When wrapping a splint or cast you should do it in what direction?

**_Always wrap distal to proximal_**

What should you remember in lab when applying the cast?

* ALWAYS WEAR GLOVES WHEN WORKING WITH THE RESIN CASTING TAPE * WE DO NOT HAVE A POWER GRINDER TO GET IT OFF YOUR HANDS. Well why not?

What are some soft tissue indications for joint injection?

* Bursitis * Tendonitis * Trigger points * Ganglion cysts * Neuroma * Entrapment syndromes * Fasciitis

What are some joint condition indications for joint injection?

* Effusion * Crystalloid arthropathies * Synovitis * Inflammatory arthritis * Advanced osteoarthritis

What are the five absolute contraindications to joint injections?

* Local cellulitis * Acute fracture * Tendon sites are at a high risk for rupture * Drug allergy * Septic arthritis – for therapeutic injection, not aspiration

What are some relative contraindications to joint injections?

* Minimal relief after 2 previous injections * Underlying coagulopathy / anticoagulation therapy * Uncontrolled diabetes * Surrounding joint osteoporosis * Anatomically inaccessible joint