9/22/14. ! None. ! Provides non- circumferential support! Accommodates swelling! Useful for acute injuries! Held in place by elastic bandage

Transcription

1 Britt Marcussen, MD Sports Medicine University of Iowa! None! 1. Discuss indications for splinting! 2. Discuss advantages/disadvantages of splints! 3. Go through splinting materials! 4. Discuss casting indications and different materials! 5. Cover a smattering of ortho pearls! 6. Discuss common fractures and assocated splints/casts! 7. Discuss basics of making each type of splint! Provides non- circumferential support! Accommodates swelling! Useful for acute injuries! Held in place by elastic bandage 1

2 ! Stabilize acute injury (sprain, fx, reduction)! Immobilization initial! Pain control! Prevent further injury! Tenosynovitis! Arthritis! Gout! Post surgery! Accommodates swelling! May take off and re- apply if needed! Faster to apply! Easier to apply! Prefabricated splints available! Allows more motion at site of injury than cast! Patients can take them off non compliance! May not provide definitive care 2

3 ! Circumferential support! Better immobilization at fracture site! Provides definitive care! Most patients can t take them off! Cost fiber glass is more $$! Moldability plaster has more! Accommodation of swelling plaster has more! Heat production! Curing time 24 hrs for plaster! Use in reduction plaster usually preferred! Contact with water plaster loses structure! Waterproof padding available! Heat production inversely proportional to setting time (fiberglass = more heat)! More layers of plaster = more heat! Increased pressure applied = more heat! Hotter water = faster setting time! Colder water = slower setting time! No water = slowest setting time, best when starting out! Mind the surface the arm is resting on! Harder to apply! Does not accommodate swelling as well as splint! Increased risk for complications! Lasts about 6 weeks, starts to crumble! Falls apart in water contact! Messy 3

4 ! Swelling accommodation <plaster and <<splint! Not as good as plaster following fx reduction! Roll on material don t pull tight! Let the material go where is wants to go! Make cuts to adjust! When wet, apply paper cut outs or cast material shapes for fun designs.! Assess the injury! Determine need for immobilization! Neurovascular exam prior to AND after splint application Function Arterial pulse Capillary refill Temperature Sensation! Stockinette! Padding! Fiberglass or plaster! Tape! Container of water! Elastic bandage (Ace wrap)! Sheets to keep the patient dry! Bandage scissors! Strong scissors to cut fiberglass 4

5 ! Pick appropriate size, no too tight, not too loose! Error on the side of leaving too long on both ends! Make slits in areas of folding! Typically 2 or 3 layers thick! More padding over areas of pressure! Overlap ~50% each time! Apply padding 2-3 cm beyond intended edges of splint! Tear out folds! Tear technique! Too much padding = less support! Cast index! Measure twice cut once! Reseal the edge!! Wet the strip pad dry! Mold to desired body location! Trim sharp edges! Skin sores! Dermatitis! Joint stiffness! Infection! Compartment syndrome! Nerve injury 5

6 ! Long arm: 1. Displaced distal radius fx 2. Scaphoid fx 3. Combined radius & ulnar fracture 4. Proximal forearm fractures 5. Elbow fractures! Short arm: 1. Thumb fx 2. Non displaced distal radius fx 3. Transition out of long arm cast! Anytime want to minimize rotation of forearm or immobilize the elbow! Never bad to start with long arm! Injuries and their associated splints/casts 6

7 ! Most common in young males yrs old! FOOSH injury! Thumb spica studies without thumb, long vs short arm healing time! Watson test! Grind test! Palpate Anatomic snuff box ulnar deviate wrist! Imaging of choice: AP&L with scaphoid view (wrist ulnar deviated/extended beam dorsally)! Consider MRI! Refer for displacement, middle or proximal fractures! Immobilize weeks! Discuss case with ortho! If nml XRAY but still concerned, splint/cast for 2 wks, then XRAY or get an MRI.! 1-2 weeks 7

8 UCL injury with avulsion fx of proximal phalanx. MRI shows Stener lesion! Common in skiers, sports, gamekeepers! Imaging of choice: Thumb XRAY! Consider MRI: Rule out Stener lesion! Thumb spica for variable time 4-6 weeks typical! Refer for grade III injury 8

9 ! MeatLOAF! Meat= Median nerve! L= Lumbricals 1&2! O= Opponens pollicus! A=Abductor pollicus! F=Flexor pollicus! Extension=Radial nerve! Adduction=Ulnar nerve! Pay special attention to the padding around the thumb avoid wrinkles! Start at the wrist and work distally towards thumb first and work your way down the forearm! Stop at mid to proximal forearm! In scaphoid fx cast doesn t need to include the IP joint! Stop padding/cast material at palmar crease 9

10 ! Boxer fx or street fighter fracture! Note angulation! Neck fracture: degrees tolerated! Shaft fracture: <20 degrees tolerated! ~6 weeks immobilization! Put padding between fingers avoid maceration! Use a wide enough splint! Cover the DIP joint! Position of function! 2 nd or 3 rd metacarpal fracture/injury 10

11 ! Augmentin first line! Doxy, Bactrim, Pen VK, Cefuroxime, Cipro, Moxi, Levo! Agents lacking activity against Eikenella corrodens should be avoided; these include: 1. First- generation Cephalosporins (such as cephalexin) 2. Penicillinase- resistant penicillins (such as Dicloxacillin) 3. Macrolides (such as erythromycin) 4. Clindamycin 5. Aminoglycosides! Local resistance patterns! Aka Torus fracture! Kids, boys>girls! FOOSH injury! Imaging of choice: at least 2 views of forearm AP&L! Splint: volar, Sugar tong, pre- fabricated splint, etc! Short arm cast 3-6 weeks! Removable splint may provide definitive tx 11

12 ! Stabilizes wrist and elbow! Minimizes pronation/supination! Minimizes flex/extend wrist! Limits elbow motion! Start/stop just shy of MCP joints! Flush with elbow! Reverse sugar tong! Colles fx Smith fx! Aka Colles fx if angulated with apex volarly (aka displaced fragment is dorsal)! Aka Smith fx if angulated with apex dorsally (aka displaced fragment is volar)! FOOSH injury wrist position! Common in kids and middle aged- older population! Imaging of choice: AP&L XRAY! *Need for reduction likely! Discuss/refer to ortho for significant displacement! Double sugar tong splint followed by long/short arm cast 12

13 ! Ideal for displaced distal radial/ulnar fractures! Ideal for elbow fractures! Minimizes flexion/extension at elbow/wrist! Minimizes supination/pronation of forearm! Transition to long arm cast! Can use long arm posterior splint! Vitamin C shown to reduce development of complex regional pain syndrome following wrist fractures in elderly! Doses of 500 mg+ for 50 days following fx! Reduced by over 50%! NNT 13! Consider possible side effects of high vitamin C! Kidney stones! Diarrhea! Drug interactions (chemotherapeutics)! Caution in renal failure 13

14 ! Most common elbow fx in adults! FOOSH injury! *Note ROM! Imaging of choice: AP&L with radial head view! Type I and stable Type II fx treated with early ROM! Sling for comfort PRN! Need degrees of flexion and 70 degrees of supination/pronation! Follow clinically 14

15 ! Most common fracture in kids! Imaging of choice: AP & L elbow films! Consider humerus and forearm! Splint: Double sugar tong or long arm posterior! Cast: Long arm! Immobilize 4-6 weeks! Refer for displaced fractures 15

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17 ! Common in inversion ankle sprain! Isolated lateral or medial malleolar fx ok to tx! Imaging of choice: standing AP&L, mortise view! Rule out multiple fx and unstable ankle! Splint/Cast of choice: CAM walking boot, posterior splint, stirrup splint, short leg walking cast! Keep ankle in 90 degrees! Cut slit in stockinette over anterior ankle! Apply extra padding over heel, malleoli (non circumferential)! Apply extra layers to heel and forefoot for walking cast! Don t compress proximal fibular head! Cut cast around toes, expose MTP joints 17

18 ! Steady hand with index finger or thumb on cast! Use multiple short cuts! Don t leave in same place too long (seconds)! Push down until feel give 18