Casting and Splinting

Question 1

1st step in assessing fx/dislocation?

Answer 1

• 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

Question 2

Steps of reducing finger dislocation?

Answer 2

• 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

Question 3

Steps for shoulder dislocation tx?

Answer 3

• 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

Question 4

What is a greenstick fx?

Answer 4

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

Question 5

What is an open fx?

Answer 5

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

Question 6

Spiral fx?

Answer 6

• spirals part of length of long bone

Question 7

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

Answer 7

• 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

Question 8

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

Answer 8

• 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

Question 9

Why were circumferential casts abandoned in ED?

Answer 9

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

Question 10

Why are splints used?

Answer 10

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

Question 11

What are the indications for splinting?

Answer 11

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

Question 12

Conditions that benefit from immobilization?

Answer 12

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

Question 13

Deciding on splinting vs casting?

Answer 13

• 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)

Question 14

Advantages and disadvantages of splinting?

Answer 14

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

Question 15

Advantages and disadvantages of casting?

Answer 15

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)

Question 16

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

Answer 16

• 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)

Question 17

Specific splints and orthoses used?

Answer 17

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)

Question 18

Indications for long arm posterior splint?

Answer 18

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

Question 19

Indications for double sugar-tong?

Answer 19

• 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

Question 20

Indications for forearm volar spint aka cockup splint?

Answer 20

• 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

Question 21

Use of forearm sugar tong?

Answer 21

• distal radius and ulnar fx

- prevents pronation/supination and immobilizes elbow

Question 22

Correct position for splinting?

Answer 22

• 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

Question 23

Indications for ulnar and radial gutter?

Answer 23

• 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

Question 24

Indications for thumb spica?

Answer 24

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

Question 25

Indications for finger splints?

Answer 25

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

Question 26

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

Answer 26

- 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

Question 27

Indications for posterior ankle splint?

Answer 27

- 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

Question 28

Indications for stirrup splint?

Answer 28

- 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

Question 29

What is a bledose brace?

Answer 29

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

Question 30

When is a hard shoe used?

Answer 30

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

Question 31

CI to casting?

Answer 31

- 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

Question 32

Complications of casts or splints?

Answer 32

- 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!

Question 33

What instructions should you give to your pt?

Answer 33

- 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

Question 34

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

Answer 34

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