Orthopedic Injuries and Immobilization - PowerPoint PPT Presentation

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Orthopedic Injuries and Immobilization

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c. slow and gentle procedure ... Clinical exam (check for circumflex nerve function) ... Reduced risk compared to casting but still a possibility ... – PowerPoint PPT presentation

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Title: Orthopedic Injuries and Immobilization


1
Orthopedic Injuries and Immobilization
  • Stanford University
  • Division of Emergency Medicine

2
History and Physical Exam
  • Immediately upon presentation with a dislocation
    or fracture, the neurovascular and circulatory
    status must be checked.
  • Attempt to ascertain the mechanism of injury.
  • - may alert physician to other possibly
    associated
  • injuries
  • as well as provide clues as to the type of injury
    involved
  • Radiographs should be obtained if fracture OR
    DISLOCATION is suspected
  • Radiographs should be obtained after reduction
    and IMMOBILIZATION of a fracture or dislocation.

3
How do you Describe This?
  • Named by where the distal articulating surface
    ends up relative to the proximal articulating
    surface
  • e.g. Anterior shoulder dislocation
  • - Humeral head is anterior to the glenoid fossa

Left Forearm fracture which is Dorsally Displaced
4
REDUCING DISLOCATIONS and SUBLUXATIONS
  • Three keys to success when attempting reduction
  • a. knowledge of anatomy
  • b. analgesia and sedation
  • c. slow and gentle procedure
  • Following reduction, the joint must be splinted
    and proper follow-up is mandatory
  • After one or two unsuccessful attempts of
    reducing a dislocation (closed reduction), it is
    necessary to reduce under general anesthesia
    (closed) or during surgery (open reduction)

5
Finger Dislocation
  • Clinical exam to determine nerve and tendon
    function if possible
  • X-ray to confirm diagnosis
  • Anesthetize with a digital block
  • Reduce dislocation
  • i. Apply traction in line with the distal portion
    of the finger
  • ii. The deformity should increase slightly just
    prior to joint going back in place
  • iii. This should be felt as a click
  • Take further X-rays if necessary to rule out a
    "chip" fracture
  • Strap injured finger to adjacent finger
  • Warn patient that swelling will persist for
    several months

6
Shoulder Dislocation
  • Take a past medical history (i.e. has this
    happened before?)
  • Clinical exam (check for circumflex nerve
    function)
  • X-ray to rule out possible fracture (i.e. head of
    the humerus)
  • Several methods for reduction
  • Scapular rotation
  • Traction/counter traction

7
Subluxation of the Radial Head (Nursemaids
Elbow)
  • Definition of subluxation a joint disruption in
    which the joint surfaces are maintained in some
    degree of apposition.
  • Description the radial head slips out from under
    the annular ligament.
  • i. Generally caused by sudden traction of the
    forearm that extends and pronates the elbow (like
    the motion of pulling a child off the ground by
    his/her wrist).
  • ii. Most common in children aging 1 - 4 years
    old, because the lip of the radial head is not
    well formed and may slip out from under the
    annular ligament with more ease.
  • iii. Minimal pain if the arm is stationary but
    pain is felt upon flexing or supinating arm,
    (parents often think it is merely a sprain and
    wait 24 - 36 hours before seeking medical help)
  • iv. No associated swelling, ecchymosis, or
    neurovascular deficit
  • Radiography - Normal findings

8
Nursemaids Elbow Reduction
9
Fracture Types
10
Greenstick
  • an incomplete fracture in a long bone of a child
    (bones are not yet fully calcified and they break
    like a green stick)

11
Open Fracture
  • the bone breaks and pierces the overlying skin
    (osteomyelitis are more common)
  • 4 grades

12
Spiral Fracture
  • a fracture that spirals part of the length of a
    long bone

13
Wrist Fractures
14
Scaphoid Fractures
  • tenuous blood supply
  • high incidence of avascular necrosis in waist and
    proximal fractures
  • often require bone grafting

15
Scaphoid Fractures
  • high clinical suspicion even with normal x-ray
  • follow up important- repeat x-rays and early
    bone scan in patients with persistent pain
  • thumb spica with prolonged immobilization

16
Learn How to Splint in 10 Easy Lessons!!!!
As Seen On TV!!
Hey Kids,
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17
Introduction
  • Evidence of rudimentary splints found as early as
    500 BC.
  • Used to temporarily immobilize fractures,
    dislocations, and soft tissue injuries.
  • Circumferential casts abandoned in the ED
  • - increased compartment syndrome and other
    complications
  • - ideal for the ED allow swelling
  • splints easier to apply

18
Indications for Splinting
  • Fractures
  • Sprains
  • Joint infections
  • Tenosynovitis
  • Acute arthritis / gout
  • Lacerations over joints
  • Puncture wounds and animal bites of the hands or
    feet

19
Splinting Equipment
  • Plaster of Paris
  • Made from gypsum - calcium sulfate dihydrate
  • Exothermic reaction when wet - recrystallizes
    (can burn patient)
  • Warm water - faster set, but increases risk of
    burns
  • Fast drying - 5 - 8 minutes to set
  • Extra fast-drying - 2 - 4 minutes to set - less
    time to mold
  • Can take up to 1 day to cure (reach maximum
    strength)
  • Upper extremities - use 8-10 layers
  • Lower extremities - 12-15 layers, up to 20 if big
    person (increased risk of burn!)

20
Splinting Equipment
  • Ready Made Splinting Material
  • Plaster (OCL)
  • 10 -20 sheets of plaster with padding and cloth
    cover
  • Fiberglass (Orthoglass)
  • Cure rapidly (20 minutes)
  • Less messy
  • Stronger, lighter, wicks moisture better
  • Less moldable

21
Splinting Equipment
  • Stockinette
  • protects skin, looks nifty (often not necessary)
  • cut longer than splint
  • 2,3,4,8,10,12-in. widths
  • Padding - Webril
  • 2-3 layers, more if anticipate lots of swelling
  • Extra over elbows, heels
  • Be generous over bony prominences
  • Always pad between digits when splinting
    hands/feet or when buddy taping
  • Avoid wrinkles
  • Do not tighten - ischemia!
  • Avoid circumfrential use
  • Ace wraps

22
Specific Splints and Orthoses
  • Upper Extremity
  • Elbow/Forearm
  • Long Arm Posterior
  • Double Sugar - Tong
  • Forearm/Wrist
  • Volar Forearm / Cockup
  • Sugar - Tong
  • Hand/Fingers
  • Ulnar Gutter
  • Radial Gutter
  • Thumb Spica
  • Finger Splints
  • Lower Extremity
  • Knee
  • Knee Immobilizer / Bledsoe
  • Bulky Jones
  • Posterior Knee Splint
  • Ankle
  • Posterior Ankle
  • Stirrup
  • Foot
  • Hard Shoe

23
Long Arm Posterior Splint
  • Indications
  • Elbow and forearm injuries
  • Distal humerus fx
  • Both-bone forearm fx
  • Unstable proximal radius or ulna fx (sugar-tong
    better)
  • Doesnt completely eliminate supination /
    pronation -either add an anterior splint or use a
    double sugar-tong if complex or unstable distal
    forearm fx.

24
Double Sugar Tong
  • Indications
  • Elbow and forearm fx - prox/mid/distal radius and
    ulnar fx.
  • Better for most distal forearm and elbow fx
    because limits flex/extension and pronation /
    supination.

10
90
25
Forearm Volar Splint aka Cockup Splint
  • Indications
  • 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 (B).
  • Not used for distal radius or ulnar fx - can
    still supinate and pronate.

26
Forearm Sugar Tong
  • Indications
  • Distal radius and ulnar fx.
  • Prevents pronation / supination and immobilizes
    elbow.

27
Hand Splinting
  • The correct position for most hand splints is the
    position of function, a.k.a. the neutral
    position.
  • This is with the the hand in the beer can
    position (which may have contributed to the
    injury in the first place) wrist slightly
    extended (10-25) with fingers flexed as shown.
  • When immobilizing metacarpal neck fractures, the
    MCP joint should be flexed to 90.
  • Have the patient hold an ace wrap (or a beer can
    if available) until the splint hardens.
  • For thumb fx, immobilize the thumb as if holding
    a wine glass.

28
Radial and Ulnar Gutter
  • Indications
  • Fractures, phalangeal and metacarpal, and soft
    tissue injuries of the little and ring fingers.
  • Indications
  • Fractures, phalangeal and metacarpal, and soft
    tissue injuries of index and long fingers.

29
Thumb Spica
  • Indications
  • Scaphoid fx - seen or suspected (check snuffbox
    tenderness)
  • De Quervain tenosynovitis.
  • Notching the plaster (shown) prevents buckling
    when wrapping around thumb.
  • Wine glass position.

30
Finger Splints
  • Sprains - dynamic splinting (buddy taping).
  • Dorsal/Volar finger splints - phalangeal fx,
    though gutter splints probably better for
    proximal fxs.

31
Jones Compression Dressing - aka Bulky Jones
  • Procedure
  • Stockinette and Webril.
  • 1-2 layers of thick cotton padding.
  • 6 inch ace wrap.
  • Indications
  • Short term immobilization of soft tissue and
    ligamentous injuries to the knee or calf.
  • Allows slight flexion and extension - may add
    posterior knee splint to further immobilize the
    knee.

32
Posterior Ankle Splint
  • Indications
  • 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 the
    posterior splint eliminates inversion / eversion
    - especially useful for unstable fx and sprains.

33
Stirrup Splint
  • Indications
  • Similiar to posterior splint.
  • Less inversion /eversion and actually less
    plantar flexion compared to posterior splint.
  • Great for ankle sprains.
  • 12-15 layers of 4-6 inch plaster.

34
Other Orthoses
  • Knee Immobilizer
  • Semirigid brace, many models
  • Fastens with Velcro
  • Worn over clothing
  • Bledsoe Brace
  • Articulated knee brace
  • Amount of allowed flexion and extension can be
    adjusted
  • Used for ligamentous knee injuries and post-op
  • AirCast/ Airsplint
  • Resembles a stirrup splint with air bladders
  • Worn inside shoe
  • Hard Shoe
  • Used for foot fractures or soft tissue injuries

35
Complications
  • Burns
  • Thermal injury as plaster dries
  • Hot water, Increased number of layers, extra
    fast-drying, poor padding - all increase risk
  • If significant pain - remove splint to cool
  • Ischemia
  • Reduced risk compared to casting but still a
    possibility
  • Do not apply Webril and ace wraps tightly
  • Instruct to ice and elevate extremity
  • Close follow up if high risk for swelling,
    ischemia.
  • When in doubt, cut it off and look
  • Remember - pulses lost late.
  • Pressure sores
  • Smooth Webril and plaster well
  • Infection
  • Clean, debride and dress all wounds before splint
    application
  • Recheck if significant wound or increasing pain

Any complaints of worsening pain - Take the
splint off and look!
36
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