The exciting world of Suture, Splinting, and Casting · 2018-04-01 · 3/6/2015 1 The exciting world of Suture, Splinting, and Casting John Shaff Hand Surgery Christopher Davis Radiology
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The exciting world ofSuture, Splinting, and
Casting
John ShaffHand Surgery
Christopher DavisRadiology
Provide multiple clinical pearls and review key clinical skills utilized in urgent care injury assessment and treatment.
Teach techniques and provide hands on practice of the following skill areas: suturing, splinting, and casting emphasizing clinical “tricks of the trade.”
Utilize memory tools, discussions, and hands on techniques to reinforce the protocols learned.
Objectives
Prepare the patient Feel the notch
Relax Take your time
The “One Stick” Block
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Volume: 2-4 cc Lidocaine – PLAIN
How deep?: Subcutaneously. Inject just on top of the tendon sheath and the infiltrate the digital nerves.
Effectiveness: Just as good as multiple sticks
Pain Level: About the same
Satisfaction: Patients – Same
Providers - Better
The “One Stick” Block
The “One Stick” Block
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LacerationsEventually all bleeding stops… one way or another
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Dogs: 5% infection risk - tear wounds.Treatment – Amox/Clav. 875mg BID, pain control, and
wound irrigation. These can be much worse due to other damage (fractures, vascular injury, deep muscle tears).
No. 1 Bacteria is Pasteurella canis
No. 2 is Staph. aureus
Cats: 80% infection rate - puncture wound.Treatment – Amox/Clav. 875mg BID,
pain control, and wound irrigation.
No. 1 Bacteria is Pasteurella multiocida
No. 2 is Staph. aureus
Animal Bites
Ah, yes… when the dog bites
Lacerations Over SinusesFinger probe technique – Listen for eggshells
Lip Laceration - “Million dollar laceration”
What is the imaging Gold Standard for facial injury?
Blunt Trauma
“Cheek just puffed out after I sneezed”
Facial Injuries
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Watch the edges
Running/Simple
Three Layers
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Severe Contamination
Suturing
Shapes:Cutting – Reverse & Conventional
Good for most skin & nailsTapered – Deep tissue and fascia
Curvature:
Types of Needles
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Nonabsorbable:Silk, NYLON, Polypropylene, Polyester fiber,
Polybutester, and Coated Polybutester
Natural Absorbable:Collagen, Plain surgical gut, Fast-absorbing
surgical gut, and Chromic surgical gut
Synthetic Absorbable:Polyglactin 910 (VICRYL), Polycaprolate
Poliglecaprone 25 (Monocryl), Polysorb,and Polydioxanone (PDSII)
Types of Sutures
Sutures:
Only needles needed – PS-2 and P-3.
Only suture needed – 6-0, 5-0, 4-0 Nylon
and 4-0 Vicryl, that’s it.
Anesthesia tips –Be nice and take your time:
Hold the syringe to warm the lidocaine.
Add 1cc bicarb for every 9cc of 1% lidocaine.Use 2% or 0.5% bupivacaine for larger or
complex lacerations.
Bottom Line
Suturing Do’s:Cut off rings
Assess neurovascular status PRIOR to anesthesia
Infuse lidocaine inside the wound edges
Irrigate – A LOT! (towels)
Approach at a 90 degree angle to the skin
Brief use of finger tourniquet – “Squeeze trick”
Listen and feel for clicking when looking for FB
Tag the corners first, EXCEPT in a thin flap
Use the “Over – Under” method
Reset your needle while holding the suture!
Tips for Suturing
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Suturing Dont’s:Perform a closure only if you are comfortable
Don’t rush the anesthesia infusion
Remember to pucker up the edges.
Loose closure only of contaminated wounds
Loose closure of the fascia layer
If it looks bad now, it will look worse later.
External staples on the scalp works fine
Don’t forget to close the galea layer.
No internal sutures in the hand-EVER!
Tips for Suturing
WOUND LOCATION TIMING OF REMOVAL (DAYS)
Face Three to five
Scalp Seven to 10
Arms Seven to 10
Trunk 10 to 14
Legs 10 to 14
Hands or feet 10 to 14
Palms or soles 14 to 21
Timing of suture and staple removal
Basic Rules:1) ICE – Not necessary
2) Gentle Compression – first hour or two
3) Elevate – first 24 hours for extremities
4) Pool Rule – No Water, especially lakes!
Wound Care Rules:1) Antibiotic Rule – Always if contaminated
2) Sensation Rule – Check often, fingers & toes
3) Smother Rule – Only a gloss coat of topical
4) Dressing Rule – Change it daily, after shower
Patient Education
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Splinting
Preparing (Helpful Hints):Choose the right material size – 2”, 3”, 4”
Need: Splint roll, ACE Wrap, water, & towel
Peel and cut back
REALLY dry it out
Applying (Do’s and Don’ts):DO Place in position of comfort… Usually
DO Roll back the ends and move ends
DON’T squeeze the corners – Ankles & Elbows
DON’T stretch the ACE, just roll it
90 Degrees at the ankle – a MUST!*
Tips for Splinting
Upper Extremity:Volar or Short Arm
Ulnar Gutter
Thumb Spika
Sugar Tong
Long Arm/Hanging Long Arm
Types of Splints
Lower Extremity:Short LegLong LegCadillac – (Short leg and sugar tong combo)
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Basic Rules:1) ICE, ICE, Baby!... - But gently
2) Elevate, Elevate, Elevate - ABOVE the heart
3) ACE RE-Wrap Rule - DON’T STRECH IT!
4) Weight Baring - There is no weight baring
Crutch Training Rules:1) Pink Flamingo Rule – draw the bad leg up
2) Lead Off Rule - Crutch first, foot second
3) Stairs Rule – NO up or down stairs, ever!
4) Backwards Rule – There is no backwards
Patient Education
Short Arm Splint
Thumb Spica Splint
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Sugar Tong Splint
Short Leg Splint
Long Leg Splint
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Assessment (NOM)First- Neurovascular
Second – Open versus Closed
Third – Mechanism of Injury
Description (TOAD)T ype – Spiral, transverse, comminutedO pen vs. ClosedA ngulation – Degrees of angulationD isplacement – Percentage
Fractures
Six Most Commonly Missed Fractures
Hand – Assume that it is fractured
Scaphoid – “Snuff Box” tenderness
Radial Head – Positive Posterior Fat Pad
Cervical – PANDA Neck Criteria
Calcaneous – Bohler’s Angle/Assess Spine
Salter-Harris – Most Common is Type II of the wrist (50%)
Fractures
Distal Radius
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Distal Radius Humerus
Supracondylar Fx
Second Metacarpal
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Boxer’s Fractures
Radius and Ulna
Spiral Tib/Fib
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Dislocation and Fracture
Casting
Upper Extremity:
Short Arm
Thumb Spika
Clam Shoveler – Boxer’s Fracture
Long Arm/Hanging Long Arm
Types of Casting
Lower Extremity:1. Short Leg2. Long Leg – slight bend at knee3. Cylinder
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Short Arm Cast
Thumb Spica Cast
Long Arm Cast
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Short Leg Cast
Long Leg Cast
Preparing (Helpful Hints):Choose the right material size – 3” or 4”
Need: Cast roll, stockinet, cast padding, water
REALLY shake off the water
Applying (Do’s and Don’ts):DO over extend the stocking
DO Roll back the ends, AFTER one pass
DON’T over pad, even distribution of padding
DON’T Pinch (Fingers and toes)
Extra PAD on the heel– a MUST!
Tips for Casting
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Basic Rules:1) ICE, ICE, Mayby... – Not as important
2) Elevate, Elevate, Elevate – first two weeks
3) Pool Rule – No Water, especially lakes!
4) Weight Baring – It depends
Cast Care Rules:1) Itching Rule – NOTHING goes in the cast!
2) Wiggle Rule – Keep wiggling fingers and toes
3) Swelling Rule – Split cast If swelling continues
4) CRPS Rule – REMOVE cast if present!
Patient Education
Bates, Barbara, A Guide to Physical Examination and History Taking, Fifth Edition, J.B. Lippincott Company, Philadelphia, PA, 1991.
Cannon B, Chan L, Rowlinson JS, Baker M, Clancy M (2010). Digital anaesthesia: one injection or two? Emergency medicine journal: EMJ, 27 (7), 533-6 PMID.
Gilbert, David, N., et. al., The Sanford Guide to Antimicrobial Therapy 2010, 40th
Edition, Antimicrobial Therapy, Inc., Sperryville, VA, 2010.
Jauch, Edward C, et. al., Acute Management of Stroke, MedScape Online,
Jul 10, 2012.
Lai, Stephen Y, et. al., Sutures and Needles, Medscape Online, June 3, 2013.
Kirkcaldy, Robert, New Treatment Guidelines for Gonorrhea: Antibiotic Change, Online CDC Expert Commentary, 08/13/2012.
Purvis, John, M. Engaging with Younger Patients, AAOS Now, May 2009.
Sarwark, John F., Put Pediatric Patients and Parents in the Picture, AAOS Bulletin, April 2004.
Staff author, Diseases Characterized by Urethritis and Cervicitis, CDC Report, April 12, 2007
Staff author, Joint dislocation, Wikipedia, 18 March 2012.
REFERENCES
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