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Orthopedic Injuries and

Immobilization

Stanford University

Division of Emergency Medicine


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History and Physical Exam Immediately upon presentation with a dislocation or

fracture, the neurovascular and circulatory statusmust be checked.

Attempt to ascertain the mechanism of injury.

- may alert physician to other possibly associatedinjuries

- as well as provide clues as to the type of injuryinvolved

Radiographs should be obtained if fracture OR

DISLOCATION is suspected Radiographs should be obtained after reduction and

IMMOBILIZATION of a fracture or dislocation.


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How do you Describe This?

Named by where the

distal articulating

surface ends up relative

to the proximalarticulating surface

e.g. Anterior shoulder

dislocation

- Humeral head is anteriorto the glenoid fossa

Left Forearm fracture which is Dorsally Displaced


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REDUCING DISLOCATIONS

and SUBLUXATIONS

Three keys to success when attempting reduction

a. knowledge of anatomy

b. analgesia and sedationc. slow and gentle procedure

Following reduction, the joint must be splinted andproper follow-up is mandatory

After one or two unsuccessful attempts of reducing adislocation (closed reduction), it is necessary toreduce under general anesthesia (closed) or duringsurgery (open reduction)


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Finger Dislocation Clinical exam to determine

nerve and tendon function ifpossible

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 increaseslightly just prior to joint goingback in place

iii. This should be felt as a click

Take further X-rays ifnecessary to rule out a "chip"fracture

Strap injured finger to adjacentfinger

Warn patient that swelling willpersist for several months


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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 possiblefracture (i.e. head of thehumerus)

Several methods for reduction

- Scapular rotation

- Traction/counter traction


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Subluxation of the Radial Head

(Nursemaids Elbow)Definition of subluxation = a joint disruption in

which the joint surfaces are maintainedin some degree of apposition.

Description: the radial head slips out fromunder the annular ligament.

i. Generally caused by sudden traction of theforearm that extends and pronates theelbow (like the motion of pulling a childoff the ground by his/her wrist).

ii. Most common in children aging 1 - 4 yearsold, because the lip of the radial head isnot well formed and may slip out fromunder the annular ligament with moreease.

iii. Minimal pain if the arm is stationary butpain is felt upon flexing or supinatingarm, (parents often think it is merely asprain and wait 24 - 36 hours beforeseeking medical help)

iv. No associated swelling, ecchymosis, orneurovascular deficit

Radiography - Normal findings


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Nursemaids Elbow Reduction


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Fracture Types


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Greenstick an incomplete

fracture in a long

bone of a child

(bones are not yetfully calcified and

they break like a

green stick)


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Open Fracture

the bone breaks and

pierces the overlying

skin (osteomyelitis

are more common)

4 grades


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Spiral Fracture

a fracture that

spirals part of the

length of a longbone


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Wrist Fractures


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Scaphoid Fractures

tenuous blood

supply

high incidence ofavascular necrosis

in waist and

proximal fractures

often require bone

grafting


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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 withprolonged

immobilization


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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 EDallow swelling- splints easier to apply


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Indications for Splinting

Fractures

Sprains

Joint infections Tenosynovitis

Acute arthritis / gout

Lacerations over joints Puncture wounds and animal

bites of the hands or feet


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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 tomold

Can take up to 1 day to cure (reach maximum

strength)

Upper extremities - use 8-10layers

Lower extremities - 12-15layers, up to 20 if bigperson (increased risk of burn!)


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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


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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


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Specific Splints and OrthosesUpper 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


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Long Arm Posterior Splint

Indications Elbow and forearm injuries:

Distal humerus fx

Both-bone forearm fx

Unstable proximal radius orulna fx (sugar-tong better)

Doesnt completely eliminatesupination / pronation -eitheradd an anterior splint or use

a double sugar-tong ifcomplex or unstable distalforearm fx.


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Double Sugar Tong

Indications

Elbow and forearm fx -

prox/mid/distal radius andulnar fx.

Better for most distal

forearm and elbow fx

because limits

flex/extension and

pronation / supination.

10

90


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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.


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Forearm Sugar Tong

Indications

Distal radius and

ulnar fx.

Prevents pronation /supination andimmobilizes elbow.


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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 tothe 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 flexedto 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.


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Radial and Ulnar Gutter

Indications

Fractures, phalangeal andmetacarpal, and soft tissue

injuries of the little and ring

fingers.

Indications

Fractures, phalangeal andmetacarpal, and soft tissue

injuries of index and long

fingers.


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Thumb Spica Indications

Scaphoid fx - seen orsuspected (check snuffboxtenderness)

De Quervain tenosynovitis. Notching the plaster (shown)

prevents buckling whenwrapping around thumb.

Wine glass position.


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Finger Splints

Sprains - dynamic

splinting (buddy

taping). Dorsal/Volar finger

splints - phalangeal

fx, though gutter

splints probably

better for proximal

fxs.


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Jones Compression Dressing

- aka Bulky Jones Indications

Short term immobilization

of soft tissue andligamentous injuries to the

knee or calf.

Allows slight flexion and

extension - may add posterior

knee splint to furtherimmobilize the knee.

Procedure Stockinette and

Webril.

1-2 layers of thickcotton padding.

6 inch ace wrap.


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Posterior Ankle Splint

Indications Distal tibia/fibula fx.

Reduced dislocations

Severe sprains Tarsal / metatarsal fx

Use at least 12-15 layers ofplaster.

Adding a coaptation splint(stirrup) to the posterior splinteliminates inversion /eversion - especially usefulfor unstable fx and sprains.


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Stirrup Splint

Indications

Similiar to posterior splint.

Less inversion /eversionand actually less plantar

flexion compared to

posterior splint.

Great for ankle sprains.

12-15 layers of 4-6 inch

plaster.


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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


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Complications Burns

Thermal injury as plaster dries

Hot water, Increased number oflayers, extra fast-drying, poorpadding - all increase risk

If significant pain - remove splint

to cool Ischemia

Reduced risk compared tocasting but still a possibility

Do not apply Webril and acewraps tightly

Instruct to ice and elevateextremity

Close follow up if high risk forswelling, 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 splintapplication

Recheck if significant wound orincreasing pain

Any complaints of

worsening pain -Take the splint off

and look!


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Questions?

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