Musculockeletal Assessment, Splinting, and Cast Care Kendra Meyer MPA, PA-C

Injury Assessment Always start with ABC’s Primary survey The obvious injury Secondary survey Catch more subtle musculoskeletal injuries

Injury Assessment Systematic approach Inspection Palpation Neurovascular status Sensation Pulses Injury Assess joints above and below the injury ROM (range of motion) Active Passive Don‘t force Strength testing

Injury Assessment Once ABC’s, primary, and secondary surveys are complete: Stable patients Splint Unstable patients Load and go Splint en route

Acronyms D – deformities C – contusions A – abrasions P – Punctures B – burns T – tenderness L – lacerations S – swelling

Signs and Symptoms Pain/tenderness Deformity/angulation Crepitus (grating) Rice krispies Swelling Bruising Open fracture Joint locking Neurovascular compromise

Compartment Syndrome Increase pressure in a closed compartment Occurs with: Long bone fractures Femur Tibia/fibula Radius/ulna Humerus Small compartments Foot Hand

Compartment Syndrome Surgical emergency Compartment needs to be opened to avoid loss of limb Increased pressure = loss of blood/oxygen supply = tissue death Can progress quickly Important to reassess neurovascular status frequently

Compartment Syndrome Neurovascular compromise Pain Pallor Pulselessness Paresthesias Poikilothermia Cool sensation Paralysis Puffiness Edema

Strains Microscopic muscle tearing S/S Excessive force Stretching Overuse S/S Hemorrhage Swelling Tenderness Pain with isometric contraction Muscle spasm

Sprains Injury of ligamentous structures S/S “Rubber band” Twist Possible joint instability S/S Rapid swelling Pain with ROM testing Decreased ROM Bruising (will likely travel distal to the injury) Later finding

Sprains I- mild II – moderate III – complete No loss of joint function Edema 25% fiber involvement Can occur with normal activities II – moderate Partial tear Weakness in ligament strength III – complete Pop Joint laxity May require surgical repair Can be as severe as a fracture

Sprain/Strain Treatment R – rest I – ice C – crutches (other immobilizing devices) C – compression E – elevation Prevent joint stiffness ROM exercises

Signs & Symptoms of fractures Pain @ site of injury Swelling & tenderness Crepitus Deformity Loss of function Ecchymosis Paresthesia Distal pulse may not be present

Fracture Description Break in the continuity of the bone Orientation of fracture line A. Transverse B. Oblique C. Spiral D. Comminuted E. Segmental F. Torus (buckle)* G. Greenstick* *kids Emergency Medicine Sixth Edition

Transverse Fracture Straight across the bone Direct trauma

Oblique Fracture At an angle across the bone

Spiral Fracture Twisted around the shaft of the bone

Comminuted Fracture Bone is splintered into more than 3 fragments

Greenstick Fracture One side of the bone is broken and the other is bent. Mostly seen in children. As long as bone is kept rigid, healing is usually quick

Depressed Fracture Fragment(s) in driven (seen in fractures of the skull)

Compression Fracture Bone collapses in on itself (seen in vertebral fractures)

Avulsion Fracture Fragment of bone pulled off by ligament or tendon attachment

Impacted Fracture Fragment of one wedged into other bone fragments

Open Fracture Skin is broken Fragments of bone will penetrate through skin Skin is broken

Splinting Indications: Protects injury Decreases pain Facilitates healing Decreases risk of further injury Decreases blood loss in trauma patients Decreases need for narcotics Decreases risk of fat emboli Maintains bony alignment (fractures) Protects the structures around/within: large lacerations lacerations with tendon injuries

Splinting Improvised splinting Pillows Blankets Lumber Cardboard Trees Rolled newspaper Umbrella, cane, broom handle

Splinting Gather equipment Stockinette Webril Plaster/OCL/fiberglass Scissors Warm water Ace wraps Other assist devices

Splinting Place joint to be immobilized in proper position before applying webril Add extra padding to bony prominences Upper inner thigh Olecranon Patella Radial styloid Fibular head Ulnar styloid Achilles tendon area Medial/lateral malleoli

Splinting Procedure N/V checks before and after splinting Remove/cut away clothing from area Cleanse area Dress any skin injuries as appropriate Avoid pressure on open fractures

Splinting Apply stockinette Joint position Add webril Wet plaster 2-3 layers 3-4 over bony areas Wet plaster Apply proper splint Ace wrap into position Allow to set 15 min Ult takes 24 hours to fully dry Fiberglass quicker

Splinting D/C instructions ICE AND ELEVATION Splint stress Follow-up is essential Temporary Home n/v checks

Splinting The patient complains of increasing symptoms AFTER the splint is placed Loosen Re-check Re-pad Re-splint

Splinting Complications Ischemia Plaster burns Pressure sores Infection Dermatitis Joint stiffness

Splinting Types of splints Compression dressing with splint Sling and swathe Volar Thumb spica Ulnar gutter Sugar tong Double splint Long arm posterior splint Jones splint Lower extremity posterior splint AO splint

Application of a Sling & Swathe These are used for injuries of arms, elbows and wrists Follow the “general rules for splinting” already discussed Prepare sling by folding cloth into triangle Fold injured arm across the chest, position sling over top of the patient’s chest

Application of a Sling & Swathe Extend one point of the triangle behind the elbow on the injured side Take bottom point and bring over the patient’s arm. Take it over the top of the injured shoulder Draw up the sling so that the patient’s hand is about 4 inches above elbow

Application of a Sling & Swathe Tie 2 ends together, make sure the knot does not press against the back of neck Make sure fingertips exposed To make a pocket: twist excess material and tie a knot in the point

Application of a Sling & Swathe Form a swathe from a second piece of material Tie it around the chest and injured arm, over the sling. Do not place over the patient’s arm of the uninjured side Alternate Sling and ace wrap

Application of an Elastic Wrap Used to help support Injured muscles, ligaments, & tendons Increase circulation and promote healing

Application of an Elastic Wrap Start distal on the injured extremity and work the elastic wrap proximal with a ¼ to ½ inch overlap Wrap firmly, but not so tight that is slows or cuts off circulation

Other Types of Splints Upper extremity compression dressing with splint Volar splint Thumb spica splint Ulna gutter splint Sugar Tong splint Double Splint Sugar tong and posterior

Other Types of Splints Long arm Posterior splint Bulky Jones splint [w/ or w/o splint] Short leg splint AO splint

Upper Extremity Compression Dressing with Splint Primarily used for: Temporary immobilization to hand/wrist injuries or fractures with significant swelling to allow for decrease in swelling before casting Post-operatively to allow for swelling and temporary immobilization all at once

Volar Splint Uses: Post-op Basic wrist injuries Sprains Non-displaced fractures Apply on the volar aspect of the forearm Wrist slightly cocked back

Thumb Spica Uses: Beer can hand Injuries to wrist and thumb Scaphoid Thumb fracture Post-op Gamekeeper’s thumb Beer can hand

Ulnar GutterSplint Uses: 4th and 5th phalanx and metacarpal fractures

Sugar Tong Splint Uses: Displaced forearm fractures Elbow fractures Bilateral ankle fractures Displaced unilateral ankle fractures

Double Splint Primarily used for: Displaced or unstable Colles’ fractures Mid-shaft forearm fractures Elbow fractures Monteggia/Galleazzi fractures/injuries

Long Arm Posterior Splint Primarily used for: Wrist and elbow injuries/fractures and distal humerus fractures

Bulky Jones Splint Primarily used for: Temporary immobilization to foot/ankle injuries/fractures with significant swelling to allow for decrease in swelling before casting

Short Leg Posterior Splint Primarily used for: Treat ankle sprains Temporary immobilization of fractures to the lower extremity

AO Splint Primarily used for: Treat ankle sprains Temporary immobilization of fractures to the lower extremity

Casts Types Short-arm Long-arm Short-leg Long-leg Body cast Spica cast

Complications of Cast Pressure on n/v and bony structures causing necrosis, pressure sores, nerve palsies Compartment syndrome Immobility and confinement in a cast, particularity a body cast, can result in multisystem problems

Application of a Cast Equipment Underlying considerations Preparatory phase Application phase Follow-up phase

Patient Assessment with Cast N/V status for signs of compromise Skin integrity Positioning and potential pressure sites C/V, respiratory, GI for possible complications of immobility Psychological reaction

Medical Intervention Elevate extremity Avoid resting on hard surface Handle moist cast with palms of hands Turn every 2 hours while cast dries Assess n/ status every hour during the first 24 hours and then as needed

Patient Education Avoid getting cast wet: causes skin breakdown Don’t cover leg cast with plastic or rubber boots: causes condensation and wetting of the cast Avoid weight bearing for 24 hours (plaster)

Patient Education Call healthcare provider if cast cracks/breaks. Instruct try not to fix it Teach how to clean cast Remove surface soil with slightly damp cloth Rub soiled areas with talcum powder Wipe off residual moisture

Cast Removal Preparatory Phase Performance Phase