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 (Nursemaid’s 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 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 hours before seeking medical help)
iv. No associated swelling, ecchymosis, or neurovascular deficit
Radiography - Normal findings

8. Nursemaid’s 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

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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 minutes to set
Extra fast-drying 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 layers, up to 20 if big person (increased risk of burn!)

20. Splinting Equipment Ready Made Splinting Material Plaster (OCL)
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)
Doesn’t 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 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. Questions?