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

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

3. 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

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

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

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

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

8. 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

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

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

11. 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

12. 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

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

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

15. 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

16. Transverse Fracture
Straight across the bone
Direct trauma

17. Oblique Fracture
At an angle across the bone

18. Spiral Fracture
Twisted around the shaft of the bone

19. Comminuted Fracture
Bone is splintered into more than 3 fragments

20. 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

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

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

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

24. Impacted Fracture
Fragment of one wedged into other bone fragments

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

26. 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

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

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

29. 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

30. 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

31. 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

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

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

34. Splinting Complications Ischemia Plaster burns Pressure sores
Infection
Dermatitis
Joint stiffness

35. 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

36. 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

37. 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

38. 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

39. 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

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

41. 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

42. 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

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

44. 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

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

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

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

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

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

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

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

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

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

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

55. 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

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

57. 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

58. 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

59. 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)

60. 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

61. Cast Removal
Preparatory Phase
Performance Phase