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 wwhhiicchh iiss DDoorrssaallllyy DDiissppllaacceedd
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 1 - 4 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 24 - 36 hours before
seeking medical help)
iv. No associated swelling, ecchymosis, or
neurovascular deficit
Radiography - Normal findings
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 - 5 - 8 minutes to set
– Extra fast-drying - 2 - 4 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 - 12-15 layers, up to 20 if big
person (increased risk of burn!)
20. 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
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
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.
31. Jones Compression Dressing
- aka Bulky Jones
• 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.
• Procedure
– Stockinette and
Webril.
– 1-2 layers of thick
cotton padding.
– 6 inch ace wrap.
32. Posterior Ankle Splint
• Indications
– Distal tibia/fibula fx.
– Reduced dislocations
– Severe sprains
– Tarsal / metatarsal fx
• Use at least 12-15 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!
