Musculockeletal Assessment, Splinting, and Cast Care

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 • Excessive force • Stretching • Overuse • S/S • Hemorrhage • Swelling • Tenderness • Pain with isometric contraction • Muscle spasm

11. Sprains • Injury of ligamentous structures • “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 • 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. Pain @ site of injury Swelling & tenderness Crepitus Deformity Loss of function Ecchymosis Paresthesia Distal pulse may not be present Signs & Symptoms of fractures

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. Straight across the bone Direct trauma Transverse Fracture

17. At an angle across the bone Oblique Fracture

18. Twisted around the shaft of the bone Spiral Fracture

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

20. 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 Greenstick Fracture

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

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

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

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

25. Open Fracture 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 • 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: • 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