Musculockeletal Assessment, Splinting, and Cast Care
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Transcript of Musculockeletal Assessment, Splinting, and Cast Care
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 Excessive force Stretching Overuse
S/S Hemorrhage Swelling Tenderness Pain with isometric contraction Muscle spasm
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
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
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*
*kidsEmergency 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
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
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
o These are used for injuries of arms, elbows and wrists
o Follow the “general rules for splinting” already discussed
o Prepare sling by folding cloth into triangleo Fold injured arm across the chest, position
sling over top of the patient’s chest
Application of a Sling & Swathe
o Extend one point of the triangle behind the elbow on the injured side
o Take bottom point and bring over the patient’s arm. Take it over the top of the injured shoulder
o Draw up the sling so that the patient’s hand is about 4 inches above elbow
Application of a Sling & Swathe
o Tie 2 ends together, make sure the knot does not press against the back of neck
o Make sure fingertips exposedo To make a pocket: twist excess material and
tie a knot in the point
Application of a Sling & Swathe
o Form a swathe from a second piece of material
o Tie it around the chest and injured arm, over the sling.
o Do not place over the patient’s arm of the uninjured side
o Alternateo 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: 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
1. Pressure on n/v and bony structures causing necrosis, pressure sores, nerve palsies
2. Compartment syndrome
3. 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
ASSESS:
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
1. Elevate extremity
2. Avoid resting on hard surface
3. Handle moist cast with palms of hands
4. Turn every 2 hours while cast dries
5. Assess n/ status every hour during the first 24 hours and then as needed
Patient Education
1. Avoid getting cast wet: causes skin breakdown
2. Don’t cover leg cast with plastic or rubber boots: causes condensation and wetting of the cast
3. Avoid weight bearing for 24 hours (plaster)
Patient Education
4. Call healthcare provider if cast cracks/breaks. Instruct try not to fix it
5. Teach how to clean castRemove surface soil with slightly damp cloth
Rub soiled areas with talcum powder
Wipe off residual moisture
Cast Removal
Preparatory Phase
Performance Phase