Case 1
You are on your Medicine Rotation at Hartford Hospital at 1am one cold January night when a 67 year old woman presents after slipping on the ice in her driveway. She fell on her Right hand when it was outstretched onto her bottom. Now she says that her wrist hurts, especially the side by her thumb. She has no other past medical history and no medications.
Her physical Exam shows mild swelling of ther radial side of her right wrist and decreased range of motion at the wrist secondary to pain. Limited pronation and supination. hand rests in a dorsiflexed position.
Radial pulses are normal and sensation over entire right hand and wrist is normal.
Xray of her Right wrist - PA view - distal metaphyseal fracture of the distal radius
Lateral view - No shortening, very mild amount of angulation of radial head. Nondisplaced radial head fracture.
You present to your attending who says that this type of fracture has a special name called a "Colle's Fracture." and that ortho likes to be called in these cases. So you call the orthopedic surgery resident on call who says that the fracture sounds stable and to splint the patient's wrist and have them follow up in clinic in the morning. You aren't sure why you would splint and not cast the injury so you ask your attending a few questions.
What is a splint for?
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- Splinting
- Used after diagnosis and treatment of an orthopedic injury
- also used for immobilization of lacerations, bites, infections, etc.
- Splints
- Stabilize and injury - decrease movement, provide support and comfort to an injury
- Decrease pain
- Prevent reinjury
- Allows room for swelling that a cast does not.
- In trauma situations splinting - decreases blood loss, minimizes risk of futher neurovascular injury and decreases risk of fat emboli
- In the Emergency Department splints are mainly used to stabilize non emergent injuries to bones until the patient can follow up with a specialist.
- Indications for a splint
- Fractures
- Dislocations - loosening of ligaments and tendons
- Lacs, puncture wounds, animal bites, deep space infections.
- Any injury that would benefit from not moving it.
When wouldn't I use a splint?
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- DO NOT SPLINT
- Complicated Fractures
- Open Fractures
- Fractures with neurovascular involvement.
What is a splint made out of?
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- Plaster
- Chemical reaction occurs in the plaster of paris (calcium sulfate)
- initiated by contact with water
- exothermic chemical process - liberates heat
- cold water - process too slow, hot water- reaction too fast, lukewarm water is just right
- Fiberglass
- Lightweight, fast setting and resistant to damage by moisture.
What do I need to get from the supply room before I get started?
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- Splinting Supplies
- Stockinette (if available)
- Padding (fluff)
- Ace bandage or wrap
- Clean lukewarm temperature water in a bowl
- Trauma Shears
- Chux
- Tape
- Plaster
I'm ready to splint, so now what?
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- Splinting Step by Step Instructions
- Clean and dry area to be splinted. Position in the neutral position it is to be splinted.
- Apply stockinette to area to be splinted. Make sure to extend it a few centimeters on either end as you will fold this edge over the hardened splint to smooth edges and prevent patient chafing
- Apply several layers of padding (fluff) to the skin over the area the splint will cover to prevent irritation by the exothermic reaction. Wrap the padding and overlap by 1/2 the width. Make sure it is smooth.
- Measure out a length of plaster. The length of the splint should provide leverage to the injured joint. Try to incorporate the joint above and joint below if possible.
- After amount of plaster measured out make it multiple layers by folding back and fourth
- Adult splint 12 layers thick.
- More layers for children as they are less careful.
- Grab each end and immerse in your lukewarm water. Submerge for about 20-30 seconds until bubbling stops.
- Wring out the plaster keeping a firm grip on each end. Then using a stripping motion remove the excess water from the plaster and mold the edges of the layers until they fuse.
- Place the splint on the area to be immobilized (careful to use palms and not leave fingerprint dents in the splint) and stabilize usihng an ace bandage over the gauze.
- Place the joint in the desired position if it has migrated.
- Check for neurovascular capacity
Step-by-step image
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What kind of splint should I use for this patient?
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- A Sugar Tong Splint
- Prevents motion of the wrist and elbow- including pronation/supination
- Location - extensor aspect of hand at the metacarpal heads
- Runs along extensor aspect of forearm, bens around elbow and ends at the metacarpal heads of the palmar surface of hand
- Position elbow at 90 degrees with neutral position of wrist
- Wrist dorsiflexed at 10 degrees
- Uses
- Distal ulna fractures
- Distal radius fractures - Colle's or Smith fractures
- (Colle's Fracture - fall on an outstreetched hand and distal radius displaced dorsally.
Picture
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