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(BQ) Part 1 book Emergency medicine procedure presents the following contents: Introductory chapters, respiratory procedures, cardiothoracic procedures, vascular procedures, gastrointestinal procedures, orthopedic and musculoskeletal procedures.
Emergency Medicine Procedures NOTICE Medicine is an ever-changing science As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication However, in view of the possibility of human error or changes in medical sciences, neither the editors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work Readers are encouraged to confirm the information contained herein with other sources For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration This recommendation is of particular importance in connection with new or infrequently used drugs Emergency Medicine Procedures Second Edition Eric F Reichman, PhD, MD, FAAEM, FACEP Associate Professor of Emergency Medicine Attending Physician, Department of Emergency Medicine Medical Director, Surgical and Clinical Skills Center University of Texas Health Science Center at Houston-Medical School Attending Physician, Emergency Department Memorial Hermann Hospital-Texas Medical Center Attending Physician, Emergency Department Lyndon Baines Johnson General Hospital Houston, Texas New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto Copyright © 2013 by Eric F Reichman, PhD, MD All rights reserved Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the editor ISBN: 978-0-07-161351-4 MHID: 0-07-161351-X The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-161350-7, MHID: 0-07-161350-1 All trademarks are trademarks of their respective owners Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark Where such designations appear in this book, they have been printed with initial caps McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs To contact a representative please e-mail us at bulksales@mcgraw-hill.com TERMS OF USE This is a copyrighted work and McGraw-Hill Education, LLC and its licensors reserve all rights in and to the work Use of this work is subject to these terms Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill Education’s prior consent You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited Your right to use the work may be terminated if you fail to comply with these terms THE WORK IS PROVIDED “AS IS.” McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE McGraw-Hill Education and its licensors not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free Neither McGraw-Hill Education nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom McGraw-Hill Education has no responsibility for the content of any information accessed through the work Under no circumstances shall McGraw-Hill Education and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise To my wife, Kristi Thanks for your patience with the semi-permanent card table and computer in the living room, and the mess with all the papers and files Thanks for your support and understanding Thanks to Joey, Jake, Rocky, and Phoebe for entertaining me each day This page intentionally left blank Contents Contributors xiii Preface xxiii 18 Supraglottic Airway Devices 106 Fred A Severyn Acknowledgments xxiv 19 Laryngeal Mask Airways 110 Katrin Takenaka and Theltonia Howard SECTION Introductory Chapters 20 Double Lumen Airway Tube Intubation 122 Joseph Weber Informed Consent for Procedures in the Emergency Department Eric Isaacs 21 Fiberoptic Endoscopic Intubation 127 Erika D Schroeder, M Scott Linscott, and Joseph Bledsoe Aseptic Technique John S Rose 22 Nasotracheal Intubation 134 Ned F Nasr, Raed Rahman, and Isam F Nasr Basic Principles of Ultrasonography 13 Gregory M Press 23 Retrograde Guidewire Intubation 139 Roland Petri Ultrasound-Assisted Procedures 24 Jehangir Meer, Sam Hsu, and Brian Euerle 24 Percutaneous Transtracheal Jet Ventilation 143 Eric F Reichman and Aaron Brown Trauma Ultrasound: The FAST Exam 28 Wes Zeger 25 Cricothyroidotomy 148 Eric F Reichman SECTION Respiratory Procedures 35 26 Tracheostomy 161 Teresa M Romano and Christopher J Haines Essential Anatomy of the Airway 35 Ned F Nasr, Serge G Tyler, Gennadiy Voronov, and Isam F Nasr Basic Airway Management 40 Christopher J Russo and Zach Kassutto Pharmacologic Adjuncts to Intubation 47 Ned F Nasr, David W Boldt, and Isam F Nasr Endotracheal Medication Administration 56 Shoma Desai 10 Rapid Sequence Induction 60 Piotr C Aljindi, Ned F Nasr, and Isam F Nasr 11 Orotracheal Intubation 64 Eric F Reichman and Joseph Cornett 12 Confirmation of Endotracheal Intubation 76 Tarlan Hedayati and Leonardo Rodriguez 13 Video-Assisted Orotracheal Intubation Devices 80 Pholaphat Charles Inboriboon 14 Fiberoptic-Assisted Orotracheal Intubation Devices 89 Michael Lutes and Olga Pawelek 27 Tracheostomy Care 171 H Gene Hern Jr 28 Transtracheal Aspiration 177 Joseph A Salomone III SECTION Cardiothoracic Procedures 181 29 Cardiac Ultrasound 181 Gregory M Press and Amy Rasmussen 30 Cardioversion and Defibrillation 193 Payman Sattar 31 Transcutaneous Cardiac Pacing 197 Todd M Larabee 32 Transthoracic Cardiac Pacing 202 Simon M Pulfrey 33 Transvenous Cardiac Pacing 205 Eric F Reichman, Myles C McClelland, and Brian Euerle 34 Pacemaker Assessment 212 Nnaemeka G Okafor 15 Endotracheal Tube Intubating Introducers and Bougies 95 Olga Pawelek and Eric F Reichman 35 Automatic Implantable Cardioverter-Defibrillator Assessment 218 Carlos J Roldan 16 Digital (Tactile) Orotracheal Intubation 100 O John Ma and Amanda Munk 36 Pericardiocentesis 225 Eric F Reichman, Elisabeth Kang, and Jehangir Meer 17 Lighted Stylet Intubation 102 Philip Bossart and Michael Wallace 37 Intracardiac Injection 236 Payman Sattar vii viii Contents 38 Needle Thoracostomy 238 Eric F Reichman and Elizabeth Sowell 61 Whole Bowel Irrigation 398 Steven E Aks and David D Gummin 39 Tube Thoracostomy 242 Kimberly T Joseph 62 Esophageal Foreign Body Removal 401 Bashar M Attar 40 Thoracentesis 250 Eric F Reichman, Cristal R Cristia, and Jehangir Meer 63 Balloon Tamponade of Gastrointestinal Bleeding 407 Bashar M Attar 41 Open Chest Wound Management 263 Eric F Reichman 64 Gastrostomy Tube Replacement 414 Maggie Ferng and Ryan C Headley 42 Emergency Department Thoracotomy 267 Kenny Banh 65 Paracentesis 421 Susan B Promes, Elizabeth M Datner, and Sam Hsu 43 Open Cardiac Massage 271 Eric F Reichman 66 Diagnostic Peritoneal Lavage 431 Sandeep Johar and Umashankar Lakshmanadoss 44 Cardiac Wound Repair 274 Eric F Reichman 67 Anal Fissure Management 439 Marilyn M Hallock and Eric F Reichman 45 Hilum and Great Vessel Wound Management 280 Eric F Reichman 68 External Hemorrhoid Management 443 Charles Orsay and Eric F Reichman 46 Thoracic Aortic Occlusion 282 Eric F Reichman 69 Prolapsed Rectum Reduction 446 Jamil D Bayram and Eric F Reichman SECTION Vascular Procedures 287 70 Anoscopy 449 Charles Orsay and Eric F Reichman 47 General Principles of Intravenous Access 287 Daniel Belmont 71 Rigid Rectosigmoidoscopy 453 Charles Orsay and Eric F Reichman 48 Venipuncture and Peripheral Intravenous Access 296 Daniel Belmont 72 Rectal Foreign Body Extraction 458 Charles Orsay and Eric F Reichman 49 Central Venous Access 308 Arun Nagdev and Craig Sisson 50 Ultrasound-Guided Vascular Access 327 Srikar Adhikari 51 Troubleshooting Indwelling Central Venous Lines 337 James J McCarthy 52 Accessing Indwelling Central Venous Lines 340 Lisa Freeman Grossheim 53 Pulmonary Artery (Swan-Ganz) Catheterization 344 Pratik Doshi 54 Peripheral Venous Cutdown 350 Flavia Nobay 55 Intraosseous Infusion 361 Amanda Munk and O John Ma 56 Umbilical Vessel Catheterization 369 Eric F Reichman, Amy Noland, and Antonio E Muñiz 57 Arterial Puncture and Cannulation 376 Zak Foy and Susan Stroud SECTION Gastrointestinal Procedures 387 58 Nasogastric Intubation 387 Lisa Freeman Grossheim 59 Activated Charcoal Administration 391 Jenny J Lu 60 Gastric Lavage 393 Jenny J Lu SECTION Orthopedic and Musculoskeletal Procedures 465 73 Bursitis and Tendonitis Therapy 465 Dedra Tolson 74 Compartment Pressure Measurement 473 Matt Kleinmaier and Sanjeev Malik 75 Fasciotomy 480 Justin Mazzillo, Sobia Ansari, and Eric F Reichman 76 Extensor Tendon Repair 490 Jaime Harper, Stanley Harper, and Ramasamy Kalimuthu 77 Arthrocentesis 495 Eric F Reichman, John Larkin, and Brian Euerle 78 Methylene Blue Joint Injection 517 Joseph E Tonna, Heather H Bohn, and Matthew R Lewin 79 Basic Principles of Fracture and Joint Reductions 522 Scott C Sherman 80 Sternoclavicular Joint Dislocation Reduction 526 Eric F Reichman 81 Shoulder Joint Dislocation Reduction 531 Eric F Reichman 82 Elbow Joint Dislocation Reduction 549 Angelique S Kelly Campen 83 Radial Head Subluxation (“Nursemaid’s Elbow”) Reduction 553 Mark P Kling and Eric F Reichman Contents ix 84 Metacarpophalangeal Joint Dislocation Reduction 557 Michael Bublewicz and Antonio E Muñiz 107 Paronychia or Eponychia Incision and Drainage 713 Lisa R Palivos 85 Interphalangeal Joint Dislocation Reduction 561 Matt Kleinmaier and Sanjeev Malik 108 Felon Incision and Drainage 716 Lisa R Palivos 86 Hip Joint Dislocation Reduction 565 George Chiampas and Steve Zahn 109 Pilonidal Abscess or Cyst Incision and Drainage 718 Lauren M Smith 87 Patellar Dislocation Reduction 571 Mark P Kling 110 Perianal Abscess Incision and Drainage 722 Maggie Ferng and Ryan C Headley 88 Knee Joint Dislocation Reduction 574 Sharad Pandit and Zach Kassutto 111 Sebaceous Cyst Incision and Drainage 728 Carlos J Roldan 89 Ankle Joint Dislocation Reduction 577 Jim Comes 112 Hemorrhage Control 731 Christopher Freeman and Eric F Reichman 90 Common Fracture Reduction 582 Eric F Reichman and Robert M Zesut 113 Trigger Point Injections 738 Danielle Campagne 91 Casts and Splints 592 Eric F Reichman and Harold A Sloas 114 Escharotomy 741 Michael A Schindlbeck SECTION Skin and Soft Tissue Procedures 609 SECTION Neurologic and Neurosurgical Procedures 747 92 General Principles of Wound Management 609 Lisa Freeman Grossheim 93 Basic Wound Closure Techniques 623 Eric F Reichman and Candace Powell 94 Tissue Adhesives for Wound Repair 647 Hagop M Afarian 95 Advanced Wound Closure Techniques 650 Eric F Reichman 96 Management of Specific Soft Tissue Injuries 659 Christopher J Russo and Ajay Desai 115 Lumbar Puncture 747 Eric F Reichman, Kevin Polglaze, and Brian Euerle 116 Burr Holes 761 Eric F Reichman 117 Lateral Cervical Puncture 767 Eric F Reichman 118 Ventriculostomy 770 Eric F Reichman 119 Ventricular Shunt Evaluation and Aspiration 775 Eric F Reichman 97 Subcutaneous Foreign Body Identification and Removal 669 Samuel J Gutman and Michael B Secter 120 Subdural Hematoma Aspiration in the Infant 779 Eric F Reichman 98 Ultrasound-Guided Foreign Body Identification and Removal 676 Daniel S Morrison 121 Skeletal Traction (Gardner-Wells Tongs) for Cervical Spine Dislocations and Fractures 783 Eric F Reichman 99 Tick Removal 679 Zach Kassutto 122 Edrophonium (Tensilon) Testing 786 Eric F Reichman 100 Fishhook Removal 681 Eric F Reichman and Renee C Hamilton SECTION Anesthesia and Analgesia 789 101 Ring Removal 684 Steven H Bowman 123 Local Anesthesia 789 Michael A Schindlbeck 102 Subungual Hematoma Evacuation 690 Steven H Bowman 124 Topical Anesthesia 795 Erika D Schroeder and Peter Taillac 103 Subungual Foreign Body Removal 694 Steven H Bowman 125 Hematoma Blocks 799 Thomas P Graham 104 Nail Bed Repair 697 Raemma Paredes Luck and Eric F Reichman 126 Regional Nerve Blocks (Regional Anesthesia) 802 Eric F Reichman, Jehangir Meer, and Nikesh Seth 105 Ganglion Cyst Aspiration and Injection 704 Thomas P Graham 127 Intravenous Regional Anesthesia 843 Christopher Freeman 106 Subcutaneous Abscess Incision and Drainage 706 Samuel J Gutman and Michael B Secter 128 Nitrous Oxide Anesthesia 849 Antonio E Muñiz 594 SECTION 6: Orthopedic and Musculoskeletal Procedures GENERAL SPLINTING CONSIDERATIONS The general considerations and techniques common to the application of all splints are discussed in this section.14,15 It describes the techniques for splints utilizing cotton cast padding, plaster, and bias stockinette Many alternative materials are available and may be substituted, such as fiberglass for plaster or elastic wraps for stockinette Prefabricated splint materials that incorporate padding may also be used The techniques described in these chapters are applicable for all splinting materials Where alterations in technique are required, they are so noted Splints are constructed of cotton padding overlaid by splinting material (i.e., strips of plaster or fiberglass) and subsequently held in position by an overwrap of bias stockinette or an elastic bandage Splint padding should be thick enough to provide protection for the skin from the plaster The splint or cast will be unable to provide sufficient immobilization of the fracture to maintain a reduction if the padding is too thick One to two layers of cotton cast padding are sufficient over the fracture site Three to four layers of cotton cast padding are required at the proximal and distal extents of the splint to distribute the stresses Thinner padding can be used when maintenance of fracture reduction is a priority (e.g., with a fracture of the distal radius) Plaster strips are available in precut slabs measuring either by 15 or by 30 in The precut strips have the advantage of speed and ease of application Alternatively, plaster and fiberglass are available in rolls of various widths ranging from to in The rolls of splinting material may be rolled out to the precise length desired and cut appropriately The rolls of splinting material are useful for splints requiring long strips, such as coaptation splints The ideal thickness for most upper extremity splints is 10 sheets or layers of plaster or five to six layers of fiberglass The use of 15 sheets or layers of plaster or to 10 sheets of fiberglass is preferable for lower extremity splints The strength of the splint depends on the number of layers as well as the lamination of the layers during their application A piece of cotton cast padding may be used as a template for the length of the required splinting material Roll a piece of cotton cast padding over the desired location of the splint to determine the length of the splinting material required (Figure 91-2A) Roll out the splinting material to the appropriate lengths and cut them slightly shorter than the template An alternative is to cut the splinting material approximately to in longer than necessary so that the ends may be folded back on themselves This will prevent any contact of the sharp splint ends with the patient’s skin Prefabricated splinting material covered with padding has jagged ends and once it has been cut it begins to harden immediately; even prior to the addition of water These sharp ends will rub against the patients exposed skin, even through cotton cast padding or bias, and for that reason should be folded back To avoid premature hardening of the prefabricated splinting material, keep it inside of the protective foil and seal it with tape or the manufacturer provided clips Bias stockinette may be applied to the extremity for extra padding and comfort This may also be omitted depending on EP preference Prepare strips of cotton cast padding The strips of cotton cast padding should always be longer and wider than the plaster This prevents the plaster from touching the skin and causing a pressure sore, abrasion, or burn Padding is especially important at the proximal and distal edges, as this is where significant pressure originates Apply additional pieces of padding over pressure points and bony prominences (e.g., the olecranon) Additional padding may also be created by folding a loose piece of cotton cast padding back on itself several times and placing it over the individual prominences Alternatively, cotton cast padding may be applied directly by wrapping the pressure point or bony prominence circumferentially as is done in cast application Begin applying the splint once the padding and splinting material have been cut to the appropriate lengths Be sure that all required materials have been collected before dipping the splinting material in water to activate it Only a limited amount of time, less than 10 minutes, is available for splint application and molding once the splinting material is wet Completely immerse all of the splinting material in a bucket of tepid, clean tap water Keep the splinting material submersed until no more bubbles arise from under the water (Figures 91-2B & C) At this point, the splinting material can absorb no more water Suspend the splinting material over the bucket and lightly squeeze out the excess water by running your fingers down its length (Figure 91-2D) It should only take two or three passes of the fingers to remove the excess water Do not wring the plaster strips like a dish rag, as that will cause loss of plaster into the bucket! Lay the splinting material on a clean flat surface Run your hands over the splinting material to laminate the individual strips into one slab Laminating the strips together adds significant strength Lay the splinting material onto the cotton cast padding (Figure 91-2E) Fold the edges of the cotton cast padding over the splinting material to cover all the edges completely Apply the splint to the extremity An alternative and more commonly used method that is preferred by many is to apply the cotton cast padding circumferentially over the extremity, overlapping each layer by 50%, and then applying the wet splinting material In this fashion, the splinting material will “stick” to the cotton cast padding Smooth the splinting material with the broad aspect of your hand and not your fingers to help minimize irregular indentations The cotton cast padding should be facing the patient and no splinting material should directly contact the skin regardless of the method used Secure the splint with a wrap of bias stockinette or an elastic bandage The wrap must be applied under minimal tension when you are using an elastic wrap to affix the splint The elastic may cause increasing pressure over time Gently apply strips of tape to the end of the wrap to secure the bias stockinette or the elastic bandage Tape should never be applied circumferentially, as this can impede expansion of the splint due to underlying swelling and create a tourniquet effect Application of the tape under tension before the splint is completely hard will cause indentations in the splinting material and result in pressure points on the underlying skin The splinting material may be molded at this point to achieve greater conformity to the extremity or better reduction of the fracture It is paramount to use only the palms and not the fingertips when molding the finished splint Finger pressure induces deformity in the splint that will result in skin breakdown under those defects All molding must stop once the splinting material begins to harden The plaster is quite fragile, and cracks that weaken the splint may be propagated Apply in wide tape in a spiral fashion to secure the bias or elastic wrap after the plaster has hardened If using prefabricated splinting materials, cut it to length, remove it from the sealed foil, and wet it to activate the splinting materials Briefly pass the prefabricated splinting material under cool water Place the wet prefabricated splinting material on a towel and roll it up This will remove any excess water The splinting material should not be soaked or placed in a bucket of water It requires only one pass under the running water The prefabricated splinting material should not be squeezed dry as CHAPTER 91: Casts and Splints 595 B A C D E FIGURE 91-2 Preparing the splint A Cotton cast padding to measure the length of material needed B Plaster is submersed in tepid water and air bubbles arising from it C Fiberglass is submerged in tepid water and air bubbles arising from it D Suspend the lengths of wet splinting material over the bucket and gently squeeze out the excess water E The splinting material is placed on the cotton cast padding 596 SECTION 6: Orthopedic and Musculoskeletal Procedures this tends to deform the splinting material and result in a poorly molded final product Apply the splint and mold it to the extremity It is paramount to use only the palms and not the fingertips when molding the finished splint Finger pressure induces deformity in the splint that will result in skin breakdown under those defects Any excess length of splinting material should be folded back on itself so that the cut ends not come in contact with the patient’s skin The distal part of any extremity should always be left visible so that the EP may recheck a neurovascular exam The patient will also be able to visualize any changes in color that may occur latter It is held in place by circumferentially wrapping the splinting material with an elastic bandage The elastic bandage should be applied relatively loosely so it will not induce increased compartment pressures A GENERAL CASTING CONSIDERATIONS The general considerations and techniques common to the application of all casts are discussed in this section.3,5,6,10 Casting requires careful circumferential turns of material instead of longitudinal layers of material, as for splints Casts are constructed of cotton cast padding overlaid with either fiberglass or plaster bandages (i.e., casting materials) The four areas that require particular attention and are discussed in this section are the application of padding, padding pressure points, application of casting material, and molding the cast Begin by organizing the required supplies Cast application requires the same material as that used in splinting (i.e., water, cotton cast padding, stockinette, and casting material) The width of the padding and casting material depends on the size of the B D C FIGURE 91-3 Preparing to place a cast A Apply an initial layer of tubular stockinette B The stockinette has been unrolled over the extremity C Begin and end the layering of the cotton cast padding at a site distal and proximal to where the casting material will end Unroll the cotton cast padding in a circumferential manner, covering each preceding layer by one-third to one-half of its width D The cotton cast padding tears easily to provide additional layers of padding over bony prominences CHAPTER 91: Casts and Splints extremity Generally, the to in wide rolls of casting material are used for lower extremity casts while or in wide rolls are used for the upper extremity Use the widest casting material available and possible in order to limit the number of turns of the fiberglass or plaster roll over joints and other curved surfaces Place all materials on a tray near the bedside, including a bucket of tepid water An assistant designated to dip and drain the casting material and help with patient positioning is immensely helpful Prepare the patient Position the extremity and the patient appropriately for cast placement The patient is frequently able to assist in the process Cover the patient with gowns or towels to keep casting material off their clothes Apply tubular stockinette to the extremity (Figures 91-3A & B) The stockinette is not a necessary component of casting, but many EP use it as a first layer.5 It provides a smooth covering over the skin that wraps neatly over both ends of the cast Roll up the stockinette Place it over the distal extremity as if you were putting on a sock (Figure 91-3A) Unroll the stockinette up the leg (Figure 91-3B) Care must be taken to apply the stockinette gently Do not create tension in the stockinette by pulling it tightly Eliminate any creases or redundancy of material by trimming any overlapping folds with a scissors For upper extremity injuries, cut a small hole one-third of the way from the end of one side of the stockinette to allow the thumb to pass through The primary layer of padding is provided by the cotton cast padding Casts and cast padding should be applied from distal to proximal Begin wrapping the cotton cast padding at a point that will be distal to the start of the plaster (Figure 91-3C) This initial band of padding is essential for protection against the cast edge Keep the roll of padding in contact with the skin so that the material conforms easily to the contours of the extremity as it unrolls Unroll the padding in a circumferential manner around the extremity The cotton cast padding must be laid down neatly and cleanly with no kinks or creases Each turn should overlap one-third to one-half of the previous turn Tear off the extra cotton cast padding to eliminate excess material as you turn angles (e.g., ankle, heel, elbow, or thumb) Lay the torn edges down by rubbing the padding smoothly Continue applying the padding, ensuring that it extends beyond the proximal end of where the cast edge will be to ensure skin protection at the cast edge Excess length can easily be torn away after the cast is applied and hardened Typically, two layers of cotton cast padding are adequate for protection between the skin and the casting material Pressure points occur over bony prominences or where excess padding has created an unnatural prominence Palpate the obvious bony prominences to get a sense of whether or not there is adequate padding after the application of the two layers of padding If the area feels vulnerable, place torn off pieces of cotton cast padding onto the exposed areas (Figure 91-3D) Do not over-pad bony prominences, as excess layering can also lead to excess pressure Two to three layers of padding are adequate for most pressure points and bony prominences Rub the torn edges of the padding so that they fuse smoothly to the underlying padding Place the rolls of casting material in a bucket of tepid water so that they are standing on end Let the casting material remain submersed as long as air bubbles rise out from the center of the roll (Figures 91-2B & C) Remove the rolls of casting material when all bubbles stop rising Hold the casting material in both hands and squeeze some of the water out (Figure 91-4) Do not wring the roll Do not eliminate all the water from the roll Squeeze it gently The remaining water in the roll is necessary for smoothing and molding the casting material into one solid unit In general, casts should be applied with “wetter” material and splints with “drier” material as less time is required to apply a splint 597 FIGURE 91-4 Hold the casting material roll in both hands and gently twist each end to squeeze out the excess water Keeping the free end of the casting material folded over will facilitate access after it has been removed from the water Apply the casting material (Figure 91-5) Place the roll of casting material on the extremity (Figure 91-5A) Unroll the casting material in a circumferential fashion around the extremity Never lift the roll of casting material off the extremity! Continue each consecutive wrap around the extremity by overlapping the casting material by approximately 50% The free border of the casting material will have excess material in it as the extremity changes in size Grasp this excess casting material with the thumb and index finger of the nondominant hand (Figure 91-5B) Pull it outward to create a tuck or a fold Wrap this fold around the extremity (Figure 91-5C) and smooth the fold down against the extremity This fold will barely be noticeable in the final product As one roll of casting material ends, another should begin with a small amount of end-to-end overlap Do not make consecutive folds at the same site as this will create bumps and add bulk to the cast Continuously mold and smooth the casting material with wet hands as each layer is applied This action ensures continuity of casting material throughout the cast and forms a smooth cast that conforms to the contours of the extremity Use only the palmar surface of the hands and proximal digits to mold and smooth the casting material (Figure 91-5D) Excessive use of the fingertips will produce irregular indentations and pressure points Molding around irregular bony areas is best accomplished with two hands simultaneously rubbing the casting material Do not allow excessive time to pass between applying each layer of the casting material, as lamination between layers may not occur This will weaken the cast considerably A cast thickness of 1/4 in is felt to be adequate This usually requires four to five layers of plaster or three to four layers of fiberglass Allow the cast to set and dry with no further manipulations by the EP or the patient The time for drying is variable depending upon the casting material used, the water temperature, and the thickness of the cast Typically, let the casting material set over a period of 10 to 15 minutes Fold the free ends of the cotton cast padding and the stockinette over the edges of the cast as it sets (Figure 91-6) This prevents the rough edges of the casting material from irritating and abrading the skin Secure the edges of the cotton cast padding neatly with tape or thin strips of casting material It is a common practice to bivalve the cast with a cast saw if the potential for increased swelling of the extremity is a concern (Figure 91-7) Cut completely through the length of the cast in two 598 SECTION 6: Orthopedic and Musculoskeletal Procedures A B C D FIGURE 91-5 Apply the casting material to form the cast A Lay the roll of casting material on the extremity and unroll it B As the limb changes in girth, there will be excess plaster Use the nondominant hand to pull on the excess material C Fold the excess material back onto the extremity in a neat tuck Each tuck should be laid down smoothly with a molding of the hand D The casting material is laminated smooth with a continuous motion of the palmar surface of the hand and the proximal fingers FIGURE 91-6 Fold the free ends of the cotton cast padding and the stockinette over the edges of the casting material to finish the cast FIGURE 91-7 Splitting of the cast can be achieved with a cast saw that cuts through the thickness of the fiberglass or plaster Cut the underlying protective material with a scissors CHAPTER 91: Casts and Splints 599 spots 180° apart (i.e., medial and lateral or anterior and posterior) This simple maneuver provides some room for edema without compromising the integrity of the reduction or the strength of the cast The underlying cast padding must also be split Splitting the plaster alone will not reduce the pressure sufficiently UPPER EXTREMITY CASTS AND SPLINTS COAPTATION SPLINT A coaptation (“to bring together”) splint is used primarily in the acute setting for humeral shaft fractures that are nondisplaced or minimally displaced This splinting technique allows for motion of the hand and wrist while limiting shoulder and elbow mobility The cotton cast padding should extend from the nape of the neck to the axilla to avoid skin breakdown The patient should then be placed in a sitting position to minimize splint displacement during the actual application process The length of the splint extends from the axilla, around the 90° flexed elbow, along the outer arm, over the deltoid muscle, and over the acromion process (Figure 91-8) It is critical that the splinting material extend over the deltoid muscle and the acromion process The shoulder portion can be held down by applying in wide tape over the portion of the splint that covers the acromion Secure the splint with an elastic bandage that covers the entire splint The major pitfall is making the splint FIGURE 91-9 The sugar tong splint Leave the metacarpal joints free for flexion and extension The overwrap has been omitted for easier visualization of the splint too short and having it fall off! A splint that is too long will not provide proper immobilization Always leave plenty of length over the shoulder Padding is required to minimize axillary irritation The disadvantages of this splint include the possibility of fracture displacement and extremity shortening The splint should be replaced with a functional brace or cast after a short period of immobilization for pain control.4 SUGAR TONG SPLINT Sugar tong splints may be used for mid-forearm fractures, distal forearm fractures, and some wrist fractures They are most commonly recommended for minimally displaced and distal ulnar and radial fractures (i.e., Colles and Smiths fractures) This splint immobilizes the elbow and wrist joints to prevent supination and pronation of the forearm (Figure 91-9) The splint begins at the palm, just proximal to the metacarpophalangeal (MCP) joints It has the distinct advantage of allowing the MCPs to remain free preventing stiffness in those joints Measure the required length of splinting material along the volar surface of the hand (starting just proximal to the MCP joints) and forearm, around the elbow, and back on the dorsal surface of the forearm ending just proximal to the MCP joints The MCP joints should be left completely free to prevent stiffness Early mobilization of the fingers will help to reduce swelling Apply cotton cast padding from the MCP joints to just proximal to the elbow The ulnar styloid process and the olecranon process are two bony prominences that need extra padding for comfort and prevention of pressure sores The free ends of the splint also need added protection to minimize hand discomfort Apply the splint Mold the splinting material with great caution to prevent closure of the sides of the splint, thus forming a closed cast Fold and/or cut the volar and dorsal splinting material to ensure that the finger MCP joints are freely mobile (Figure 91-9) POSTERIOR LONG ARM SPLINT FIGURE 91-8 The coaptation splint The overwrap has been omitted for easier visualization of the splint Distal humeral fractures and proximal forearm fractures can be immobilized in a posterior long arm splint (Figure 91-10) It is also useful for fractures of the radial head and neck, olecranon fractures, and severe ligamentous injuries to the elbow The posterior long arm splint extends from the axillary crease area, behind the elbow, distally to incorporate the wrist joint, and ending at the MCP shafts (Figure 91-10) This splint immobilizes the elbow in a range of 45° to 90° with the forearm in supination, pronation, or neutral 600 SECTION 6: Orthopedic and Musculoskeletal Procedures FIGURE 91-10 The posterior long arm splint The forearm and wrist are in a neutral position The padding and overwrap have been omitted for easier visualization of the splint positioning depending upon the type of injury The wrist can also be in a flexed, extended, or neutral position The metacarpals should not be immobilized in this splint unless the distal forearm or wrist fracture is comminuted Despite the many possibilities, the posterior long arm splint is usually applied with the elbow flexed 90°, the forearm neutral, and the wrist neutral (Figure 91-10) RADIAL GUTTER SPLINT The radial gutter splint is used for the treatment of stable phalangeal and metacarpal fractures of the index or middle fingers The splinting material extends from the pulp of the distal fingers to the proximal forearm (Figure 91-11) It is helpful to measure and cut a hole in the middle of the splinting material to allow for the insertion of the thumb prior to wetting the splinting material Place cotton cast padding between the index and middle fingers prior to applying the splint to prevent skin maceration Mold the width of the splinting material around the radial aspect of the index finger, middle finger, hand, and forearm to create a stabilizing force The ulnar aspect of the hand and forearm is left entirely free The hand is immobilized in what is considered a “safe” position with the wrist dorsiflexed 20°, the MCP joints flexed 60° to 90°, and the interphalangeal (IP) joints extended or slightly flexed at 10°9 (Figure 91-11) This is also known as the “position of comfort.” It can be described as if the patient were A FIGURE 91-11 The radial gutter splint with the hand in the “safe” position.9 holding a can of soda The fingertips should be visible to allow for repeat neurovascular examinations ULNAR GUTTER SPLINT This splint is used for the treatment of stable metacarpal and phalangeal fractures of the ring and small fingers (Figure 91-12) The long axis of the plaster extends from the pulp of the distal fingers to the proximal forearm Place cotton cast padding between the ring and little fingers to prevent any maceration (Figure 91-12A) The width of the plaster must wrap around the ulnar aspect of the hand and forearm Mold the splint around the forearm, hand, fourth finger, and fifth finger The radial side of the hand is left entirely free The hand is immobilized in the “safe” position with the wrist dorsiflexed 20°, the MCP joints flexed 60° to 70°, and the IP joints extended or slightly flexed at 10°9 (Figure 91-12B) The fingertips should remain visible to allow for repeat neurovascular examinations VOLAR SPLINT The volar splint can be used for the treatment of wrist fractures, radial styloid fractures, ulnar styloid fractures, metacarpal fractures, middle phalangeal fractures, and proximal phalangeal fractures This splint remains only on the volar surface of the hand and forearm, as the name suggests The splint begins at the proximal forearm and ends just proximal to the MCP joints (Figure 91-13) The splint can be modified and extended to include the fingers B FIGURE 91-12 The ulnar gutter splint A Padding is necessary between any fingers that are immobilized together B The final product with the hand in the “safe” position.9 CHAPTER 91: Casts and Splints 601 for phalangeal fractures with the wrist dorsiflexed 20°, the MCP joints flexed 60° to 90°, and the IP joints extended or slightly flexed at 10° DORSAL (“CLAM DIGGER”) SPLINT The dorsal splint can be used in place of a volar splint for injuries of the distal forearm, wrist, or hand The splint runs along the dorsal surface of the forearm and hand, from the proximal forearm to the ends of the digits As with the volar splint, the wrist is extended 15° to 20°, the MCP joints are flexed 60° to 90°, and the IP joints are extended or slightly flexed to a maximum of 10° The dorsal splint maintains better control of the MCP and IP joints, assuring that the hand remains in the “safe position,” when compared to the volar splint Pad the splint adequately to prevent pressure sores, since the dorsal surface of the hand lacks the intrinsic fat pads of the palm THUMB SPICA SPLINT FIGURE 91-13 The volar splint The overwrap has been omitted for easier visualization of the splint A C Scaphoid fractures, navicular fractures, carpometacarpal subluxations and dislocations of the thumb, and collateral ligament injuries of the thumb can all be immobilized in a thumb spica splint (Figure 91-14) This splint extends to the proximal forearm It can be extended proximally to include the elbow joint if required It is positioned on the forearm, like a radial gutter splint, but only the thumb is immobilized There are several methods to forming a thumb spica splint One can simply lay the plaster over the radial aspect of the forearm and thumb It is useful to cut one side of the splint into a shape that conforms to the thumb to facilitate the placement of the splint material around the thumb (Figure 91-14A) Cutting a wedge out of one side of the plaster will allow for easier splinting of the thumb without excess material B FIGURE 91-14 The thumb spica splint A One technique of thumb spica application with the splinting material cut to conform to the thumb B Cutting the splinting material facilitates this different technique of thumb spica application C The final product with the wrist dorsiflexed 20° and the thumb positioned as if a glass were being held in the hand 602 SECTION 6: Orthopedic and Musculoskeletal Procedures collecting in the first web space (Figure 91-14B) Position the thumb as if a glass were being held in the hand with the wrist in 20° of dorsiflexion (Figure 91-14C) FINGER SPLINTS Immobilization of the finger lends itself to great creativity in the field of splinting Finger splints may be adequate for immobilization of stable finger fractures, reduced dislocated joints, or ligamentous strains Splint the finger in full extension if it involves an extraarticular fracture of the distal phalanx Splint the finger in slight flexion if it involves the strain of a joint or ligament The finger can be splinted in isolation, or it can be immobilized with the adjacent finger for additional stability Applying a single-digit or two-digit splint allows neighboring joints to remain mobile Splinting material is rarely used for finger splints in the modern Emergency Department setting The creation of foam-padded metal or plastic splints has facilitated immobilization of the affected digit Nonetheless, small strips of cut splinting material can still be used to stabilize any finger injuries The juxtaposition of the affected finger with its neighboring finger requires padding between the digits to prevent skin maceration and breakdown A B C D E F FIGURE 91-15 The short arm cast A Flex the elbow 90° The patient can help position the wrist and fingers in a position of function B Tubular stockinette is applied to the entire arm in anticipation of a long arm cast C Cotton cast padding is applied to the forearm Adequate padding is also needed at the thumb, as it will remain exposed and mobile D Cut one side of the casting material as it is wrapped around the thumb Less bunching of excess material occurs with quick cuts of the casting material E An additional length of casting material (four to five layers) can be applied along the ulnar length of the cast This serves as reinforcement if additional strength is necessary F Mold the cast with the palmar aspect of the hands CHAPTER 91: Casts and Splints G H SHORT ARM CAST The short arm cast is used for stable fractures of the metacarpals, the carpal bones, the distal radius, and the radial or ulnar styloid processes (Figure 91-15) The short arm cast begins at the proximal forearm and extends to include the palm and the dorsum of the hand The metacarpophalangeal and elbow joints are left exposed to allow for full motion at these joints Flex the patient’s elbow 90° (Figure 91-15A) Place the wrist in the desired position The extent of flexion and ulnar-radial deviation of the wrist is determined by the underlying injury The forearm can be in a neutral, pronated, or supinated position Apply bias stockinette (Figure 91-15B) Apply cotton cast padding (Figure 91-15C) Ensure that extra padding is applied to the bony prominences of the base of the thumb and the ulnar styloid Apply the casting material Roll the casting material over the padding from the hand to the forearm A quick trim of the casting material will allow for a better fit as it passes around the thumb (Figure 91-15D) Provide adequate space for the thumb so that its motion is not limited The application of additional layers to the anteromedial surface will strengthen the cast (Figure 91-15E) Mold the cast with an anterior–posterior force applied to the forearm and not up and down strokes (Figure 91-15F) Use smooth, rapid, and repetitive motions to mold and laminate the casting material Trim the casting material while it is still wet to even out the thumb opening and the cast ends (Figure 91-15G) Ensure that all protective padding is pulled out from under the casting material to protect the skin from the sharp edges (Figure 91-15G) The patient should be able to touch the tips of the thumb and index fingers when the cast is properly applied (Figure 91-15H) 603 FIGURE 91-15 (continued) G The wet casting material and underlying padding are cut and folded back to fully expose the thumb H The “okay” sign of a properly exposed thumb LOWER EXTREMITY SPLINTS AND CASTS ANKLE (SHORT LEG) SPLINT The ankle splint helps to immobilize isolated ankle injuries with the joint at a 90° angle (Figure 91-17) This splint is commonly used for ankle fractures and sprains It can also be helpful for certain stable fractures of the foot This splint can be applied as a posterior splint or a lateral to medial stirrup splint.13 Combining the two techniques can provide additional support for the ankle and is known as a trilaminar splint The first part (posterior splint) provides posterior support to the foot and ankle The second part creates a medial-to-lateral stirrup-like splint around the sides of the ankle for additional stability Place the patient prone with their knee flexed 90° and the foot pointing upward (Figure 91-17A) Place the posterior support of splint material from the proximal posterior calf, passing under the heel, and along the plantar surface of the foot (Figure 91-17B) It LONG ARM CAST A short arm cast can easily be extended into a long arm cast if needed Simply extend the cast proximally with the elbow in 90° of flexion Extend the padding and the casting material to the proximal humerus, ending two or three finger breadths distal to the axilla (Figure 91-16) Be careful to provide adequate padding around the axilla or the patient will complain about the sharp cast edge FIGURE 91-16 The short arm cast is extended into a long arm cast The axilla needs adequate padding for protection of its sensitive skin 604 SECTION 6: Orthopedic and Musculoskeletal Procedures A FIGURE 91-17 The ankle splint A Stockinette is applied and the leg is positioned B The splinting material is applied posteriorly C A stirrup splint is applied around the medial to lateral ankle D Fold the corners and smooth out the splint E An elastic wrap is applied over the splint after folding back the stockinette The foot is maintained in this position until the plaster sets B C D E can be extended distal to the toes to provide protection Place the foot 90° to the tibia and in neutral rotation For a “stirrup” support of the ankle, begin by applying splinting material onto the length of the medial aspect of the proximal calf, over the medial malleolus, under the heel, and up the lateral aspect of the ankle and calf (Figure 91-17C) The stirrup portion should be long enough to go from mid-tibia to mid-fibula when wrapped under the affected foot Fold and smooth the edges of the stirrup around the heel (Figure 91-17D) Keep the ankle flexed 90° with the foot neutral while the splint material sets (Figure 91-17E) LONG LEG SPLINT This splint is commonly used for knee and tibial injuries prior to and after surgical fixation It is basically a longer extension of the short leg splint described above Posterior, medial, and lateral lengths of splinting material are used to stabilize the leg while the anterior aspect of the leg is left exposed Measure the extremity from the gluteal crease distally to the tips of the toes It is important to add an additional to in to the measured length so that the splinting material can be folded back on itself to protect the patient from the sharp ends The application of medial and lateral splinting material begins at the upper thigh just below the level of the gluteal crease and travels down the knee, calf, and under the ankle The posterior portion of splinting material begins at this same level and travels down the posterior aspect of the leg, behind the knee, curving around the heel, and ending just beyond the ends of the toes Flex the foot 90° to the tibia, flex the knee 10° to 30°, and mold the splint Failure to keep the ankle at 90° will allow the Achilles tendon to shorten and stiffen A pillow may be placed under the knee to maintain 20° to 30° of flexion while the splint hardens CHAPTER 91: Casts and Splints 605 FIGURE 91-19 The short leg cast leaves the knee and tibial tuberosity exposed The finger is pointing to the tibial tuberosity FIGURE 91-18 Positioning and splinting of the patient with an Achilles tendon injury SPLINT FOR ACHILLES TENDON RUPTURE Rupture of the Achilles tendon can be managed surgically or conservatively with immobilization Surgery is often delayed and the patient will require immobilization Position the patient as if placing an ankle splint or have the patient sit up with the affected extremity hanging over the gurney’s edge Position the foot in 20° to 30° of plantarflexion (Figure 91-18) This is a position that the foot will naturally relax into Place a posterior splint on the lower extremity extending from the proximal calf to the distal aspect of the toes Cut out wedges of plaster in order to minimize buckling at the malleoli as the splint material wraps around the heel The short leg cast begins at the proximal calf, below the knee, and extends down to the toes (Figure 91-19) The knee and tibial tuberosity are left entirely free to allow for full flexion and extension The toes can be left entirely exposed or the cast can provide a hard sole of support and protection beneath the toes Apply cotton cast padding with extra attention to the areas of bony prominence such as the fibular head, the lateral malleolus, and the medial malleolus Apply the casting material from the calf to the toes as if applying a short arm cast Mold the casting material around the Achilles tendon, away from the malleoli and to conform to the plantar arch Cut the wet casting material under the metatarsal heads to expose the toes or leave it long to support the entire toes Converting a short leg non-weight bearing cast to a walking cast requires small adjustments to the existing cast Supplement the arched foot of the short leg cast with additional casting material to form a flat surface Apply a preformed heel after the cast has completely dried to prevent any indentation Place the walking heel in the midsagittal plane of the foot with the center aspect lining up with the anterior calf Secure the heel in place with copious casting material wrapped around the foot and ankle (Figure 91-20) SHORT LEG CAST The short leg cast is used for stable ankle fractures and stable fractures of the hindfoot, midfoot, and forefoot (Figure 91-19) Place the patient either supine or sitting on the edge of the gurney Place a padded block under the distal thigh if the patient is supine Instruct an assistant to hold the patient’s toes to help keep the lower extremity in a good position Holding the leg by the toes may allow the force of gravity to disrupt fracture alignment Care must be taken to prevent this outcome The patient can sit upright on the edge of the gurney with the affected leg hanging down freely if no assistant is available FIGURE 91-20 Converting the short leg cast into a walking cast A walking heel is secured with an additional casting material over-wrappings 606 SECTION 6: Orthopedic and Musculoskeletal Procedures fingers and toes should be encouraged to help reduce edema in the extremity The cast or splint must be kept completely dry Should bathing be desired, instruct the patient to place two plastic bags over the extremity and tape the proximal edge to the skin of the extremity Sufficient pain medication should be supplied to last the patient until their follow-up visit with an Orthopedic Surgeon This should include nonsteroidal anti-inflammatory drugs supplemented with narcotic analgesics A sling may facilitate mobilization for some upper extremity injuries COMPLICATIONS The most common complications associated with the application of a cast or splint include plaster sores, compartment syndrome, joint stiffness, thermal injury, infection, and allergic reactions The following section focuses on the prevention of these complications.4,6,10 FIGURE 91-21 The long leg cast LONG LEG CAST The long leg cast can be used for immobilization of distal femoral or proximal tibial fractures (Figure 91-21) The cast extends from the metatarsal heads to several finger breadths below the groin The leg is immobilized with the knee in slight flexion and the foot 90° to the tibia with no internal or external rotation (Figure 91-21) Extending the short leg cast up to the groin is a safe and stepwise technique of forming a long leg cast Be sure to provide sufficient overlap of casting material at the junction between the two casts Inadequate overlap will weaken the integrity of the cast Support the knee in slight flexion while the casting material sets Make sure that there is adequate padding around the proximal free edge of the cast to protect the groin KNEE IMMOBILIZERS Knee immobilizers can be made using splinting material and are indicated for ligamentous injuries Measure the extremity starting 10 in above the patella to 10 in below the patella Double that length and cut the splinting material Fold the splinting material end-to-end Make a cut in the folded side extending from one edge to the middle of the folded side to create a hinge Apply cotton cast padding starting 10 in above the patella to 10 in below the patella Place the hinged portion of the splinting material 10 in below the anterior patella with the cut ends extending proximally up both the medial and lateral leg Secure the splinting material with a loose fitting elastic bandage AFTERCARE The most feared complication of a splint or cast application is the development of a compartment syndrome The aftercare is geared toward edema reduction and patient education Instruct the patient regarding the early signs of a compartment syndrome This includes increased pain, pain with passive motion, paresthesias, pallor, decreased or altered sensation, as well as delayed capillary refill The patient should return to the Emergency Department immediately if they develop any of these symptoms, if the digits become cold or blue, or if the patient has other concerns The extremity should be maintained above the level of the heart for the first 48 to 72 hours after the injury Ice should be applied to the surface of the cast or splint for at least 15 minutes three times a day The cold therapy will be transmitted through the cast or splint and result in significant reduction of edema Active motion of the PLASTER SORES Plaster sores result from ischemic necrosis of the skin underneath a cast or splint The skin begins to exhibit necrosis after only 2 hours of continuous pressure Great care should be taken in applying a cast or splint and only molding it with the broad surfaces of the hands Molding with the fingers can result in indentations and localized areas of pressure The cast or splint should never be allowed to rest on a hard or pointed surface until it is completely dry Points of contact on the hard surfaces may cause impressions that result in increased pressure Extra padding over bony prominences may decrease the incidence of plaster sores Complaints of pain should be taken very seriously The cast or splint should be split or removed immediately and the skin examined If the pressure point is not addressed rapidly, the pain will often subside as the skin becomes necrotic This oversight often results in a foul smelling pressure sore under the cast or splint when the patient returns for follow-up Cast and splint treatment may be rife with complications for patients with limited sensation from underlying medical conditions (i.e., diabetes, paraplegia, and myelomeningocele) Great care should be taken and extra padding used when casting or splinting these individuals Common areas of pressure necrosis also include the proximal and distal ends of the cast or splint These are areas of stress concentration Great care should be taken in padding the ends of the cast or splint during the application No plaster or fiberglass should ever touch the skin directly If the edges of the splint are sharp or too long, they should be folded out and away from the patient COMPARTMENT SYNDROME A compartment syndrome is a significant complication from the application of a cast or, less commonly, a splint The rigid immobilization prevents soft tissue expansion from edema and decreases the amount of fluid needed to raise compartment pressures.11 In cases of acute fractures, casts should be used with caution and always split in the direction perpendicular to the force needed to maintain the reduction For example, after casting a distal radius fracture where a dorsal mold is needed to maintain the reduction, split the cast longitudinally on the volar and dorsal surfaces (i.e., bivalved) to allow for mediolateral spread of the plaster Splinting greatly reduces the chance of iatrogenic-induced compartment syndromes because unlike casting, splints not harden circumferentially It is not sufficient to split only the plaster The plaster and underlying cotton cast padding must be split to visualize the skin underneath Making a single longitudinal cut (i.e., univalving) in CHAPTER 91: Casts and Splints 607 the cast can also decrease the compartment pressure Univalving the cast can decrease intracompartmental pressures by 30%.12 Spreading the cast cm after cutting it can lower the pressure 60%.12 Splitting the cotton cast padding will decrease the pressure by 70%.12 used in the application of a cast or splint to anesthetized patients, insensate limbs, or confused patients JOINT STIFFNESS Infection secondary to a cast or splint is uncommon and is usually related to open wounds or exposed surgical pins underneath the plaster Fresh water should be used to wet the plaster Do not use standing or previously used water, as it is an excellent culture medium All wounds should be dressed with sterile gauze and cotton cast padding prior to applying the cast or splint Windows can be created over wound sites to allow for regular care and evaluation Patients should be instructed to keep casts and splints clean and dry so as to prevent skin maceration Joint stiffness is a significant complication of joint immobilization with casts and splints Sometimes the immobilization is unavoidable, as the incorporation of the ankle and the knee in a long leg cast Every effort should be made to decrease adjacent joint immobilization as soon as it is safe and practical For example, by converting a long leg cast into a short leg cast Immobilize the extremity in a position of function as long as this does not interfere with the maintenance of fracture reduction For example, take great care not to immobilize the ankle in plantarflexion when applying a lower extremity splint or cast This mistake is commonly seen when a long leg cast is placed This pitfall may be avoided by the stepwise application of the cast First apply the cast to the foot and ankle with the ankle held 90° to the tibia Second, extend the cast proximally to become a short leg cast and mold the reduction Finally, extend the cast up the thigh as needed An additional benefit is the reduction of anterior compartment pressures of the leg when the foot is held in 0° to 37° of dorsiflexion Great care should also be taken in splinting the upper extremity Every effort should be made to leave the fingers mobile at the metacarpophalangeal joints Immobilization of the metacarpophalangeal joints in extension results in shortening of the collateral ligaments and thus limits flexion Immobilize the metacarpophalangeal joints in 90° of flexion if they must be immobilized This position keeps the collateral ligaments in a lengthened position and allows a rapid return to function THERMAL INJURY Thermal injury may result from the exothermic reaction of plaster or fiberglass as it sets (i.e., dries) The heat generated during the setting increases as the number of layers (i.e., thickness) increases as well as the temperature of the water increases Also important is the ability to dissipate the heat generated by the drying plaster or fiberglass Placing a cast or splint on a plastic pillow as it dries will result in reflection of the heat and an increased temperature within the cast or splint The use of cloth pillows or towels under the cast or splint allows for some dissipation of the heat Optimal heat dissipation occurs by exposing the cast or splint to circulating air Sufficient cotton cast padding must be used to protect the skin Plaster and fiberglass must never touch the skin directly The incidence of thermal injury can be decreased by using cool water and as thin a layer of plaster or fiberglass as possible to accomplish stable immobilization of the extremity Great care should be INFECTION ALLERGIC REACTIONS Allergic reactions to cotton, fiberglass, and plaster have been reported but are exceedingly rare Orthopedists and orthopedic technicians may develop a contact dermatitis from continued exposure to plaster over many years Gloves should be worn for plaster and fiberglass application SUMMARY The initial management of orthopedic trauma is a fundamental aspect of Emergency Medicine Fractures and dislocations of the extremities are routinely handled in the Emergency Department with prompt Orthopedic follow-up or consultation The application of external immobilization can be the definitive or temporizing management of the injured extremity The application of splints accounts for the majority of immobilization of injured extremities Cast application plays a role in maintaining bony alignment following closed reductions of fractures Clear benefits of external immobilization include pain relief and the reduction of further soft tissue injury from bony fragments Immobilization of the fracture decreases motion and traction on the nerve-rich periosteum.4,7 The immobilization of fracture ends protects adjacent neurovascular structures from injury and helps prevent bony fragments from penetrating the skin External immobilization also reduces the area available for hemorrhage and decreases bone bleeding.4 Early immobilization leading to fracture stabilization is also important in reducing the morbidity associated with long bone fractures.12 Finally, the closed treatment of fractures facilitates the body’s natural processes of repair External periosteal and internal intramedullary callus formation is optimized in the setting of bony alignment that has been secured by casting or splinting The application of splints is an essential skill for any Emergency Physician The application of a cast in the Emergency Department is appropriate in some select situations The casting or splinting of an extremity is simple, easy to perform, and relatively quick This page intentionally left blank ... 75, 77, 80, 81, 83, 90, 91, 93, 95, 10 0, 10 4, 11 2, 11 5, 11 6, 11 7, 11 8, 11 9, 12 0, 12 1, 12 2, 12 6, 13 3, 14 2, 14 3, 14 4, 14 5, 14 6, 14 9, 15 7, 15 9, 16 0, 16 8, 17 0, 17 2, 17 5, 17 6, 17 8, 17 9, 19 2] Associate... Reichman 17 3 Laryngoscopy 11 13 Steven Charous 17 4 Airway Foreign Body Removal 11 20 David L Walner xi SECTION 15 Podiatric Procedures 11 69 18 4... editor ISBN: 978-0-07 -16 13 51- 4 MHID: 0-07 -16 13 51- X The material in this eBook also appears in the print version of this title: ISBN: 978-0-07 -16 1350-7, MHID: 0-07 -16 1350 -1 All trademarks are trademarks