Splinting and Casting for the Busy Clinician

1. Splinting and Casting for the Busy Clinician

2. Objectives Place an appropriate short arm cast and splint. Place a sugar-tong or reverse sugar-tong splint. Place a thumb splica cast or splint Know the codes used for both the application of a cast or splint as well as the Q code for the supplies to insure proper billing / reimbursement

3. Why splint/cast? Acute musculoskeletal injuries common in primary care (especially in military!) Continuity Reduce orthopedic referral rate (experienced FP in orthopedics only 16-25% fracture referral rate excluding hip/face fractures) Studies concluding that most FP managed fractures heal well and most complications can be avoided with appropriate selection of which fractures to manage RVU density! Orthopedics pays

4. Pre / Post - Splint / Cast Checks F � Function A � Arterial Pulse C � Capillary Refill T � Temperature (Skin) S - Sensation

5. Thumb Spica � 3� Indications for thumb spica Navicular / Scaphoid Fractures Thumb Dislocations/Proximal thumb fractures Ulnar Collateral Ligament Sprains Tendonitis Key Points 3 fingerbreadths from antecubital fossa Tip of thumb spiral 2 figure of 8 wraps with wrap

6. When do I need an orthopedist? Indications for orthopedic referral Scaphoid Fractures: any displacement or angulation, non-union or avascular necrosis develops after conservative treatment, or scapholunate dissociation (>3mm distance) Proximal Thumb Fractures: any intra-articular fracture, comminution, any fracture where adequate closed reduction cannot be maintained Ulnar Collateral Ligament Injuries: avulsion fracture with more than 2 mm displacement, fractures with more than 20% articular surface involvement, complete rupture of UCL (tested at 30 degrees flexion of MCP after radiographs are obtained)

7. Volar Splint � 3� or 4� Indications Wrist Sprains Carpal Tunnel Syndrome Lacerations Night Splints Key Points Palmer crease to 2� antecubital (3 Fingers) 1� fold @ angle of palmer crease

10. Teardrop Splint � 4�-5� Indications 2nd & 3rd Metacarpal Fractures Flexor Tendon Repairs or Extensor Tendon Crushing Injuries Lacerations Key Points Tip of 3rd finger to 2� antecubital fossa (3 Fingers) Cut 2 �� hole for thumb & tape edges Flex metacarpals 45� (70-90� if distal) and wrist 20�-30� extension

11. Boxer Splint � 4�-5� Indications 5th Metacarpal Fractures 4th Metacarpal Fractures Key Points Tip of 5th finger to 2� from antecubital (3 Fingers) Pad b/t 4th and 5th fingers Ulnar gutter Mold to position, MCP at 70-90� flexion to maintain positioning in distal

15. Thumb Spica � 3� Indications Navicular / Scaphoid Fractures Thumb Dislocations Ulnar Collateral Ligament Sprains Tendonitis Key Points 2 inches from antecubital to tip of thumb Tip of thumb spiral 2 figure of 8 wraps with wrap

16. Reverse Sugar Tong � 3�- 4� Indications Colles� Fracture Forearm Fracture Key Points Measure from behind the elbow up both sides of the arm to the tip of the fingers Cut at mid-point leaving 1/2� and slide over the hand Overlap the ends at the elbow, wrap from the hand down

19. Figure 8 Splint Indications Mid-shaft clavicular fractures (Proximal/distal clavicular fractures often treated with sling/swath +/- operative treatment) Key Points Measure so �position of attention� attained Advantage of leaving elbow and hand free BUT requires assistance to put on Counsel patient bony deformity possible Orthopedic referral rarely indicated for mid-clavicular fractures

20. Posterior Ankle � 4� - 5� Indications Distal Tib / Fib Fractures Ankle Sprains Achilles Tendon Tears Metatarsal Fractures Key Points 2� below popliteal to 2� beyond toes Fold 1� under toes Wrap from the toes up Figure 8 with tape to hold in position

21. Reinforced Posterior Leg SplintButterfly Indications Severe Ankle Sprain Metatarsal Fractures Hair Line Fractures Distal Tibia / Fibula Fractures Non Displaced Ankle Fracture Key Points 2� below popliteal to 2� beyond the toes At base of heel snip padding Cut substrate 3-4� either side of mark Fold in Butterfly fashion Reinforced side away from patient

26. SAM Splints

27. When do I need an orthopedist? Referral decisions: Avoid managing an orthopedic injury beyond your training/skill unless proper guidance is available Be able to identify patients with complicated fractures Need for surgical intervention to maintain reduction High risk of non-union Inability to maintain closed reduction Significant intraarticular involvement Strongly consider referring patients who are likely to be non-compliant

28. Avoiding pitfalls Worst outcomes in fracture management: Fractures requiring reduction Intraarticular fractures Scaphoid fractures Reference resources: Up To Date � Fracture Management For Primary Care, by Eiff, Hatch, and Calmbach Rockwood and Green�s

29. RVU �density� Example: Healthy 5 year old female comes in after FOOSH injury with nondisplaced torus fx of distal radius on x-ray, normal exam except for tenderness over distal radius On initial visit: 99213 visit (0.67 RVUs) with CPT 29125, application of short arm splint (0.59 RVUs) with total RVUs on initial visit: 1.26 RVUs THEN patient f/u done 3-4 days later after swelling has decreased and 99213 coded (0.67 RVUs) and CPT 25500, closed treatment of radial shaft fracture without manipulation (2.51 RVUs) with total of : 3.18 RVUs Follow up in 3 weeks with removal of cast, 99213 (0.67 RVUs) Total of 5.11 RVUs for treatment and orthopedic referral avoided 2008 RVU values (increased 0.82 RVUs for CPT 25500 vs 2006 values)

30. RVU Credit

31. Lets Pair up and Splint Questions