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Why splint/cast?. Acute musculoskeletal injuries common in primary care (especially in military!)ContinuityReduce 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
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1. Common Splinting Techniques Jenniffer L. LaPointe, MD
Lt Col, USAF, MC
2. 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
3. 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)
4. Pre and Post Splint 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 intraarticular 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/Night Splints
Lacerations
Simple/nondisplaced radius or ulna fractures
Key Points
palmar crease to 3 fingerbreadths from antecubital fossa
1 fold @ angle of palmar 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 3 fingerbreadths from antecubital fossa
Cut 2 ˝ hole for thumb & tape edges
Flex metacarpals 45° (70-90° if distal fracture) and wrist 20-30° extension
11. Boxer Splint 4-5 Indications
5th Metacarpal Fractures
4th Metacarpal Fractures
Key Points
Tip of 5th finger to 3 fingerbreadths from antecubital fossa
Pad b/t 4th and 5th fingers
Ulnar gutter
Mold to position, MCP at 70-90° flexion to maintain positioning in distal fractures
15. Reverse Sugar Tong 3- 4 Indications
Colles Fracture
Forearm Fractures
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
18. 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
19. 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
24. 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
25. 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
26. Avoiding pitfalls Worst outcomes in fracture management:
Fractures requiring reduction
Intraarticular fractures
Scaphoid fractures
Reference resources:
Up To Date Ž
Fracture Management For Primary Care, by Eiff, Hatch, and Calmbach
Rockwood and Greens