by Joseph Pinero, Timothy Snow, Suzanne Bentley

Case Presentation 1

65-year-old female with a history of hypertension and diabetes presenting with right wrist pain and swelling after suffering a fall from standing, landing on an outstretched hand. Plain radiographs of the wrist will show a distal radius fracture, otherwise known as a Colles fracture.

 

Procedure: Sugar Tong

Emergency Indication

• Colles Fracture (Distal Radius Fracture)
• Distal Ulna Fracture
• Smith Fracture (Reverse Colles Fracture)
• Barton Fracture (Dorsal or volar rim fracture of the distal radius)

Precaution

The presence of an open fracture requires an emergent orthopedic surgical consultation and surgical fixation with open reduction and internal fixation.

Equipment and Patient Preparation

• Syringe
• Lidocaine
• 4” Plaster
• Soft web roll lining
• 4” ace wrap
• Sling

Procedure Steps

1. Obtain standard radiographs including posteroanterior and lateral films
2. Local anesthesia via hematoma block
   • Contraindicated if overlying cellulitis or grossly contaminated wound
   • Clean skin with an antiseptic solution
   • First, anesthetize skin with a small wheal of lidocaine
   • Then dive deeper into the largest area of swelling and hematoma and aspirate blood. Once confirmed that you are within the hematoma, gently inject 10-15 cc of anesthetic.
   • Wait at least 10 minutes for the anesthetic to be absorbed prior to beginning your manipulation.
3. Perform a closed reduction with the aim of creating a neutral volar tilt (15-degree angulation in wrist flexion)
   ○ The sugar tong splint should be applied by placing a U-shaped splint from the dorsal metacarpal-phalangeal joints down around the elbow joint and wrap back around to come up to just below the metacarpal-phalangeal joints on the palmar surface.
   ○ The plaster should be measured prior to placement and should be 8-10 layers thick
4. Place the patient in a sling and perform post-reduction plain radiographs

Hints and Pitfalls

• Using too much padding can cause your splint not to provide enough support, resulting in malunion.
• Using too little padding can result in plaster burning the skin.

Post Procedure Care and Recommendations

Always take post-reduction radiographs

Complications

• Malunion
• Nonunion
• Median nerve injury

 

Case Presentation 2

11-year-old male with no past medical history presents with right arm pain around the elbow after falling off of the monkey bars at the playground earlier today. Plain radiographic films will show a supracondylar fracture.

 

Procedure: Posterior Long Arm Splint

Emergency Indication

• Supracondylar fracture
• Distal Humerus fracture
• Monteggia’s fracture
• Proximal forearm fractures
• Radial head and neck fractures
• Olecranon fractures
• Severe ligamentous injuries of the elbow

Precaution

The presence of an open fracture requires an emergent orthopedic surgical consultation and surgical fixation with open reduction and internal fixation

Equipment and Patient Preparation

• Syringe
• Lidocaine
• 4” Plaster
• Soft web roll lining
• 4” ace wrap
• Sling

Procedure Steps

1. Obtain standard radiographs including posteroanterior and lateral films
2. Local anesthesia is typically not effective in this group as these fractures are typically seen in young children that require minimal manipulation if any at all.
3. If a child cannot tolerate the placement of the splint, it is possible to utilize procedural sedation (administration of a small amount of sedative making the child less aware of the procedure).
4. Placing the splint requires pre-measurement of plaster casting material from the proximal posterior humerus at the axillary crease to the wrist joint without crossing into the hand.
   • The plaster should be layered at 8-10 layers thick, as this is a long arm splint and will be heavier than the average short arm splint.
   • The elbow should be placed at 90 degrees of flexion with the wrist in a neutral position, which is neither supinated nor pronated.
5. Place the patient in a sling and perform post-reduction plain radiographs.
   Hints and Pitfalls
6. Be sure to place the arm in the proper position of neutrality.
   Post Procedure care and recommendations
7. Make sure to provide adequate analgesia both before and after the placement of the splint.

Complications

• Malunion
• Nonunion
• Median nerve injury
• Pressure ulcers
• Decreased range of motion

Case Presentation 3

26-year-old male with no past medical history presents with left ankle pain after landing on another player’s foot while jumping up during a basketball game.

Procedure: Short Leg Splint

Emergency Indication

• Ankle fracture
• Tibia fracture
• Severe ankle sprain
• Metatarsal fractures

Precaution

The presence of an open fracture requires an emergent orthopedic surgical consultation and surgical fixation with open reduction and internal fixation.

Equipment and Patient Preparation

• Chucks (or any material that you can use to keep the counters and floors clean)
• Water source (basin half full of water will suffice)
• Syringe
• Lidocaine
• 4” or 6” Plaster (depending on the size of the leg)
• Soft web roll lining
• 6” ace wrap
• Crutches

Procedure Steps

1. Obtain standard radiographs including posteroanterior and lateral films
2. Local Anesthesia via hematoma block
   • Contraindicated if overlying cellulitis or grossly contaminated wound
   • Clean the skin with an antiseptic solution
   • First, anesthetize skin with a small wheal of lidocaine
   • Then dive deeper into the wound overlying the largest area of swelling and hematoma and aspirate blood. Once confirmed that you are within the hematoma, gently inject 10-15 cc of anesthetic.
   • Wait at least 10 minutes for the anesthetic to be absorbed prior to beginning your manipulation.
3. Placing a short leg splint for this type of fracture involves pre-measuring two separate strips of plaster.
   • The first strip is measured from the superior calf to just beyond the toes of the foot for your posterior support
   • The second strip is measured from the head of the fibula, down and around the heel, up to the tibial plateau medially.
   • Once both strips are measured, wrap the leg in web roll padding and place the plaster on the leg with the U-shaped splint above the posterior support strip.
   • Cover both with a thin layer of the web roll, followed by your ace bandage.
   • The leg will typically require more than one 6” ace wrap
     Perform post-reduction plain radiographs and educate the patient on the use of crutches

Hints and Pitfalls

Test for neurovascular function

Post Procedure care and recommendations

Make sure to provide adequate analgesia both before and after the placement of the splint.

Complications

• Malunion
• Nonunion
• Pressure ulcers
• Decreased range of motion
• Early onset arthritis

 

Case Presentation 4

A 8-year-old male presenting with thigh pain after falling from a bicycle. Plain radiographs show a fracture of the distal femur.

 

Procedure: Long Leg Splint

Emergency Indication

• Distal femur fracture
• Tibia plateau fracture

Precaution

The presence of an open fracture requires an emergent orthopedic surgical consultation and surgical fixation with open reduction and internal fixation.

Equipment and Patient Preparation

• Chucks (or any material that you can use to keep the counters and floors clean)
• Water source (basin half full of water will suffice)
• Syringe
• Lidocaine
• 4” or 6” Plaster (depending on the size of the leg)
• Soft web roll lining
• 6” ace wrap
• Crutches

Procedure Steps

1. Obtain standard radiographs including posteroanterior and lateral films
2. Local Anesthesia via hematoma block
   • Contraindicated if overlying cellulitis or grossly contaminated wound
   • Clean skin with an antiseptic solution
   • First, anesthetize skin with a small wheal of lidocaine
   • Then dive deeper into the wound overlying the largest area of swelling and hematoma and aspirate blood. Once confirmed that you are within the hematoma, gently inject 10-15 cc of anesthetic.
   • Wait at least 10 minutes for the anesthetic to be absorbed prior to beginning your manipulation.
3. Placing a long leg splint for this type of fracture involves pre-measuring three strips of plaster: one from the plantar surface of the toes to the gluteal fold, one support strut from the medial ankle up to the proximal inner thigh, and the last support strut from the lateral ankle up to the greater trochanter of the femur.
4. Wrap the leg in web roll padding
5. Firmly secure the splint with a top layer of web roll and ace wrap
   Hints and Pitfalls
6. Test for neurovascular function
7. If the fracture is in the midshaft of the femur or proximal femur, casting is not an appropriate option. Orthopedic consultation and traction fixation will be required temporarily, prior to surgical fixation.

Post Procedure Care and Recommendations

Make sure to provide adequate analgesia both before and after the placement of the splint.

Complications

• Malunion
• Nonunion
• Pressure ulcers
• Decreased range of motion
• Early onset arthritis

 

Case Presentation 5

54-year-old female with no past medical history presents with right ankle pain after stepping off of a curb and “rolling over her ankle.” X-ray shows a non-displaced malleolar fracture.

 

Procedure: Short Leg Cast

Emergency Indication

• Definitive treatment for nondisplaced ankle and foot fractures
  Precaution
• The presence of an open fracture requires an emergent orthopedic surgical consultation and surgical fixation with open reduction and internal fixation.

Equipment and Patient Preparation

• Chucks (or any material that you can use to keep the counters and floors clean)
• Water source (basin half full of water will suffice), lukewarm temperature
• Syringe
• Lidocaine
• 4” and 6” Plaster (depending on the size of the leg)
• Soft web roll lining
• 6” ace wrap X 2
• Crutches

Procedure Steps

• Obtain standard radiographs including posteroanterior and lateral films
• Local anesthesia via hematoma block, and for more severe fractures, systemic analgesia may be required.
  • Contraindicated if overlying cellulitis or grossly contaminated wound
  • Clean the skin with an antiseptic solution
  • First, anesthetize skin with a small wheal of lidocaine
  • Then dive deeper into the wound overlying the largest area of swelling and hematoma and aspirate blood. Once confirmed that you are within the hematoma, gently inject 10-15 cc of anesthetic.
  • Wait at least 10 minutes for the anesthetic to be absorbed prior to manipulation.
• Placing a short leg cast for this type of fracture involves first ensuring the foot is sitting in proper anatomical alignment ankle flexed at 90 degrees.
  • The first step is to adequately pad the entire area of casting (from 1-2cm distal to the tibial plateau) to the distal foot (covering the base of the phalanges) leaving the tips of the toes uncovered. Extra padding should be placed at the areas of pressure (the ends of the cast) and the heal to prevent ulcers.
  • The second step is to apply the plaster ensuring the ankle remains at 90 degrees of flexion. The entire rolls of plaster are dipped and soaked in lukewarm water and then squeezed to remove some of the water. The thumb and index finger should be placed at each end of the plaster to prevent “bananaing” of the plaster when applying.
  • Plaster or fiberglass is then wrapped around the foot and ankle up to the proximal tibia ensuring it remains in 90 degrees of flexion.
  • A foot plate can be added by placing 6 layers of plaster on the bottom of them for support.
  • To prevent cutting off blood flow to the distal foot when the injury swells, bi-valving of the cast should be done by cutting along the medial and lateral shin, through the plaster or fiberglass.
• Give the patient crutches and perform post-reduction plain radiographs

Hints and Pitfalls

• Extra padding should be applied to areas of pressure (tips of toes, heal at the malleoli and top of the cast at the tibial plateau) to prevent pressure ulcers.
• Test for neurovascular function after casting
• Short leg casts are often “bi-valved” or cut in half prior to discharge from the hospital. This is done in order to allow for some room for swelling.

Post Procedure Care and Recommendations

Make sure to provide adequate analgesia both before and after the placement of the splint.

Complications

• Malunion
• Nonunion
• Pressure ulcers
• Decreased range of motion
• Early onset arthritis
• Contracture of the Achilles tendon if the foot is <90 degrees of flexion

 

References and Further Reading

• Sugar Tong Splint Application – https://www.youtube.com/watch?v=wDlWU-DSQDw
• Mels CG, Sugar-Tong Forearm Splinting. Medscape, 2017 – http://emedicine.medscape.com/article/80127-overview
• Posterior Long Arm Splint – https://www.youtube.com/watch?v=ofFRGu7Bll4
• Jacobson L, Posterior Long Arm Splinting, Medscape, 2017 – http://emedicine.medscape.com/article/1355110-overview
• Short leg splint – https://www.youtube.com/watch?v=KuMMZuM8yf0
• Grimm LJ, Ankle splinting. Medscape. 2018 – http://emedicine.medscape.com/article/80070-overview
• Long leg splint – https://www.youtube.com/watch?v=1Qrq3KgFUCQ
• Cast treatment of tibial fractures – http://www.wheelessonline.com/ortho/cast_treatment_of_tibial_fractures
• Bentley S, Posterior long leg splinting. Medscape, 2018. http://emedicine.medscape.com/article/1355131-overview
• Nonoperative treatment of ankle fractures – http://www.wheelessonline.com/ortho/nonoperative_treatment_of_ankle_fractures
• Short leg casting – https://www.youtube.com/watch?v=NNVVUwrow10
• Synstethic casting short leg application – https://www.youtube.com/watch?v=VYB6FBSN8gw