Splinting, Casting, Wrapping and Taping Faculty Disclosure

Home , Ankle fracture, Intraarticular fracture, Jones fracture, Mallet finger

11/2/2016

Faculty Disclosure

I have nothing to disclose. Splinting, Casting, Wrapping and Taping

Wade M. Rankin, DO, CAQSM Assistant Professor University of Kentucky College of Medicine, Department of Family and Community Medicine

Educational Need/Practice Gap Objectives

Gap = Lack of fracture knowledge and ability Upon completion of this educational activity, to manage some outpatient fractures in your you will be able to: outpatient clinic • Outline common fractures seen in outpatient family medicine clinics. • Discuss strategies for fracture management Need = Ability to manage common and fracture care for common outpatient outpatient non-operative fracture care fractures. • Review common indications for taping and wrapping in outpatient settings.

Expected Outcome Active Learning

-Comfort with common outpatient fractures At the end of this session will discuss certain and ability to manage certain fractures cases and have some audience response -Comfort with splinting, taping, wrapping questions to gauge learning. -Comfort with pre-fabricated splints and common applications

1 11/2/2016

Most Common Fractures? Most Common

• Depends on the source: – Clavicle –Arm –Ankle – Wrist – Hip –Foot – Toes –Hand – Finger –Nose

Depends on the age: Depends on Age

• Common Fractures in Children – 1. Distal radius fractures – 2. Phalanges of the hands – 3. Carpal-metacarpal region – 4. Clavicle

Incidence Pediatric Fractures

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Types of Pediatric Fractures Salter-Harris Fracture Types

Salter-Harris Fracture Types Salter-Harris Fracture I

• S- “slipped” “Straight” • If xray findings are negative (need comparison views), • A- “above” but patient TTP over the physis •L-“lower” – Treat like a Salter-Harris • T- “through” Type 1 • Splint if reliable, cast if • R- “rammed or not • Reassess in 2 weeks, if ruined” still tender, 2 more weeks • Patient remain immobilized until no longer TTP over physis

Salter-Harris Fracture Distal Radius Fracture

• Salter-Harris I and II • Distal Radius Fracture – Can usually be managed with closed – 40% of all pediatric long manipulation and immobilization bone fracture • Salter-Harris III and IV – Distal radius most common site – Due to being intra-articular and often displaced, often require open reduction with internal fixation – Male/female – Peak incidence: 10-12 • Salter-Harris V yo girls, 12-14 yo boys – Difficult to diagnose,usually retrospectively – Most common fracture diagnosed when angulation develops, can be children <16yo diagnosed early with MRI, need specialist referral – Usually FOOSH, often if diagnosed during sports/play

http://www.orthobullets.com/pediatrics/4014/distal-radius-fractures--pediatric

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Distal Radius Fracture Distal Radius Fracture

Imaging • AP/lateral radiographs of wrist, forearm and elbow • Consider CT if intraarticular, use sparingly however due to concerns of radiation

http://www.orthobullets.com/pediatrics/4014/distal-radius-fractures-- http://www.orthobullets.com/pediatrics/4014/distal-radius-fractures--pediatric pediatric

Distal Radius Fracture Distal Radius Fracture

• Treatment-immobilization – Short arm cast for 2-3 weeks • Treatment-Operative without reduction • Greenstick with <10 deg – Closed reduction with percutaneous pinning angulation • Torus/buckle • Unstable patterns with loss of reduction in cast – Closed reduction under conscious sedation • S-H I/II in setting of NV compromise • Greenstick >10-20 deg angulation • S-H I/II with unacceptable • Any fracture unable to be reduced in ED but alignment reduced in OR or under anesthesia – Short-arm vs. Long-arm casting • Short-arm considered equal to – Open reduction with internal fixation long-arm for distal radius fractures, conservative often utilizes Long-arm • Displaced S-H III/IV unable to be closed reduced

– http://www.orthobullets.com/pediatrics/4014/distal- • Irreducible fracture closed-anatomic block to radius-fractures--pediatric reduction (muscle/periosteum)

http://www.orthobullets.com/pediatrics/4014/distal-radius-fractures--pediatric

Distal Radius Fracture Distal Radius Fracture

• Casting and Follow-Up • Take Home – Casting – Greenstick with <10 deg angulation • Operative fixation-usually long-arm cast for 6-8 (radiograph will describe) or torus/buckle weeks, then short-arm for 2-4 weeks pending type fracture – Follow-up • Can treat in short-arm case for 2-3 weeks • All forearm fractures should have serial • Repeat radiographs every 1-2 weeks to insure radiographs performed every 1-2 weeks to ensure continued reduction reduction maintained. • No utility for pre-fabricated splints

http://www.orthobullets.com/pediatrics/4014/distal- radius-fractures--pediatric

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Pediatric Hand/Phalanx Fracture Distal Tuft Fracture

• Distal Tuft Fracture • 15% of all fractures seen in ED – Secondary to crush injury – Nearly half of all fractures result of either sports – Most common toddler and preschool age or fights – Crush injury to fingertip resulting in fracture • Hand fractures make up 2.3% of all ED visits – Represents 80% of hand fractures in this group • 65-75% of fractures occur in males – Can involve soft tissue lacerations and nail bed injuries • Peak incidence between ages of 9-14 yo – Irrigation, debridement mainstay of therapy – Immobilization with clamshell • Phalanx more common in 9-12 yo plastic splint for 2-3 weeks – Antibiotics usually prescribed • Metacarpal fracture more common 12-14 yo but no better outcomes than irrigation/debridement

Hand Clin. 2013 Nov; 29(4): 569–578.

Distal Tuft Fracture Bony Mallet Finger Fracture

• Flexion force to an actively extended finger • Causes an avulsion of epiphysis resulting in intraarticular fracture extending in metaphysis of distal phalanx • Should be recognized at S-H III/IV

Hand Clin. 2013 Nov; 29(4): 569–578.

Bony Mallet Finger Fracture Bony Mallet Finger Fracture

• Treatment – Usually operative – If <1/3rd of joint surface can be treated with extension splinting – Strict adherence to splinting is mandatory

Hand Clin. 2013 Nov; 29(4): 569–578.

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Proximal Phalanx Fracture Proximal Phalanx Fracture

• If no rotational deformities or deficiencies in tight fist or grip strength, can be treated conservatively • Buddy taping to adjacent finger and encouragement of early motion until no longer tender, usually 3-4 weeks

Hand Clin. 2013 Nov; 29(4): 569–578.

Scaphoid Fracture Scaphoid Fracture

• 3% of pediatric • Treatment fractures of hand/wrist • Most common carpal – Thumb spica casting for 2 weeks with repeat fracture imaging to determine course of treatment • Ossification finished – 2 weeks-xrays negative and improved age 13-15 years symptoms, no further immobilization • Peak age of 15 yo – 90% union rate for casting acute fractures • 13-30% of fractures, initial radiographs are – 23% union of chronic fractures with casting negative – Fracture distal pole take 4-8 weeks to heal, waist fractures can take 5-16 weeks

Hand Clin. 2013 Nov; 29(4): 569–578. Hand Clin. 2013 Nov; 29(4): 569–578.

Scaphoid Fracture Supracondylar Fracture Elbow

• Common elbow injury in children • Accounting for 16% of all pediatric fractures • Significant fracture associated with morbidity due to malunion, NV complications and compartment syndromes

Curr Rev Musculoskelet Med. 2008 Dec; 1(3-4): 190–196

6 11/2/2016

Supracondylar Fractures Supracondylar Fractures

• Treatment – Type I • Above elbow cast at 90 degrees flexion for 4 weeks – Type II • Percutaneous pinning – Type III • Closed reduction with percutaneous pinning

Curr Rev Musculoskelet Med. 2008 Dec; 1(3-4): 190–196 Curr Rev Musculoskelet Med. 2008 Dec; 1(3-4): 190–196

Clavicle Fracture Clavicle Fx

• Clavicular Fx • Treatment – Common, 2-5% in – Group I (Middle 1/3) adults, 10-15% in children, 44-66% of all •Adult -2/3rds of Fx shoulder fractures • Peds - 90% of Fx – Trauma – Pain/crepitus over – Group II (Distal 1/3) clavicle • Approximately 25% of – Pos Cross Arm adult Fxs aDDuction test – Group III (Proximal) – Auto splinting by the pt • 2-3% of adult Fxs – Xray demonstrates Fx

Transl Med UniSa. 2012 Jan-Apr; 2: 47–58.

Clavicle Fx Ankle Fracture

• Treatment • Expanded Danis-Weber – Group I classification • Nonoperative treatment with simple sling or – Type A figure 8 brace • Lateral malleolus • PT at 4-6 wks helpful for fracture below the return of ROM syndesmosis – Group II – Type B • Displaced fx (Neer II) • Lateral malleolus need ORIF fracture at level of – Group III syndesmosis • Rare fx (1-5% of all fx) – Type C • Usually nonoperative txt due to proximity of major • Lateral malleolus neurovascular structures fracture above the syndesmosis

Dtsch Arztebl Int. 2014 May; 111(21): 377–388.

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Ankle Fracture Ankle Fracture

– Type B/C – treated in • Treatment vacuum boot/walking boot – Any stable fracture with • Leg cast are uncomfortable and should not be used non-displaced or slightly – For 6 weeks, should be displaced fragments can immobilized in a walking boot for pain-adapted weight be treated conservatively bearing – Type A – can be treated – Boot stays on at night like external ligament – If unable to full weight-bear, consider antithrombotic ruptures in a stabilizing drugs ankle orthosis for early – Concerns for displacement function with weight and widening of joint, so follow-up Xrays should be bearing obtained at 4, 7, 11, and 30 days after fracture.

Dtsch Arztebl Int. 2014 May; 111(21): 377–388. Dtsch Arztebl Int. 2014 May; 111(21): 377–388.

Pediatric Ankle Fracture Distal Radius Fracture (Colles)

• Salter I (all non-displaced) • Surgery is recommended for fractures with shortening of – 6-15%, 10.5 yo average age >3mm, dorsal tilt >10 degrees or intra-articular displacement – Stable fracture, immobilization is boot for 3-4 weeks or until non-tender to palpation over physis or step-off >2mm. • Salter II • Unsure if surgery for patients over age 55 is recommended – 75%, concern for growth arrest • Rigid casting preferred to removable splints for non-operative – Immobilization for 3-4 weeks, then transition to weight-bearing for additional 2-3 weeks management • Salter III • Can use removable splints when treating non-displaced – 8%, 8-12 years old, potential for growth arrest fractures – Non-displaced can cast/boot, usually displaced and require ORIF • Salter IV • No evidence to support immobilization of the elbow in cast – 10%, 8-11 year old immobilization – Treatment similar to SIII, most require ORIF • Recommend following fractures with serial radiographs for 3 •Salter V weeks and at the end of immobilization – Very rare, about 1% of cases, hard to diagnose, no specific algorithm for treatment

http://www.podiatryinstitute.com/pdfs/Update_2015/2015_26.pdf http://www.aaos.org/research/guidelines/drfguideline.pdf

Distal Radius Fracture (Colles) Metatarsal Fractures

• Most are transverse or oblique • Displacement is usually minimal unless multiple MT are fractured

Am Fam Physician. 2007 Sep 15;76(6):817-26.

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Metatarsal Fracture Fifth Metatarsal Fracture

• Treatment • Three distinct fracture – Reduction needed for displacement >3-4mm or if zones are present in plantar angulation >10 degrees fifth MT with each zone – Most treated with soft elastic treated differently dressing with firm, supportive shoe (post-op • 1-Tuberosity (Avulsion) shoe) – If pain despite the post-op Fx (Dancer’s Fx) shoe, patient can be placed in short walking boot for • 2- Metaphyseal- comfort Diaphyseal Fx (Jones) – Repeat xray in one week, then again at 4-6 weeks post • 3- Diaphyseal Stress Fx injury – Usually heal within 6 weeks

Am Fam Physician. 2007 Sep 15;76(6):817-26. Am Fam Physician. 2007 Sep 15;76(6):817-26.

Fifth Metatarsal Fracture Fifth Metatarsal Fractures

• Zone 1- Tuberosity • Treatment Avulsion fractures (Dancer’s) – Non-displaced – Ankle inversion with avulsion fractures plantar flexed foot (Zone 1) • Zone 2- Jones Fx • Post-op shoe may be – Vertical/mediolateral used force to lateral aspect of • Short walking boot if plantar flexed foot post-op shoe still too • Zone 3- Diaphyseal painful Stress • Heal usually in 3-6 – Chronic overloading, weeks jumping/pivoting activities

Am Fam Physician. 2007 Sep 15;76(6):817-26. Am Fam Physician. 2007 Sep 15;76(6):817-26.

Zone2/3 Fracture Treatment Zone 2/3 Fractures

Jones Fracture Diaphyseal Stress

Am Fam Physician. 2007 Sep 15;76(6):817-26.

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Vertebral Compression Fractures Vertebral Compression Fracture

• 1.5 million annually in the US • 25% of all post-menopausal women in the US will get one fracture within their lifetime • Prevalence increases with age reaching 40% by age 80 • Incidence of 10.7/1000 in women and 5.7/1000 in men • Common is Asian/Caucasian women and less common in African-American women • Most common cause is osteoporosis, but trauma, infection, and neoplasm can cause

Perm J. 2012 Fall; 16(4): 46–51. Perm J. 2012 Fall; 16(4): 46–51.

Vertebral Compression Fracture Vertebral Compression Fractures

• Treatment • Operative Treatment – Nonsurgical approach is preferred – Has gained popularity – Short period of rest followed by gradual – Produces rapid, significant, and sustained mobilization with external bracing improvements in back pain, function and – Hyperextension bracing is used, beneficial for quality of life the first few months until pain resolves – Indicated for intractable pain failing – Immobility can lead to morbidity conservative therapy – Percutaneous vertebroplasty and kyphoplasty

Perm J. 2012 Fall; 16(4): 46–51. Perm J. 2012 Fall; 16(4): 46–51.

Vertebroplasty versus Kyphoplasty Hip Fractures

• Women experience 80% of all hip fractures • Average age at time of fracture is 80 • Lifetime prevalence is 20% for women and 10% for men • Estimated annual cost to US is approximately 10.3-15.2 billion dollars • Increased mortality-12-17% of patients with hip fracture die within 1 year of fracture

Am Fam Physician. 2014 Jun 15;89(12):945-51.

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Hip Fractures Splinting

• Surgery is most viable • Reasons option for most patients • Non-surgical reserved – Decrease movement and provide support to those with severe – Stabilization of an injury debilitation, unstable – Stabilization of non-emergent injuries until patients with uncorrectable diseases, patient can be evaluated by specialist non-ambulatory – Stabilization of injury giving time for swelling patients or patients at to improve prior to casting end stages of a terminal disease

Am Fam Physician. 2014 Jun 15;89(12):945-51.

Splinting Common Splints

 Ulnar gutter splint • Contraindications  Radial gutter splint – Complicated fractures  Thumb spica splint  Dorsal extension block splint – Open fractures  Aluminum u-shaped splint – Associated neurovascular compromise  Mallet finger splint  Volar/dorsal splint  Sugar tong splint- single vs double  Long arm posterior splint  Posterior ankle splint  Stirrup splint  Posterior knee splint

Ulnar Gutter Splint Radial Gutter Splint

•4th/5th Metacarpal Fx •2nd/3rd Metacarpal Fx • Boxer’s Fx •2nd/3rd •4th/5th proximal/middle proximal/middle phalanx Fx phalanx fx • 29125 • Distal radius fx • 29125

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Thumb Spica Splint Volar/Dorsal Forearm Splint

• Scaphoid Fx • Soft tissue injury to • Ligamentous injury to hand and wrist thumb • Carpal bone •1st Metacarpal base fx dislocation or fx • de Quervain’s (scaphoid/trapezium) tenosynovitis • 29125 •1st CMC arthritis • 29130

Sugar Tong Splint Long Arm Posterior Splint

• Distal ulna and radius • Elbow injuries fx • Proximal and • 29125 midshaft forearm injuries • Wrist injuries • Distal radius and/or ulna fx in children • 29105

Posterior Ankle Splint Stirrup Splint

• Ankle sprains • Acute ankle injuries • Malleolar fx • Malleolar fx • Acute Foot fx • 29515 • Achilles injuries • 29515