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 2 11/2/2016 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 3 11/2/2016 Distal Radius Fracture Distal Radius Fracture Imaging • AP/lateral radiographs of wrist, forearm and elbow • Consider CT if intra- articular, 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 4 11/2/2016 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. 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. 5 11/2/2016 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. 7 11/2/2016 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