Splints and Traction Lecture Notes - Orthopedics - PDF

https://www.slideshare.net/vhjokhi/splint-ppt-by-rupeshkumar SPLINTS BY ASS.PR.DR WAHID M. HASSAN ...

https://www.slideshare.net/vhjokhi/splint-ppt-by-rupeshkumar SPLINTS BY ASS.PR.DR WAHID M. HASSAN  What is a splint? A splint is a rigid support with padding made from metal, plaster or plastic. It is used to support, protect, or immobilize an injured or inflamed part of the body. The splint is secured in place with an elastic bandage or an ACE wrap. The purpose of the splint is to prevent movement of the injured extremity which helps prevent further injury and to minimize pain  Indications for Splinting Sprain is an injury to the ligaments and capsule of a joint. Fractures Strain is an injury to muscles or tendons. Sprains injury to the ligaments around a joint Joint infections Tenosynovitis inflammation of the fluid-filled synovium within the tendon sheath Acute arthritis / gout Lacerations over joints Puncture wounds and animal bites of the hands or feet  To reduce/prevent contracture To increase grip strength To stabilize and rest joint in ligamentous injury To correct deformity To support and immobilize joints and limbs postoperatively until healing has occured  Contraindications of Splinting ▪Compartment syndrome ▪Skin at high risk for infection  Splinting Material Plaster of Paris Made from gypsum - calcium sulfate dehydrate Exothermic reaction when wet - recrystallizes (can burn patient) Average setting time – 3-9 min Average drying time – 24-72 hours Time from mixing gypsum powder with water until half-hardened gypsum is called initial setting time, while the final setting time is the time from mixing until the material hardens and can be removed from the mold  Factors decreasing setting time :- Hot water, Salt, Borax, Resins Factors increasing setting time :- Cold water, sugar Upper extremities :– use 8-10 layers Lower extremities :-12-15 layers up to 20 if big person (increased risk of burn!)  Advantage Disadvantage Easier to mold More difficult to apply Less expensive Gets soggy when getting wet  Splinting Material Ready Made Splinting Material (1) Plaster (OCL) 10 -20 sheets of plaster with padding and cloth cover (2) Fiberglass (Orthoglass) Cure rapidly (20 minutes) Less messy Stronger, lighter, wicks moisture better Less moldable Disadvantage More expensive More difficult to mold (3) Prefabricated splints Plastic shells lined with air cells, foam or gel components Same advantages and disadvantages as fiberglass splints (4)Air splints Provide less support than plaster and fiberglass Splints Used for ankle sprains rather than fractures or Dislocations Used to prevent eversion/inversion while permitting free flexion and extension of ankle Provides clear view of injury during x-ray (4) Vacuum splints - Styrofoam chips contained inside an airtight cloth, pliable sleeve - Molds to shape of injury using a handheld pump to draw out the air from within the sleeve  Pre / Post - Splint Checks F – Function A – Arterial Pulse C – Capillary Refill T – Temperature (Skin) S - Sensation  Choose your splints Upper Extremity Shoulder And Arm Hand/Fingers - Figure of eight Ulnar Gutter - Sling and Swathe Radial Gutter - Aeroplane splint Thumb Spica Elbow/Forearm Finger Splints Knuckle-bender splint Long Arm Posterior Double Sugar - Tong Forearm/Wrist Volar Forearm / Cockup Sugar - Tong Lower Extremity Spine Hip and Thigh - Cervical Collar Von Rosen’s Splint - Four-post Collar Thomas Splint - SOMI (Sternal Occipital Bohler-Braun Splint Mandibular Immobilizer) Knee Knee Immobilizer / Bledsoe - Scoliosis Bulky Jones - Milwaukee Brace Posterior Knee Splint - Boston Brace Taylor’s Brace Ankle Posterior Ankle Stirrup Foot Denis-Brown splint Buddy taping  Traction 1. Manual Traction 2. Skin Traction 3. Skeletal Traction Traction: act of drawing or exerting pulling force applied to limbs or bones along the longitudinal axis to pull the tissues apart for realignment. Indications: Reduce fractures , reduce dislocations , hold fractures , relieve pain , correct soft tissue contractures. Upper Extremity  Choose your splints Upper Extremity Shoulder And Arm Hand/Fingers - Figure of eight Ulnar Gutter - Sling and Swathe Radial Gutter - Aeroplane splint Thumb Spica Elbow/Forearm Finger Splints Knuckle-bender splint Long Arm Posterior Double Sugar - Tong Forearm/Wrist Volar Forearm / Cockup Sugar - Tong  Shoulder and Arm (1) Figure of eight Indications: – Clavicle fractures Most figure of eight splints are prefabricated and Application is simple. Apply with patient standing and hands on iliac crest. Shoulders should be abducted  (2) Sling and Swathe Indication: – Shoulder and humeral injuries Slings supports weight of shoulder Swathe holds arm against chest to prevent shoulder rotation Apply the sling and swath with the patient standing. Place the injured arm in the sling with the elbow at 90 degrees of flexion. Next place the strap that is attached to the sling over the patient head so that the weight of the arm is supported  Sling and Swathe Apply the swath. – This can be anything from an ACE wrap to a prefabricated swath. This is designed to hold the patients affected arm that is in the sling against the body. The swath should wrap around the front and back of the sling keeping the affected extremity against the mid-abdomen  (3) Aeroplane Splint Indication- Brachial plexus injury  Elbow/Forearm https://m.youtube.com/watch?v=kXyGIqvYWts (1) Long Arm Posterior Indications: - Forearm and elbow injuries - Olecranon and radial head fractures - Distal humeral fracture Not recommended for unstable fractures Applied from palmer crease extending up to posterior arm with elbow flexed at 90 degrees NOTE - Doesn’t completely eliminate supination / pronation – either add an anterior splint or use a double sugar-tong if complex or unstable distal forearm fx. Long Arm Posterior  (2) Double Sugar - Tong Indications :- - Elbow and forearm fx - prox/mid/distal radius and ulnar fx. Better for most distal forearm and elbow fx because limits flex/extension and pronation / supination. (2) Double Sugar - Tong  Forearm/Wrist (1) Volar Forearm / Cockup Indications: - Distal forearm and wrist fractures - Soft tissue hand / wrist injuries - sprain,carpal tunnel night splints, etc - 2nd -5th metacarpal fx. - Radial Nerve palsy Applied from volar palmer crease to 2/3 forearm Allows elbow and finger ROM NOTE - Not used for distal radius or ulnar fx - can still supinate and pronate. Volar Forearm / Cockup  (2) Forearm Sugar - Tong Indications – Wrist and distal forearm fractures Extends from MCP joints on dorsum of hand, tracks along the forearm, wraps around back of elbow to volar surface of the forearm and extends down to mid-palmer crease Immobilises wrist, forearm, and elbow Forearm Sugar - Tong  Hand/Fingers (1) Ulnar Gutter Splint (2) Radial Gutter Splint Indications: Indications – Phalangeal and metacarpal - Fractures, phalangeal and fractures metacarpal and soft tissue Most common use-Boxer injuries of the index and fractures middle fingers. 5th MCP fracture Soft tissue injury to little and ring finger.  Ulnar Gutter Splint Extends from DIP joint to the proximal 2/3 of the forearm Should immobilize the ring and little finger MCP should be in 70 degrees of flexion, PIP should be in 30 degrees of flexion and DIP in no more than 10 degrees of flexion  Ulnar Gutter Splint  Ulnar Gutter Splint Radial Gutter Splint  (3) Thumb Spica Indications: – Scaphoid fractures , thumb phalanx fractures or dislocations Most Common use: 1) Gamekeepers thumb or skiers thumb 2) Dequiervans tenosynovitis Extends from DIP joint of thumb, incorporates the thumb and extends up 2/3 of the proximal lateral forearm Skier's thumb: acute partial or complete rupture of the ulnar collateral ligament (UCL) of the thumb’s MCP joint due to a hyperabduction trauma of the thumb Thumb Spica (4) Finger Splints Sprains - dynamic splinting (buddy strapping). Dorsal/Volar finger splints - phalangeal fx, though gutter splints probably better for proximal fxs.  Finger Splints (a) Stack Splint Use – management of mallet finger  (b) Aluminium Splint Uses - phalangeal fx, -mallet finger (c) Oval-8 Finger splint Oval-8 Finger splint Finger splints  (d) Tripoint Splint Uses – Boutonniere deformity , Swan neck deformity Tripoint Splint (5) Knuckle-bender Splint Indication- Ulnar Nerve Palsy Lower Extremity Lower Extremity Spine Hip and Thigh - Cervical Collar Von Rosen’s Splint - Four-post Collar Thomas Splint - SOMI (Sternal Occipital Bohler-Braun Splint Mandibular Immobilizer) Knee Knee Immobilizer / Bledsoe - Scoliosis Bulky Jones - Milwaukee Brace Posterior Knee Splint - Boston Brace Taylor’s Brace Ankle Posterior Ankle Stirrup Foot Denis-Brown splint Buddy taping  (1) Von Rosen’s Splint Indication – Congenital dislocation of the Hip ‘H’ shaped malleable splint Hip should be properly reduced before it is splinted Object is to held hip somewhat flexed and abducted Extreme positions are avoided and Joint should allowed some movement in the splint  (2) Hip Spica Cast Uses- Fracture shaft of femur in children and in young adults once the fracture becomes ‘sticky’ encircles one or both legs and the chest or trunk. It generally is strengthened with a reinforcement bar.  Hip Spica Cast When applied to a lower extremity , the cast is trimmed in the anal and genital areas to allow elimination of urine and stool. Hip Spica Cast (3) Thomas Splint Devised by H.O. Thomas initially for T B of the knee. Indication - Now commonly used for immobilisation of hip and thigh injuries It has a ring and two bars joined distally. The ring is at an angle of 120 degree to the inside bar The ring size is found by addition of 2 inches to the thigh circumference at the highest point of the groin The length is the measurement from the highest point on the medial side of the groin up to the heel plus 6 inches. Thomas Splint - used as traction splint  (4) Bohler-Braun Splint Indication ;- Fracture femur – anywhere More convenient than Thomas splint since it has no ring. As the ring of Thomas splints is a common cause of discomfort, especially in old people. No in-built system of counter-traction ,hence it is not suitable for transportation.  Knee (1) Knee Splint Indications: - knee injuries - proximal Tib/fib fractures Place knee in full extension or 15 degrees flexion. The plaster is placed from the posterior buttocks to 3 inches above level of bilateral malleoli Knee Splint  Ankle (1) Posterior Ankle Splint Indications - Distal tibia/fibula fx. - Reduced dislocations - Severe sprains - Tarsal / metatarsal fx Use at least 12-15 layers of plaster. Placed from metatarsal heads on plantar surface foot, extends up back of leg to level of fibular neck NOTE - Adding a coaptation splint (stirrup) to the posterior splint eliminates inversion / eversion - especially useful for unstable fx and sprains.  (2) Stirrup Splint Indications - Similar to posterior splint. - Unstable ankle fx Less inversion /eversion and actually less plantar flexion compared to posterior splint. Great for ankle sprains. 12-15 layers of 4-6 inch plaster.  Stirrup Splint The splint should be long enough to involve the leg from below the medial side of knee, wrap around the under surface of the heel, and back up to the lateral side of the same knee. Stirrup Splint  Foot (1) Denis-Brown splint Indication – Congenital Talipes Equino Varus (C.T.E.V.) Used after successful correction of deformity ,to prevent relapse. used throughout the day before child starts walking. Once child starts walking ,a DB splints is used at night and CTEV shoes during the day. Denis-Brown splint  (2) Buddy strapping Indications: – Phalangeal fractures of the toes Small piece of wadding placed between toes to prevent maceration Fractured toe secured to adjacent toe with tape  Buddy strapping Use a small piece of wadding and place between the injured toe and an adjacent toe to prevent maceration The fractured toe is secured to the adjacent toe with a piece of tape  Spine Spine Boston Brace: Used for thoracic or lumbar scoliosis, for curves between 20-40 degrees. Milwaukee Brace: used for thoracic curves, especially in adolescents. Taylor Brace: used for lumbar scoliosis. Lyon Brace: used mainly for adolescent idiopathic scoliosis. Boston for thoracic scoliosis (high degree curved) Milwaukee for high thoracic curve (commonly used in adult) Lower Extremity Spine Hip and Thigh - Cervical Collar Von Rosen’s Splint - Four-post Collar Thomas Splint - SOMI (Sternal Occipital Bohler-Braun Splint Mandibular Immobilizer) Knee Knee Immobilizer / Bledsoe - Scoliosis Bulky Jones - Milwaukee Brace Posterior Knee Splint - Boston Brace Taylor’s Brace Ankle Posterior Ankle Stirrup Foot Denis-Brown splint Buddy taping  (1) Cervical Collar Flexible foam/Rigid/Adjustable collar Encircles the neck to support the skull against the thorax inferiorly Motion control and keeping warm at cervical level Soft tissue injury, minor sprains for first few days after injury Post operative immobilisation Note :- They are not useful for very unstable injury pattern Cervical Collar Soft Cervical Collar Commonly used for mild soft tissue strains and sprains Cervical Collar Semi-Rigid Cervical Collar Can provide access to the trachea Moderate Control of ROM Adjustable  (2) Four-post Collar Indication – Neck immobilisation in cervical spine injury More stable than cervical collar Applying pressure to mandible , occiput , sternum and upper thoracic spine They can be uncomfortable  (3) SOMI (Sternal Occipital Mandibular Immobilizer) Uses ––cervical Uses cervicalspine injuries spine Rigid injury Rigid FrameDesign Frame Design Commonly used in stable fractures and Moderate to Severe soft tissue damage Limits Flexion and Extension Extends Inferior into the Thoracic Region for greater control of all cervical levels  (4) Milwaukee Brace Indication- Scoliosis Named after the city of Milwaukee where it was designed. It fits snugly over the pelvis below; chin and head pads promote active postural correction and thoracic pad presses on the ribs at the apex of the curves  (4) Boston Brace Indication-Scoliosis Used for low curves Worn 23 Hours / Day Made of semi-rigid plastic and foam (5) Lyon Brace Indication-Scoliosis (6) SpineCore Brace Indication-Scoliosis  (7)Taylor’s Brace Indication – Dorso-lumbar Immobilisation Anterior Compression Fractures of the vertebral body Semi rigid design Commonly used for osteoporosis, trauma, Degenerative spine disease  Traction  Traction Traction is a pulling effect exerted on a part of the skeletal system. It is a treatment measure for musculoskeletal trauma and disorders. Traction is used to : Reduce muscle spasms Realign bones Relieve pain Prevent deformities Types of Traction  1. Manual Traction Manual traction means pulling on the body using a person's hands and muscular strength. It most often is used briefly to realign a broken bone. It also is used to replace a dislocated bone into its original position within a joint. Manual Traction  2. Skin Traction Skin traction means a pulling effect on the skeletal system by applying devices, such as a pelvic belt and a cervical halter to the skin. Commonly applied forms of skin traction are – Buck's traction Russell's traction Bryant’s (gallows) traction Dunlop traction  Skin Traction Limited force can be applied - generally not to exceed 1/10 kg body weight. More commonly used in pediatric patients Can cause soft tissue problems especially in elderly or rheumatoid patients Not as powerful when used during operative procedure for both length or rotational control  Skin Traction A)Pelvic Traction (B) Cervical halter.  (1) Pelvic Traction Uses –Relief pain of Sciatica and other backaches Traction is applied to a pelvic harness with weights over the end of bed An alternative in Sciatica is the 90-90 traction  (2) Cervical halter Uses - short term cervical traction -minor neck injuries e.g. Whiplash injury, neck muscle spasm , conservative treatment of cervical disk lesion Note – Contraindicated in mandibular fracture  (3) Buck's traction Uses - femoral fractures, lower backache Acetabular and hip fractures Conventional skin traction  Buck's traction Provide temporary comfort in hip fractures Maximal weight 4.5-5 Kg Watch closely for skin problems, especially in elderly or rheumatoid patients (4) Russell's traction Uses - Trochanteric fractures  (5) Gallows traction Uses- fracture shaft of femur in children below 2 years Imp –check the state of th circulation in the limb frequently , because of danger of vascular complications  Bryant’s Traction Useful for treatment femoral shaft fx in infant or small child Combines gallows traction and Buck’s traction Raise mattress for counter traction Rarely, if ever used currently  (6) Dunlop traction Use- mainly used in the maintenance of reduction in supracondylar fractures of humerus in children. Forearm skin traction with weight on upper arm Elbow flexed 45 degrees Allows swollen elbow to settle Contraindicated in open fractures and skin defects Dunlop traction  (7) Femoral Traction Older Child in Balkan Frame Indications Child> 12 kg Femoral fractures Skin must be intact Balkan Frame  3. Skeletal Traction Skeletal traction means pull exerted directly on the skeletal system by attaching wires, pins, or tongs into or through a bone. Skeletal traction is applied continuously for an extended period.  Skeletal Traction More powerful than skin traction May pull up to 20% of body weight for the lower extremity Requires local anesthesia for pin insertion if patient is awake Preferred method of temporizing long bone, pelvic, and acetabular fractures until operative treatment can be performed (1) HALO TRACTION Rigid Frame Design Commonly used in unstable fractures Limits All motion Extends Inferior into the Thoracic Region for greater control of all cervical levels Screws Directly into the skull Disadvantages - Pin problems - Respiratory compromise HALO TRACTION BRACE (2) Gardner Wells Tongs Used for C-spine reduction / traction Pins are placed one finger breadth above pinna, slightly posterior to external auditory meatus Apply traction beginning at 5 lbs. and increasing in 5 lb. increments with serial radiographs and clinical exam  (3) Olecranon Traction Uses - supracondylar and comminuted fractures of lower end of the humerus and unstable fracture of shaft of humerus Rarely used today Small to medium sized pin placed from medial to lateral in proximal olecranon - enter bone 1.5 cm from tip of olecranon and walk pin up and down to confirm midsubstance location. Support forearm and wrist with skin traction - elbow at 90 degrees  (4)Distal Femoral Traction Uses- Method of choice for acetabular and proximal femur fractures If there is a knee ligament injury usually use distal femur instead of proximal tibial traction Place pin from medial to lateral at the adductor tubercle - slightly proximal to epicondyle  (5) 90-90 Traction Useful for subtrochanteric and proximal 3rd femur fx Especially in young children Matches flexion of proximal fragment Can cause flexion contracture in adult  (6) Acetabular Traction Uses- to maintain reduction in central fracture dislocation of acetabulum  How do I take care of the splint? Do not get the splint wet. Use plastic bags to cover the splint while bathing. Do not walk on the splint. Do not stick anything down the splint Such as a coat hanger to scratch or itch. This may lead to injury and infection. What danger signs should to look for? Numbness, tingling, increased pain, change in coloration of fingers or toes, or swelling in fingers or toes.  Complications Burns - Thermal injury as plaster dries - Hot water, Increased number of layers, extra fast-drying ,poor padding all increase risk - If significant pain - remove splint to cool Ischemia - Do not apply Webril and ace wraps tightly - Instruct to ice and elevate extremity - Close follow up if high risk for swelling, ischemia. - When in doubt, cut it off and look Remember - pulses lost late. Pressure sores Smooth Webril and plaster well Infection - Clean, debride and dress all wounds before splint application - Recheck if significant wound or increasing pain TH AN K , D YO ea U r