Practical Techniques in Injury Management CASTS AND SPLINTS

Transcription

1 Practical Techniques in Injury Management CASTS AND SPLINTS

2 SEPTEMBER 2006 Prepared by the Accident and Medical Practitioners Association and the ACC Provider Development Unit Endorsed by NZ Orthopaedic Association and the Decade of Bone and Joint ACC P O Box 242, Wellington, New Zealand Phone (Provider Helpline)

3 Contents Contents... 1 Introduction... 3 Above Elbow Backslab (Adult)... 5 Below Elbow Backslab (Adult)...6 Below Elbow Complete Cast (Adult)... 7 Above Elbow Complete Cast (Adult)...8 Below Knee Complete Cast(Adult)...9 Below Knee Backslab (Adult) Volar Slab ( of Splint)...11 Scaphoid Cast Bennett s Cast...13 Cast Check Buddy Strapping Fingers and Toes...15 Mallet or Stax Splint Finger Splint Knee...17 Velcro Brace Wrist Spica Strapping Thumb Taping Knee...20 Taping Ankle Sling High Arm Sling Broad Arm Sling Collar and Cuff Compression Bandaging Wrist, Ankle, and Knee R.I.C.E. Rest, Ice, Compression, Elevation

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5 Introduction Although the treatment of sprains and strains is common in primary care, treatment providers can often be unaware of tips and techniques that help optimise recovery. Fractures are less frequently encountered, and yet the application of a plaster cast can be quite difficult. Skills can be easily lost through lack of day-to-day practice. This publication and the accompanying DVDs aim to provide a ready reference with easy to follow instructions on the application of a range of plaster casts and the management of soft tissue injuries. We hope this will be a useful resource for you in your practice. Some may find it contains new techniques that are useful, while for others it will serve as a reminder of some of the finer points in injury management. The material has been prepared by experienced practitioners and has been through a rigorous validation process with comments from specialists, GPs, and nurses. Pages are laminated so the book can be left in the procedure room and wiped down if plaster sprays onto the pages. By providing guidance on these practical techniques for treating common injuries our hope is that this will assist you in fostering an early return to work or independence for injured New Zealanders. I trust it will be a useful addition to your knowledge base. Gerard McGreevy Chief Operating Officer Accident Compensation Corporation 3

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7 Above Elbow Backslab (Adult) Acute distal radius and ulna fractures greater than 2.5cm from epiphysis of the radius Clinical fractures of elbow, hand, wrist or forearm Forearm and elbow fractures Refer to Treatment Profiles for relevant diagnostic tests. Immobilise elbow and wrist allowing full movement of fingers. Wrist in neutral, limb held by assistant with elbow at 90 Proximal limit axilla, leaving shoulder free Distal limit proximal palmar crease. Refer to Treatment Profiles for time off work guidelines Often used when transporting to secondary site for definitive treatment and/or diagnosis. Double thickness 15 20cm slab POP 2 x 10cm slab for struts (Fig 3). Apply double layer cast padding from proximal palmar crease to axilla, ensuring no edges in elbow crease (Fig 1) Measure slab from palmar crease to 2cm distal to axilla Wet slab; apply from palmar crease to axilla covering 50% of dorsal and ventral surfaces of wrist, forearm and upper arm along ulnar border of limb (Fig 2) Wet 10cm slabs; apply struts to elbows as shown in diagram (Fig 3) Turn back padding Apply bandage firmly (Fig 4) Put arm in broad arm sling for forearm fractures or a collar and cuff (Fig 5) for elbow injuries. Post Follow-up Cast care instructions given in multiple languages Cast check 24 hours Removal of cast dependent on injury and age of patient. fig 5 fig 6 5

8 Below Elbow Backslab (Adult) Acute distal radius and ulna fractures less than 2.5 cm from epiphysis of the radius Severe soft tissue injuries of wrist or forearm Clinical factures of wrist or forearm Refer to Treatment Profiles for relevant diagnostic tests. To provide immobilisation allowing movement of fingers and elbow and to allow rotation of forearm. Refer to Treatment Profiles for time off work guidelines Often used when transporting to secondary site for definitive treatment and or diagnosis. Wrist in neutral (Fig 3) Proximal limit 4cm distal to elbow crease Distal limit proximal palmar crease. Stockinet Cast padding POP slab double thickness Bandage and sling. Below elbow cast incorrect Apply stockinet to forearm Cut hole for thumb Apply single layer of padding from proximal palmar crease to 4cm distal to elbow crease with double layer over bony prominences Cut slab to shape (Fig 1) Check slab length on arm extending from proximal palmar crease to 4cm from elbow crease Dip slab in water holding both ends and squeeze gently maintaining shape Lay on dorsal aspect of forearm ensuring MCP joints are visible and there is a gap along ventral surface (Fig 2) Turn back stockinet (Fig 3) Apply wet bandage (Fig 4) Apply sling. Post Follow-up Cast care instructions given in multiple languages Cast check 24 hours Complete cast in one week if required. POP too distal to palmar crease POP not close enough to elbow Pressure crease at wrist. 6

9 Below Elbow Complete Cast (Adult) Non-acute distal radius and ulna fractures less than 2.5cm proximal to the distal radial epiphysis Refer to Treatment Profiles for relevant diagnostic tests. Contra-indications Acute injuries or gross swelling. Immobilise wrist Allow full movement of MCPs and elbow. Refer to Treatment Profiles for time off work guidelines. Wrist in neutral Proximal limit 4cm distal to elbow crease Distal limit proximal palmar crease. Stockinet Cast padding 10cm slabs for reinforcing 1 2 rolls of 7.5cm POP. Apply stockinet to forearm Cut hole for thumb Apply single layer of padding from palmar crease to 4cm distal to elbow crease with double layer over bony prominences Cut double layer POP slab to reinforce the ulnar border and a hand piece split for thumb web space (Fig 1) Apply wet POP slabs as shown (Fig 2) Turn over edges of stockinette/padding Complete cast with roll of POP Mould well while POP setting (Fig 3) Leave cast with smooth finish (Fig 4) Apply sling. Post Follow-up Cast care instructions given in multiple languages Cast check 24 hours Removal of cast dependent on injury and age of patient. 7

10 Above Elbow Complete Cast (Adult) Post-acute radius and ulna fractures more than 2.5cm proximal to distal radial epiphysis Non-acute forearm and elbow fractures Refer to Treatment Profiles for relevant diagnostic tests. Contra-indications Acute fractures Swelling of wrist, forearm or elbow. Provides immobilisation of elbow and wrist while allowing full movement of fingers Prevents rotation of forearm. Forearm in neutral/pronation/ supination Limb held by assistant Elbow at 90 Proximal limit axilla, leaving shoulder free Distal limit proximal palmar crease. Refer to Treatment Profiles for time off work guidelines. Stockinet Cast padding POP slabs as shown 2-3 rolls cm POP. fig 5 Cut POP as indicated (Fig 1) Assistant to hold fingers as shown (Fig 2) Apply stockinet to arm, adjusting around elbow to prevent creases. Cut hole for thumb Apply single layer of cast padding from palmar crease to 2cm distal to axilla, ensuring no edges in elbow crease by applying in figure of 8 around elbow (Fig 3) Wet and apply reinforcing slabs (Fig 4) Wet and apply 1 POP roll from palmar crease to 2cm distal to axilla Turn over edges of stockinet Complete cast by applying last rolls of POP (wet) and smooth cast surface (Fig 5) Mould well at wrist and elbow to ensure snug fit Broad arm sling. Post Follow-up Cast care instructions given in multiple languages Cast check 24 hours Follow-up dependent on injury. 8

11 Below Knee Complete Cast(Adult) Post-acute fractures of ankle and foot Refer to Treatment Profiles for relevant diagnostic tests. Contra-indications Swelling of ankle and foot Acute injury (use below knee back slab). To immobilise ankle and foot while allowing movement of toes and knee joint. Refer to Treatment Profiles for time off work guidelines. Avoid common peroneal nerve behind fibular neck. 90 o Ankle at 90 Proximal limit tibial tuberosity, and 1cm below (distal to) fibular head to avoid damage to common peroneal nerve Distal limit web of toes. Wedge Assistant Stockinet Cast padding 15cm POP slab 2 x 15cm POP rolls. Patient supine, quadriceps relaxed Wedge under knee, assistant holding toes (Fig 1). Try to keep knee bent to relax gastrocnemius Apply stockinet Apply cast padding distal to tibial tuberosity down to web of toes, double layer over bony prominences. Do not overpad ensuring snug fit Wet and apply 1 x 15cm POP roll distal to tibial tuberosity to toes (Fig 2) Measure and apply wet slab posteriorly, moulding well around ankle (Fig 3) Turn back padding Apply 2nd POP roll (Fig 4) Mould well, leaving cast with smooth finish. Post Follow-up Cast care instructions given in multiple languages Emphasise to the patient that they must not weight-bear Crutches should be used until further instructed, or until rocker is added Crutches demonstration and instructions Cast check 24 hours Follow up dependent on injury. 9

12 Below Knee Backslab (Adult) Acute fractures of tarsals / metatarsals Acute fractures of distal tibia/fibula Severe soft tissue injuries of foot, ankle or lower leg Refer to Treatment Profiles for relevant diagnostic tests. Ankle immobilisation for acute lower leg, ankle or foot injuries. Ankle at 90 Proximal limit tibial tuberosity, and 1cm below (distal to) fibular head to avoid damage to common peroneal nerve Distal limit web of toes. Refer to Treatment Profiles for time off work guidelines Often used when transporting to secondary site for definitive treatment and/or diagnosis Avoid common peroneal nerve. Wedge Assistant Cast padding 15cm crepe bandage 15-20cm POP slab double thickness 10cm POP slab for ankle struts. fig 5 Below knee cast incorrect Patient supine, quadriceps relaxed Must keep knee bent to relax gastrocnemius Wedge under knee, assistant holding toes (Fig 1) Apply double layer of cast padding, extra around malleoli and shin Pre-measure slab to fit from tibial tuberosity and distal to fibular head down to web of toes Wet and apply double thickness slab (Fig 2) Measure 10cm slab down each side of leg and under foot Wet and apply as shown (Fig 3) and (Fig 4) Turn back padding Apply crepe bandage (Fig 5) Ensure patient can fully extend and flex knee and toes. Post Follow-up Cast care instructions given in multiple languages Emphasis to patient that they must not weight-bear Crutches should be used until further instructed or until rocker is added Cast check 24 hours Removal of cast, dependent on injury and age of patient. Below knee cast incorrect POP proximal to tibial tuberosity Ankle inverted and plantarflexed POP too distal covering little toes POP wrinkled at ankle. 10

13 Volar Slab ( of Splint) Finger and hand fractures Finger, hand, tendon and ligament injuries Severe soft tissue injuries of the hand Refer to Treatment Profiles for relevant diagnostic tests. Provides immobilisation in position of function of wrist, hand and fingers. Wrist 45 dorsiflexion MCP joints 90 Fingers fully extended Proximal limit 4cm distal to elbow crease Distal limit to finger tips. All fingertips must be visible to allow easy assessment of circulation Refer to Treatment Profiles for time off work guidelines Discussion or referral to Specialist is recommended for all hand and finger fractures. Stockinet Cast Padding 10cm POP slab Bandage. Apply stockinet covering all of hand and ensuring it extends far enough past fingertips to allow turnover (Fig 2). Cut hole for thumb Apply single layer cast padding (extra over bony prominences) Measure double thickness POP slab to extend from fingertips to 4cm distal to elbow crease. Trim to fit neatly around thumb Wet slab and apply to hand and forearm (Fig 3) Turn stockinet edges down ensuring that all fingertips are visible Apply bandage and mould to shape (Fig 4 and Fig 5) High arm sling. Post Follow-up Cast check 24 hours Clinical review within seven days Cast care instructions given in multiple languages. fig 5 11

14 Scaphoid Cast Suspected or clinical fracture of scaphoid Significant delay in Xray or specialist assessment If fracture is confirmed or clinical, then referral to specialist should be arranged. In this case it may not be necessary to apply a full scaphoid cast as it will be removed for assessment Refer to Treatment Profiles for relevant diagnostic tests Many surgeons treat scaphoid fractures which do not require ORIF in BE complete cast, allowing some thumb function and ability to work. To hold the thumb in opposition and immobilise wrist. Thumb in opposition Middle finger and thumb forming an O (Fig 1) Wrist in neutral Proximal limit 4cm distal to elbow crease Distal limit to ip joint of thumb and proximal palmar crease Refer specialist opinion Follow up essential Refer to Treatment Profiles for time off work guidelines. Stockinet Cast Padding 10cm slab as diagram 1-2 rolls 7.5cm POP. fig 5 Ensure hand in correct position (Fig 1) Cut POP slabs as shown (Fig 2) Apply stockinet Apply layer of padding around thumb to IP joint and wrist and to 4cm distal to elbow crease (Fig 3) Apply reinforcing slabs to base of thumb (Fig 4) Turn back padding Complete with POP bandage Cut bandage to ensure snug fit around thumb web (Fig 5) Mould well while setting (Fig 6) Ensure full movement of IP joint Apply sling. Post Follow-up Cast care instructions in multiple languages Cast check 24 hours Definite review one week refer specialist Clinical fracture review minimum 14 days for re-xray If Xray fracture or clinical fracture refer specialist. fig 6 12

15 Bennett s Cast Fracture to base of thumb metacarpal (Bennett s fracture) See Treatment Profiles for relevant diagnostic tests. Provides immobilisation of thumb while allowing full movement of fingers. Wrist in neutral with thumb extended (Fig 1) Proximal limit 4cm distal to elbow crease Distal limit tip of thumb and proximal palmar crease. Tip of thumb must be visible to allow easy assessment of circulation Refer to Treatment Profiles for time off work guidelines Referral to, or discussion with, specialist is recommended for all Bennett s fractures. Stockinet Thumb stockinet Cast padding 10cm slab for reinforcing (Fig 3) 1-2 rolls 7.5cm POP. Ensure hand in correct position (Fig 1) Apply stockinet to arm, separate piece to thumb (Fig 2) Apply single layer of padding from palmar crease to 4cm distal to elbow crease (Fig 4) Wet POP slabs and apply (Fig 5) Fold over edges of stockinet Wet and apply POP roll ensuring smooth finish (Fig 6) Mould well around base of thumb and thenar eminence (Fig 7), keeping thumb abducted Broad arm sling. Post Follow-up Cast care instructions given in multiple languages Cast check 24 hours Clinical review within seven days. fig 5 fig 7 fig 6 13

16 Cast Check Below elbow cast correct Immediately post application At one day 24 hours At any time concerns arise. Below elbow cast incorrect To check appropriate choice of cast To check position To assess function of the limb To minimise complications (iatrogenic or due to the underlying injury). of any cast has the potential to cause serious harm to a patient hence the importance of a cast check Clearly identify proximal and distal limits of cast Refer to Treatment Profiles for relevant diagnostic tests and time off work. POP too distal to palmar crease POP not close enough to elbow Pressure crease at wrist. Appropriate for choice of cast. Specific Advice Elevation advice Crutches demonstration and advice Weight-bearing restrictions Slings Patient-driven problem solving. Below knee cast correct Procedure Below knee cast incorrect Below knee cast incorrect POP proximal to tibial tuberosity Ankle inverted and plantarflexed POP too distal covering little toes POP wrinkled at ankle. Post-application check Check that the appropriate cast has been applied Ask the patient about comfort and fit including tingling numbness pain Examine and document neurovascular status swelling distal limb movement/distal tendon function Check: Pressure points Analgesia requirements Patient knows follow-up instructions for next check/change. Day 1 and subsequent checks Check that this is the cast that was ordered Ask the patient about comfort and fit Ask the patient about pain Examine and document neurovascular status swelling distal limb movement/tendon function condition of cast (any damage?) Check: Pressure points Analgesia requirements Patient knows follow-up instructions for next check/change Split and remove cast if necessary for pain and swelling. General Follow-up Written material: cast care instructions in multiple languages As appropriate: appointment copy of clinical record Xrays. 14

17 Buddy Strapping Fingers and Toes Joint injuries of fingers Some simple fractures of phalanges or metacarpals. Mobilisation Support. Tape leaves PIP and DIP joints free to mobilise. Leaves DIP and PIP joints free. 1cm zinc oxide tape Gauze padding Scissors. Pre-cut gauze to fit between toes and fit in place (Fig 4) Gauze may also be used for fingers Apply two pieces of tape to hold fingers/toes together (Fig 2 and 5) Ensure finger joints are mobile. Post Follow-up Encourage gentle hand movement and use Within one week Replace if loose Release strapping if swelling increases. fig 5 fig 6 15 ACC Pr#11.indd 15 10/26/06 11:50:58 AM

18 Mallet or Stax Splint Finger Mallet finger injuries including Extensor tendon injuries Extensor tendon avulsion fractures of base of terminal phalanx. Immobilisation (DIP Joints) to allow healing of fracture/scarring of extensor apparatus. DIP Joint hyperextended (Fig 2) or neutral Ensure the plastic splint is not loose fitting (results in extension lag). DIP Joint must be neutral or mildly hyper-extended Instruction sheet essential for selfmaintenance The key is not to let the DIP flex even slightly during the period of immobilisation. 1cm zinc oxide tape 2cm elastoplast tape Splints (various sizes) Scissors. Add tubinette and talcum, then apply 1cm tape to finger in figure of 8 position (Fig 3) (maintain) (see Note below) Maintain full extension at DIP joint Avoid hyper-extension as this is painful and skin can necrose Apply splint (Fig 4) Tape splint in place (Fig 5). Note: Some practitioners apply the splint without the initial figure of 8 tape. Post Follow-up Instructions sheet for self maintenance Review if splint is lost or loose Relevant to injury Splint needs to be cleaned daily maintain extension Slide splint off, wash and talcum powder Splint must stay for 6 weeks. fig 5 16

19 Splint Knee Acute knee injuries including Contusions/sprains Patella fractures Ligamentous tears. Immobilisation Support. Knee extended. Partially immobilises knee joint Temporary splint only Early referral if diagnosis/ management unclear. Knee splint Crutches +/- Tubigrip. Patient s leg horizontal (Fig 2) Patella sits in keyhole (Fig 3) Velcro strap firmly tightened (Fig 3) Crutches for walking (Fig 4) Encourage partial weight bearing Tubigrip over skin if swelling present. Post Follow-up Two to three days for reassessment Must take some weight with crutches Concentrate on isometric static quadriceps exercises and lifting leg if possible. 17

20 Velcro Brace Wrist Wrist injuries including Sprains Tenosynovitis Contusions to wrist. Immobilisation Support. Immobilises wrist Temporary splint only Early referral if diagnosis/ management is unclear. of function of wrist and hand. Establish most appropriate size of splint ( Fig 2) Fit firmly to wrist Mould in position of function (Fig 3 and Fig 4). Post Follow-up Patient advice about removal Follow-up depending on injury. Velcro wrist splint. 18

21 Spica Strapping Thumb Injuries to MCP joint at thumb: eg UCL. Partial Immobilisation Support. Prevents radial deviation at MCP Joint Allows movement at IP Joint and wrist Temporary splint only Early referral if diagnosis/ management is unclear. Thumb in neutral. 2cm elastoplast tape Scissors. Apply in figure 8 method (Fig 3) starting distally and overlapping by moving proximally down thumb (Fig 4) Apply final strip in figure 8 then secure around wrist (Fig 5 and Fig 6). Post Follow-up Review at one to two weeks and then at two to four weeks depending on injury. fig 5 fig 6 19 ACC Pr#11.indd 19 10/26/06 11:51:03 AM

22 Taping Knee Medial collateral tears of knee. Immobilisation (partial) Proprioception Support. Shaved skin best Check for contact allergy Tubigrip over strapping if swelling. Standing leg flexion (Fig 2). Leuko 3cm tape Scissors. Standing Apply anchor tape one-hand width above and below knee (Fig 3) Apply cross straps from top anchor to bottom anchor on medial side of knee (Fig 4) Apply successive cross strap layers (Fig 5) Lock anchor straps top and bottom (Fig 6). Post Follow-up Two to four days for review Self-removal if irritation present Emphasise isometric static quadriceps exercises. fig 5 fig 6 20 ACC Pr#11.indd 20 10/26/06 11:51:05 AM

23 Taping Ankle Tears of ankle ligaments. Immobilisation (partial) Proprioception Support. Ankle in neutral Tape follows skin and joint contours Check for contact allergy. Ankle in neutral (Fig 2) (foot at 90 to lower leg). Leuko 3cm tape Scissors. Apply anchor tape one-hand space above ankle (Fig 3) Apply 2 3 stirrups (Fig 4) Stirrup applied from medial side of leg around arch of foot to lateral side Locking tape applied last (Fig 5). Post Follow-up Three to four days for check and /or replacement Self-removal if irritation present. fig 5 21 ACC Pr#11.indd 21 10/26/06 11:51:06 AM

24 Sling High Arm Injuries to hand, fingers and wrist To elevate an injured area above the heart, including: Significant wounds Fractures Dislocations Tendon injuries Soft tissue injuries. Immobilisation Elevation Support. Injured limb s hand on opposite shoulder. High arm sling provides better hand elevation than broad arm sling. Sling Scissors. Sling over injured arm (Fig 1) Point of sling position at elbow (Fig 1 and Fig 2) Lower point rolled under arm (Fig 2) and tied behind neck (Fig 3) Pinned at elbow (Fig 3). Post Follow-up Advice about showering/night-time removal Relevant to specific injury. 22

25 Sling Broad Arm Forearm fractures Casts including below elbow casts Some shoulder injuries fractured clavicles a-c joints Elbow injuries. Immobilisation Elevation Support. Elbow at 90 flexion. Broad arm sling does not provide as much hand elevation as a high arm sling and so is less suited to finger and hand injuries. Sling Scissors. sling under injured arm Point of sling positioned at elbow (Fig 1) Lift lower point and tie behind neck (Fig 2) Pin the elbow (Fig 3) Avoid pressure over the AC joint. Post Follow-up Advice about showering/night-time removal Relevant to specific injury. 23

26 Sling Collar and Cuff Hanging casts Humerus fractures proximal or shaft. Immobilisation Elevation Support. Elbow at 90 flexion Greater flexion may be required for some elbow injuries. A broadarm sling may be more comfortable for elbow and forearm injuries Supporting the weight of the arm is important after shoulder dislocation as the injured tissue needs to tighten with the joint supported, therefore use a sling. Collar and cuff material Scissors. Collar and cuff around neck (Fig 1) One end lower than the other (Fig 1) Fold lower end up and pin to upper end (Fig 2) In children, pin tightly enough to gently trap wrist Can be worn under clothes. Post Follow-up Advice about showering/night-time removal Relevant to specific injury. 24

27 Compression Bandaging Wrist, Ankle, and Knee Any soft tissue injury where swelling is occurring Used to mobilise limb injuries unless used in conjunction with a rigid splint. Limited mobilisation Support. Mould to limb contours Double over for extra compression Use applicator for reduced pain to patient Do not twist or spiral. Hand and forearm leave MCP joints free to move Lower leg leave MTP joint free to move Knee leave knee joint free to move. Tubigrip (various sizes) Use sizing tape Applicator (various sizes) Scissors. Wrist and Hand: Cut thumb hole (Fig 2) Leave MCP joints free to move and for swelling/circulatory assessment. Ankle: Leave MTP joints and toes free. Knee: Extends two-hand breadths above and below the knee joint. Post Follow-up Advice about washing/removal at night. fig 5 fig 6 25 ACC Pr#11.indd 25 10/26/06 11:51:09 AM

28 R.I.C.E. Rest, Ice, Compression, Elevation Acute soft tissue injuries with actual or potential swelling. Minimise swelling by reducing bleeding Reduce pain Reduce further injury. Limb elevated with injured area above the level of the heart (Fig 1). Elevate affected area above the level of the heart where possible Apply ice during first 48 hours Do not apply ice to bare skin Caution use with children, elderly and people with circulatory problems Beware of ice burns which may add complications if ice left in place for too long. Ice (Fig 2 and Fig 3) Plastic bag Cloth wrapping. Rest Rest localised injured area Eg. Upper limb sling, splint Lower limb splints, crutches or cushioned rest Ice 10 minutes every one to two hours for up to 48 hours Compression bandage eg. Tubigrip/padding/crepe monitor often and adjust where necessary Elevation during the acute phase of the injury whenever possible above level of heart (Fig 1). Post Follow-up Encourage ongoing elevation of the injured limb Referral when necessary to ascertain the extent of injury to appropriate health professional. These may include doctor, A & M Clinic, physiotherapist, nurse, paramedic Encourage gentle exercise when comfortable and within limits of pain. 26

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30 ISBN X ACC2373