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Suturing and splintingSuturing and splinting
Presented by
Dr. Osama Kentab, M.D, FAAP, FACEP
Assistant Professor Pediatrics and Emergency Medicine
King Saud bin Abdulaziz University for Health silences
October 2014
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ObjectivesObjectives Describe the principles of wound healing Identify the various types and sizes of suture material. Choose the proper instruments for suturing. Identify the different injectable anesthetic agents and correct dosages. Demonstrate various biopsy methods: punch, excision, shave. Demonstrate different types of closure techniques: simple interrupted,
continuous, subcuticular, vertical and horizontal mattress, dermal Demonstrate two-handed, one-handed, instrument ties Recommend appropriate wound care and follow-up.
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Critical Wound Healing PeriodCritical Wound Healing Period
Tissue
Skin
Mucosa
Subcutaneous
Peritoneum
Fascia
5-7 days
5-7 days
7-14 days
7-14 days
14-28 days
0 5 7 14 21 28
Tissue Healing Time/Days
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Model of Wound HealingModel of Wound Healing (1) Hemostasis: within minutes post-injury, platelets aggregate at the
injury site to form a fibrin clot. (2) Inflammatory: bacteria and debris are phagocytosed and removed,
and factors are released that cause the migration and division of cells involved in the proliferative phase.
(3) Proliferative: angiogenesis, collagen deposition, granulation tissue formation, epithelialization, and wound contraction
(4) Remodeling: collagen is remodeled and realigned along tension lines and cells that are no longer needed are removed by apoptosis.
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Wound Healing ConceptsWound Healing Concepts
Patient factorsWound classificationMechanism of injuryTetanus/antibiotics/local anestheticsSurgical principles and wound prepSuture/needle/stitch choiceManagement/care/follow-up
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Common Patient FactorsCommon Patient Factors
Age Blood supply to the
area Nutritional status Tissue quality Revision/infection Compliance
Weight Dehydration Chronic disease Immune response Radiation therapy
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CDC Surgical Wound ClassificationCDC Surgical Wound Classification
Clean: (1-5% risk of infection) uninfected operative wounds in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed, and if necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria.
Clean-contaminated: (3-11% risk) operative wounds in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered.
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CDC Surgical Wound ClassificationCDC Surgical Wound Classification
Contaminated: (10-17% risk) open, fresh, accidental wounds, operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered.
Dirty or infected: (>27% risk) old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.
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Surgical PrinciplesSurgical Principles
Incision Dissection Tissue handling Hemostasis Moisture/site Remove infected,
foreign, dead areas Length of time open
Choice of closure material/mechanism
Primary or secondary Cellular responses Eliminate dead space Closing tension Distraction forces and
immobilization/care
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Suture MaterialsSuture Materials
Criteria – Tensile strength– Good knot security– Workability in handling– Low tissue reactivity– Ability to resist bacterial infection
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Types of SuturesTypes of Sutures Absorbable or non-absorbable (natural or synthetic) Monofilament or multifilament (braided) Dyed or undyed Sizes 3 to 12-0 (numbers alone indicate progressively
larger sutures, whereas numbers followed by 0 indicate progressively smaller)
New antibacterial sutures
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Non-absorbableNon-absorbable Not biodegradable
and permanent– Nylon (Ethilon)– Prolene– Stainless steel– Silk (natural, can
break down over years)
Degraded via inflammatory response– Vicryl– Monocryl– PDS– Chromic– Cat gut (natural)
AbsorbableAbsorbable
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Natural SutureNatural Suture
Biological Cause inflammatory
reaction– Catgut (connective
from cow or sheep)– Silk (from silkworm
fibers)– Chromic catgut
SyntheticSynthetic
Synthetic polymers Do not cause
inflammatory response– Nylon– Vicryl– Monocryl– PDS– Prolene
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MonofilamentMonofilament Single strand of suture
material Minimal tissue trauma Smooth tying but more
knots needed Harder to handle due to
memory Examples: nylon, monocryl,
prolene, PDS
Multifilament (braided)Multifilament (braided) Fibers are braided or twisted
together More tissue resistance Easier to handle Fewer knots needed Examples: vicryl, silk,
chromic
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Suture MaterialsSuture Materials
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Suture SelectionSuture Selection
Do not use dyed sutures on the skin Use monofilament on the skin as multifilament
harbor BACTERIA Non-absorbable cause less scarring but must be
removed Plus sutures (staph, monocryl for E. coli,
Klebsiella) Location and layer, patient factors, strength,
healing, site and availability
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Suture SelectionSuture Selection
Absorbable for GI, urinary or biliaryNon-absorbable or extended for up to 6 mos
for skin, tendons, fasciaCosmetics = monofilament or subcuticularLigatures usually absorbable
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Suture SizesSuture Sizes
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Surgical NeedlesSurgical Needles
Wide variety with different company’s naming systems
2 basic configurations for curved needles
– Cutting: cutting edge can cut through tough tissue, such as skin
– Tapered: no cutting edge. For softer tissue inside the body
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Surgical NeedlesSurgical Needles
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Surgical InstrumentsSurgical Instruments
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Scalpel BladesScalpel Blades
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Anesthetic SolutionsAnesthetic Solutions Lidocaine (Xylocaine®)
– Most commonly used– Rapid onset – Strength: 0.5%, 1.0%, &
2.0% – Maximum dose:
5 mg / kg, or 300 mg
– 1.0% lidocaine = 1 g lidocaine / 100 cc = 1,000mg/100cc
– 300 mg = 0.03 liter = 30 ml
Lidocaine (Xylocaine®) with epinephrine– Vasoconstriction– Decreased bleeding– Prolongs duration – Strength: 0.5% & 1.0%– Maximum individual
dose: 7mg/kg, or 500mg
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Anesthetic SolutionsAnesthetic Solutions
CAUTIONS: due to its vasoconstriction properties never use Lidocaine with epinephrine on: – Eyes, Ears, Nose – Fingers, Toes– Penis, Scrotum
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Anesthetic SolutionsAnesthetic Solutions
BUPIVACAINE (MARCAINE):– Slow onset– Long duration– Strength: 0.25%– DOSE: maximum individual dose 3mg/kg
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Local AnestheticsLocal Anesthetics
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Injection TechniquesInjection Techniques
25, 27, or 30-gauge needle
6 or 10 cc syringe Check for allergies Insert the needle at the
inner wound edge
Aspirate Inject agent into tissue
SLOWLY Wait… After anesthesia has
taken effect, suturing may begin
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Wound EvaluationWound Evaluation
Time of incidentSize of woundDepth of woundTendon / nerve involvementBleeding at site
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When to ReferWhen to Refer
Deep wounds of hands or feet, or unknown depth of penetration
Full thickness lacerations of eyelids, lips or ears Injuries involving nerves, larger arteries, bones,
joints or tendons Crush injuries Markedly contaminated wounds requiring
drainage Concern about cosmesis
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Contraindications to SuturingContraindications to Suturing
Redness Edema of the wound margins Infection Fever Puncture wounds Animal bites Tendon, nerve, or vessel involvement Wound more than 12 hours old (body) and 24 hrs
(face)
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Closure TypesClosure Types Primary closure (primary intention)
– Wound edges are brought together so that they are adjacent to each other (re-approximated)
– Examples: well-repaired lacerations, well reduced bone fractures, healing after flap surgery
Secondary closure (secondary intention)– Wound is left open and closes naturally (granulation)– Examples: gingivectomy, gingivoplasty,tooth extraction sockets, poorly
reduced fractures
Tertiary closure (delayed primary closure)– Wound is left open for a number of days and then closed if it is found to be
clean– Examples: healing of wounds by use of tissue grafts.
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Wound PreparationWound Preparation
Most important step for reducing the risk of wound infection.
Remove all contaminants and devitalized tissue before wound closure.– IRRIGATE w/ NS or TAP WATER (AVOID H2O2,
POVIDONE-IODINE)– CUT OUT DEAD, FRAGMENTED TISSUE
If not, the risk of infection and of a cosmetically poor scar are greatly increased
Personal Precautions
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Basic Laceration RepairBasic Laceration Repair
Principles And Techniques
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Langer’s Lines
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Principles And TechniquesPrinciples And Techniques Minimize trauma in skin
handling Gentle apposition with slight
eversion of wound edges– Visualize an Erlenmeyer
flask Make yourself comfortable
– Adjust the chair and the light
Change the laceration – Debride crushed tissue
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Types of ClosuresTypes of Closures● Simple interrupted closure – most commonly used, good for shallow
wounds without edge tension● Continuous closure (running sutures) – good for hemostasis (scalp
wounds) and long wounds with minimal tension● Locking continuous - useful in wounds under moderate tension or in those
requiring additional hemostasis because of oozing from the skin edges● Subcuticular – good for cosmetic results● Vertical mattress – useful in maximizing wound eversion, reducing dead
space, and minimizing tension across the wound● Horizontal mattress – good for fragile skin and high tension wounds● Percutaneous (deep) closure – good to close dead space and decrease
wound tension
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Simple Interrupted SuturingSimple Interrupted Suturing
Apply the needle to the needle driver– Clasp needle 1/2 to 2/3 back from tip
Rule of halves:– Matches wound edges better; avoids dog ears– Vary from rule when too much tension across
wound
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Simple Interrupted SuturingSimple Interrupted Suturing
Rule of halves
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Simple Interrupted SuturingSimple Interrupted Suturing
Rule of halves
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SuturingSuturing The needle enters the
skin with a 1/4-inch bite from the wound edge at 90 degrees– Visualize Erlenmeyer
flask– Evert wound edges
Because scars contract over time
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SuturingSuturing Release the needle from the needle driver, reach into the wound and
grasp the needle with the needle driver. Pull it free to give enough suture material to enter the opposite side of the wound.
Use the forceps and lightly grasp the skin edge and arc the needle through the opposite edge inside the wound edge taking equal bites.
Rotate your wrist to follow the arc of the needle.
Principle: minimize trauma to the skin, and don’t bend the needle. Follow the path of least resistance.
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SuturingSuturing
Release the needle and grasp the portion of the needle protruding from the skin with the needle driver. Pull the needle through the skin until you have approximately 1 to 1/2-inch suture strand protruding form the bites site.
Release the needle from the needle driver and wrap the suture around the needle driver two times.
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Simple Interrupted SuturingSimple Interrupted Suturing Grasp the end of the suture material with the needle driver and
pull the two lines across the wound site in opposite direction (this is one throw).
Do not position the knot directly over the wound edge.
Repeat 3-4 throws to ensuring knot security. On each throw reverse the order of wrap.
Cut the ends of the suture 1/4-inch from the knot.
The remaining sutures are inserted in the same manner
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Simple, InterruptedSimple, Interrupted
http://www.youtube.com/watch?v=PFQ5-tquFqY
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The trick to an instrument tieThe trick to an instrument tie
Always place the suture holder parallel to the wound’s direction.
Hold the longer side of the suture (with the needle) and wrap OVER the suture holder.
With each tie, move your suture-holding hand to the OTHER side.
By always wrapping OVER and moving the hand to the OTHER side = square knots!!
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Continuous Locking and Nonlocking SuturesContinuous Locking and Nonlocking Sutures
http://www.youtube.com/watch?v=xY4cAqk30K4
http://cal.vet.upenn.edu/projects/surgery/5000.htm
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http://www.youtube.com/watch?v=sgOaBojcX-chttps://www.youtube.com/watch?v=hIqTDvofekM
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Vertical MattressVertical Mattress
Good for everting wound edges (neck, forehead creases, concave surfaces)
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http://www.youtube.com/watch?v=824FhFUJ6wc
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Horizontal MattressHorizontal Mattress
Good for closing wound edges under high tension,and for hemostasis.
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Horizontal MattressHorizontal Mattress
http://www.youtube.com/watch?v=9DdaooEXshk
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http://www.youtube.com/watch?v=I7C7nsl5Tuk
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Suturing - finishingSuturing - finishing
After sutures placed, clean the site with normal saline.
Apply a small amount of Bacitracin or white petroleum and cover with a sterile non-adherent compression dressing (Tefla).
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Suturing - before you go…Suturing - before you go… Need for tetanus globulin and/or vaccine?
– Dirty (playground nail) vs clean (kitchen knife)– Immunization history (>10 yrs need booster or >5 yrs if
contaminated)
Tell pt to return in one day for recheck, for signs of infection (redness, heat, pain, puss, etc), inadequate analgesia, or suture complications (suture strangulation or knot failure with possible wound dehiscence)
It should be emphasized to patients that they return at the appropriate time for suture removal or complications may arise leading to further scarring or subsequent surgical removal of buried sutures.
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Patient instructions and follow up carePatient instructions and follow up care
Wound care – After the first 24-48 hours, patients should gently wash
the wound with soap and water, dry it carefully, apply topical antibiotic ointment, and replace the dressing/bandages.
– Facial wounds generally only need topical antibiotic ointment without bandaging.
– Eschar or scab formation should be avoided. – Sunscreen spf 30 should be applied to the wound to
prevent subsequent hyperpigmentation.
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Suture RemovalSuture Removal
Average time frame is 7 – 10 days– FACE: 3 – 5 d– NECK: 5 – 7 d– SCALP: 7 – 12 days– UPPER EXTREMITY, TRUNK: 10 – 14 days– LOWER EXTREMITY: 14 – 28 days– SOLES, PALMS, BACK OR OVER JOINTS: 10 days
Any suture with pus or signs of infections should be removed immediately.
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Suture RemovalSuture Removal
Clean with hydrogen peroxide to remove any crusting or dried blood
Using the tweezers, grasp the knot and snip the suture below the knot, close to the skin
Pull the suture line through the tissue- in the direction that keeps the wound closed - and place on a 4x4. Count them.
Most wounds have < 15% of final wound strength after 2 wks, so steri-strips should be applied afterwards.
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Topical AdhesivesTopical Adhesives
Indications: selection of approximated, superficial, clean wounds especially face, torso, limbs. May be used in conjunction with deep sutures
Benefits: Cosmetic, seals out bacteria, apply in 3 min, holds 7 days (5-10 to slough), seal moisture, faster, clear, convenient, less supplies, no removal, less expensive
Contraindicated with infection, gangrene, mucosal, damp or hairy areas, allergy to formaldehyde or cryanoacrylate, or high tension areas
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DermabondDermabond®®
A sterile, liquid topical skin adhesive
Reacts with moisture on skin surface to form a strong, flexible bond
Only for easily approximated skin edges of wounds– punctures from minimally
invasive surgery– simple, thoroughly cleansed,
lacerations
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DermabondDermabond®®
Standard surgical wound prep and dry Crack ampule or applicator tip up; invert Hold skin edges approximated horizontally Gently and evenly apply at least two thin layers on
the surface of the edges with a brushing motion with at least 30 s between each layer, hold for 60 s after last layer until not tacky
Apply dressing
http://www.youtube.com/watch?v=oa13wriWTus&feature=related
http://www.youtube.com/watch?v=YhyPxFsYtXk&NR=1
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Follow Up Care with AdhesivesFollow Up Care with Adhesives No ointments or medications on dressing May shower but no swimming or scrubbing Sloughs naturally in 5-10 days, but if need to remove use
acetone or petroleum jelly to peel but not pull apart skin edges
Pt education and documentation
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EBM Take Home PointsEBM Take Home Points
Suturing is preferred technique for skin laceration repair LOE SORT C
Saline or tap water should be used for wound irrigation LOE SORT B
Use of white petrolatum to promote wound healing is as effective as antibiotic ointment LOE SORT B
Tissue adhesives show comparable results with regards to cosmetic, infection or dehisence rates LOE SORT A
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ReferencesReferences
http://depts.washington.edu/uwemig/media_files/EMIG%20Suture%20Handout.pdf Thomsen, T. Basic Laceration Repair. The New England Journal of Medicine. Oct.
355: 17. Edgerton, M. The Art of Surgical Technique. Baltimore, Williams & Wilkins, 1988. www.uptodateonline.com; 2009, topic lacerations, etc. http://dermnetnz.org/procedures/pdf/suturing-dermnetnz.pdf http://www.mnpa.us/handouts/Session%2005%20%20-%20%20Basic%20Suturing
%20%202010%20MNPA.pdf http://www.practicalplasticsurgery.org/docs/Practical_01.pdf http://health.usf.edu/NR/rdonlyres/ABB54A41-80A1-4E2B-8AE8-
7EB5D06CE8DF/0/wound_healing_manual.pdf Jackson, E. Wound Care – Suture, Laceration, Dressing: Essentials for Family
Physicians. AAFP Scientific Assembly. 2010. http://www.aafp.org/online/etc/medialib/aafp_org/documents/cme/courses/conf/assembly/2010handouts/071.Par.0001.File.tmp/071-072.pdf
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Splinting and Casting
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Immediate Treatment of Orthopedic Injury
• One primary goal– Reduction of swelling
• PRICE– Protection– Rest– Ice– Compression– Elevation
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Cold Application
• Decreases pain
• Produces vasoconstriction
• Controls hemorrhage and edema
• Decreases local cell metabolism– Decreases tissues’ need for oxygen– Reduces hypoxia
• Sensations- Cold, burning, aching, numb
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Emergency Splinting
• Two vital principles– Splint from one joint above the fracture to
one joint below the fracture– Splint the injury in the position it is found
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Indications for Splinting
• Fractures• Sprains• Joint infections• Tenosynovitis• Acute arthritis / gout• Lacerations over joints• Puncture wounds and animal
bites of the hands or feet
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Splinting Equipment• Plaster of Paris
– Made from gypsum - calcium sulfate dihydrate– Exothermic reaction when wet - recrystallizes (can
burn patient)– Warm water - faster set, but increases risk of burns– Fast drying - 5 - 8 minutes to set– Extra fast-drying - 2 - 4 minutes to set - less time to
mold– Can take up to 1 day to cure (reach maximum
strength)– Upper extremities - use 8-10 layers– Lower extremities - 12-15 layers, up to 20 if big
person (increased risk of burn!)
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Splinting Equipment• Ready Made Splinting Material
– Plaster (OCL)• 10 -20 sheets of plaster with padding and cloth
cover
– Fiberglass (Orthoglass)• Cure rapidly (20 minutes)• Less messy• Stronger, lighter, wicks moisture better• Less moldable
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Splinting Equipment• Stockinette
• protects skin, looks nifty (often not necessary)• cut longer than splint• 2,3,4,8,10,12-in. widths
• Padding - Webril• 2-3 layers, more if anticipate lots of swelling• Extra over elbows, heels• Be generous over bony prominences• Always pad between digits when splinting hands/feet or when
buddy taping• Avoid wrinkles• Do not tighten - ischemia!• Avoid circumfrential use
• Ace wraps
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Specific Splints and OrthosesUpper Extremity• Elbow/Forearm
– Long Arm Posterior– Double Sugar - Tong
• Forearm/Wrist– Volar Forearm / Cockup– Sugar - Tong
• Hand/Fingers– Ulnar Gutter– Radial Gutter– Thumb Spica– Finger Splints
Lower Extremity• Knee
– Knee Immobilizer / Bledsoe– Bulky Jones– Posterior Knee Splint
• Ankle– Posterior Ankle– Stirrup
• Foot – Hard Shoe
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Long Arm Posterior Splint
• Indications– Elbow and forearm injuries:– Distal humerus fx– Both-bone forearm fx– Unstable proximal radius or
ulna fx (sugar-tong better)• Doesn’t completely eliminate
supination / pronation -either add an anterior splint or use a double sugar-tong if complex or unstable distal forearm fx.
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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.
10
90
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Forearm Volar Splint aka ‘Cockup’ Splint
• Indications– Soft tissue hand / wrist
injuries - sprain, carpal tunnel night splints, etc
– Most wrist fx, 2nd -5th metacarpal fx.
– Most add a dorsal splint for increased stability - ‘sandwich splint’ (B).
– Not used for distal radius or ulnar fx - can still supinate and pronate.
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Forearm Sugar Tong
• Indications– Distal radius and
ulnar fx.
• Prevents pronation / supination and immobilizes elbow.
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Hand Splinting
• The correct position for most hand splints is the position of function, a.k.a. the neutral position.
• This is with the the hand in the “beer can” position (which may have contributed to the injury in the first place) : wrist slightly extended (10-25°) with fingers flexed as shown.
• When immobilizing metacarpal neck fractures, the MCP joint should be flexed to 90°.
• Have the patient hold an ace wrap (or a beer can if available) until the splint hardens.
• For thumb fx, immobilize the thumb as if holding a wine glass.
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Radial and Ulnar Gutter
•Indications•Fractures, phalangeal and metacarpal, and soft tissue injuries of the little and ring fingers.
•Indications•Fractures, phalangeal and metacarpal, and soft tissue injuries of index and long fingers.
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Thumb Spica• Indications
– Scaphoid fx - seen or suspected (check snuffbox tenderness)
– De Quervain tenosynovitis. • Notching the plaster (shown)
prevents buckling when wrapping around thumb.
• Wine glass position.
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Finger Splints
• Sprains - dynamic splinting (buddy taping).
• Dorsal/Volar finger splints - phalangeal fx, though gutter splints probably better for proximal fxs.
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Jones Compression Dressing - aka Bulky Jones
• Indications– Short term immobilization
of soft tissue and ligamentous injuries to the knee or calf.
• Allows slight flexion and extension - may add posterior knee splint to further immobilize the knee.
• Procedure– Stockinette and
Webril.– 1-2 layers of thick
cotton padding.– 6 inch ace wrap.
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Posterior Ankle Splint
• Indications– Distal tibia/fibula fx.– Reduced dislocations– Severe sprains– Tarsal / metatarsal fx
• Use at least 12-15 layers of plaster.
• Adding a coaptation splint (stirrup) to the posterior splint eliminates inversion / eversion - especially useful for unstable fx and sprains.
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Stirrup Splint
• Indications– Similiar to posterior splint.– Less inversion /eversion
and actually less plantar flexion compared to posterior splint.
– Great for ankle sprains.– 12-15 layers of 4-6 inch
plaster.
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Other Orthoses• Knee Immobilizer
– Semirigid brace, many models– Fastens with Velcro– Worn over clothing
• Bledsoe Brace– Articulated knee brace– Amount of allowed flexion and extension can be adjusted– Used for ligamentous knee injuries and post-op
• AirCast/ Airsplint– Resembles a stirrup splint with air bladders– Worn inside shoe
• Hard Shoe– Used for foot fractures or soft tissue injuries
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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– Reduced risk compared to
casting but still a possibility– 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
Any complaints of worsening pain - Take the splint off and look!