PRINCIPLES OF CLOSED REDUCTION

• Displaced fractures, including those that will undergo internal fixation, should be reduced to minimize soft tissue trauma and provide patient comfort.

• Splints should respect the soft tissues.

  • Pad all bony prominences.

  • Allow for postinjury swelling.

• Adequate analgesia and muscle relaxation are critical for success.

• Fractures are reduced using axial traction and reversal of the mechanism of injury.

• One should attempt to correct or restore length, rotation, and angulation.

• Reduction maneuvers are often specific for a particular location.

• One should try to immobilize the joint above and below the injury.

• Three-point contact and stabilization are necessary to maintain most closed reductions.

  COMMON SPLINTING TECHNIQUES

• Splints may be prefabricated or custom made.

• “Bulky” Jones (refers to padding)

  • Lower extremity splint, commonly applied for foot and ankle fractures and fractures about the knee, which uses fluffy cotton or abundant cast padding to help with postinjury swelling. The splint is applied using a posterior slab and a U-shaped slab applied from medial to lateral around the malleoli for ankle/tibia or a knee immobilizer for knee injuries. The extremity should be padded well proximal and distal to the injury.

• Sugar-tong splint

  • Upper extremity splint for distal forearm fractures that uses a U-shaped slab applied to the volar and dorsal aspects of the forearm, encircling the elbow (Fig. 1.1).

     

     

     

• Coaptation splint

  • Upper extremity splint for humerus fractures that uses a U-shaped slab applied to the medial and lateral aspects of the arm, encircling the elbow and overlapping the shoulder.

• Ulnar gutter splint

• Volar/dorsal hand splint

• Thumb spica splint

• Posterior slab (ankle) with or without a U-shaped splint

• Posterior slab (thigh)

• Knee immobilizer

• Cervical collar

• Pelvic sheet/binder

  Visit the University of Ottawa web site for general casting techniques and specifics on placing specific splints and casts: www.med.uottawa.ca/procedures/cast/

  CASTING

• The goal is semirigid immobilization with avoidance of pressure or skin complications.

• Used with caution in the treatment of acute fractures owing to swelling and soft tissue complications.

  • Padding: This is placed from distal to proximal with a 50% overlap, a minimum of two layers, and extra padding for bony prominences (fibular head, malleoli, patella, condyles, and olecranon).

  • Plaster: Cold water will maximize the molding time. Hot water may lead to thermal injury of the skin. Room temperature water is preferred.

    • 6-inch width for thigh

    • 4- to 6-inch width for leg

    • 4- to 6-inch width for arm

    • 2- to 4-inch width for forearm

  • Fiberglass

  • This is more difficult to mold but more resistant to moisture and breakdown.

  • Generally, it is two to three times stronger for any given thickness.

    Visit the University of Ottawa web site for general casting techniques and specifics on placing specific splints and casts: www.med.uottawa.ca/procedures/cast/

    Below Knee Cast (Short Leg Cast)

• This should support the metatarsal heads.

• The ankle should be placed in neutral; apply with the knee in flexion.

• Ensure freedom of the toes.

• Build up the plantar surface for walking casts.

  • Fiberglass is preferred for durability.

• Pad the fibula head and the plantar aspect of the foot.

  Above Knee Cast (Long Leg Cast)

• Apply below the knee first.

• Maintain knee flexion at 5 to 20 degrees.

• Mold the supracondylar femur for improved rotational stability.

• Apply extra padding anterior to the patella.

  Short and Long Arm Casts

• The metacarpophalangeal (MCP) joints should be free.

  • Do not go past the proximal palmar crease.

• The thumb should be free to the base of the metacarpal; opposition to the fifth digit should be unobstructed.

• Even pressure should be applied to achieve the best mold.

• Avoid molding with anything but the heels of the palm to avoid pressure points.

  COMPLICATIONS OF CASTS AND SPLINTS

• Loss of reduction

• Pressure necrosis as early as 2 hours after cast/splint application

• Tight cast or compartment syndrome

  • Univalving alone: 30% pressure drop

  • Bivalving alone: 60% pressure drop

  • Cutting of cast padding to further reduce pressure

  • Use of “cast spreaders” in univalved casts minimizes contact pressure significantly

• Thermal injury

  • Avoid plaster thicker than 10 ply

  • Avoid water hotter than 24°C

  • Unusual with fiberglass

• Cuts and burns during cast removal due to poor technique

• Thrombophlebitis or pulmonary embolus: increased with lower extremity fracture and immobilization but prophylaxis debated. Upper extremity incidence may be up to 0.7%.

• Joint stiffness: Joints should be left free when possible (i.e., thumb MCP for short arm cast) and placed in a position of function when not possible to leave free.

  POSITIONS OF FUNCTION

• Ankle: neutral dorsiflexion (no equinus)

• Hand: MCP flexed (70 to 90 degrees), interphalangeal joints in extension (also called the intrinsic plus position) (Fig. 1.2)

   

   

   

  TRACTION

• This allows constant controlled force for initial stabilization of long bone fractures and aids in reduction during operative procedures.

• The option for skeletal versus skin traction is case dependent.

  Skin Traction

• Limited force can be applied, generally not to exceed 10 lb.

• This can cause soft tissue problems, especially in elderly patients or those with or rheumatoid-type skin.

• It is not as powerful when used during operative procedures for both length and rotational control.

• Buck’s traction uses a soft dressing around the calf and foot attached to a weight off the foot of the bed.

  • This is an option to provide temporary comfort in hip fractures and certain children’s fractures.

  • A maximum of 7 to 10 lb of traction should be used.

  • Watch closely for skin problems, especially in elderly or rheumatoid patients.

     

    Skeletal Traction (Fig. 1.3)

     

     

     

• This is more powerful, with greater fragment control, than skin traction.

• It permits pull up to 15% to 20% of body weight for the lower extremity.

• It requires local anesthesia for pin insertion if the patient is awake.

  • Local anesthetic should be infiltrated down to the sensitive periosteum.

• It is the preferred method of temporizing long bone, pelvic, and acetabular fractures until operative treatment can be performed.

• Choice of thin Kirschner wire (K-wire) versus Steinmann pin

  • K-wire is more difficult to insert with a hand drill and requires a tension traction bow (Kirschner).

  • The Steinmann pin may be either smooth or threaded.

    • A smooth pin is stronger but can slide through bone.

    • A threaded pin is weaker and bends more easily with increasing weights, but it will not slide and will advance more easily during insertion.

    • In general, the largest pin available (5 to 6 mm) is chosen, especially if a threaded pin is

      selected.

      Tibial Skeletal Traction

• The pin is placed 2 cm posterior and 1 cm distal to the tibial tubercle.

  • It may go more distal in osteopenic bone.

• The pin is placed from lateral to medial to direct the pin away from the common peroneal nerve.

• The skin is released at the pin’s entrance and exit points.

• Optimally, avoid penetrating the anterior compartment.

• A sterile dressing is applied next to the skin. Sharp ends should be protected.

  Femoral Skeletal Traction (Fig. 1.4)

   

   

   

• This is the method of choice for pelvic, acetabular, and many femoral shaft fractures (especially in knees with ligamentous injuries).

• The pin is placed from medial to lateral (directed away from the neurovascular bundle) at the adductor tubercle, slightly proximal to the femoral epicondyle.

  • The location of this pin can be determined from the anteroposterior (AP) knee radiograph using the patella as a landmark.

• One should spread through the soft tissue to bone to avoid injury to the superficial femoral artery.

  Calcaneal Skeletal Traction

• This is most commonly used with a spanning external fixation for “traveling traction,” or it may be used with a Bohler-Braun frame.

• It is used for irreducible rotational ankle fractures, some pilon fractures, and extremities with multiple ipsilateral long bone fractures or compromised soft tissues.

• The pin is placed from medial to lateral, directed away from the neurovascular bundle, 2 to 2.5 cm posterior and inferior to the medial malleolus.

  Olecranon Traction

• Rarely used today.

• A small- to medium-sized pin is placed from medial to lateral in the proximal olecranon; the bone is entered 1.5 cm from the tip of the olecranon.

• The forearm and wrist are supported with skin traction with the elbow at 90 degrees of flexion.

  Gardner-Wells Tongs

• Used for cervical spine reduction and traction.

• Unicortical screws are placed into the skull one fingerbreadth above the pinna of the ear, slightly posterior to the external auditory meatus.

• Traction is applied starting with 5 lb and increasing in 5-lb increments with serial radiographs and clinical examination.

  Halo

• Indicated for certain cervical spine fractures as definitive treatment or supplementary protection to internal fixation.

• Disadvantages

  • Pin problems

  • Respiratory compromise

• Technique

  • Positioning of patient to maintain spine precautions

  • Fitting of halo ring

  • Preparation of screw sites

    • Anterior: above the eyebrow, avoiding the supraorbital artery, nerve, and sinus

    • Posterior: superior and posterior to the ear

  • Tightening of pins to 6 to 8 ft-lb of torque

  • Retightening pins if loose

    • Only once at 24 hours after insertion

    • Frame as needed

      Spanning External Fixation

• Concept of Damage Control Orthopaedics (DCO).

• Allows for the temporary stabilization of long bones.

• Allows for the transfer of patient in and out of bed.

• Does not foster elevated compartment pressures in affected extremities.

  • Usually performed in the operating room with fluoroscopy present but can be done at the bedside in emergency settings or the field if necessary.

  • Half pins can be placed into the ilium, femur, tibia, calcaneus, talus, and forefoot.

  • Connected by various clamps and bars.

  • Traction applied across affected long bones and joints.