Immobilization techniques are implemented in the emergency setting to:
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Reduce swelling
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Decrease pain
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Decrease tension on soft tissue injuries such as lacerations to skin, nerves, ligaments or tendons during healing
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Maintain anatomic alignment of fractures during healing
Immobilization is achieved through splinting or casting. Acutely injured tissue tends to swell, sometimes even more so in the days following an injury. It is important to reduce the risk of injury to soft tissue structures secondary to tissue compression from swelling with proper immobilization technique. Casts provide rigid circumferential immobilization, however they do not stretch or expand in response to swelling. As such, casts are typically reserved for definitive fracture management (after the swelling has resolved) or to stabilize complex fracture reductions (anatomic realignment of the bone). Splints provide rigid support that is noncircumferential and can accommodate tissue swelling. Because of this quality, splints are more commonly the preferred initial method of immobilization in the emergency setting and will be the focus of this chapter.
Although immobilization is an important adjunct to care, it is not without risk. Improper technique or excessive or prolonged immobilization can lead to skin breakdown (pressure ulcers) and associated infection, peripheral nerve injury, vascular compromise, joint stiffness, muscle atrophy, deep vein thrombosis, and chronic pain disorders. Choosing an appropriate method of immobilization based on the type, acuity, anatomic location, and stability of the injury, combined with good technique, is essential to ensuring the best outcomes for your patients. Additionally, all patients who are immobilized require close monitoring and follow-up to help decrease the liklihood of developing complications.
Prefabricated Immobilization Products
Splinting materials may be preformed to provide a specific anatomic alignment or made from malleable materials that are manipulated to conform to the extremity in the desired position ( Table 19.1 ).
| Type | Characteristics | Common Applications | Image |
|---|---|---|---|
| Stack splint ( Fig. 19.1 ) | Plastic, positions finger with slight extension at DIPJ, multiple sizes | Avulsion of extensor tendon at DIPJ (mallet finger) | |
| Aluminum with foam pad ( Fig. 19.2 ) | May be preshaped or come in moldable strips, multiple lengths and widths | Finger sprain, dislocation, simple fracture, tendon injury | |
| Velcro wrist splint ( Fig. 19.3 ) | Semirigid, holds wrist in 30-degree extension, universal as well | Wrist sprain, carpal tunnel syndrome, arthritis | |
| Velcro thumb spica ( Fig. 19.4 ) | Semirigid, holds wrist in 30-degree extension and thumb aligned with radius | Tenosynovitis, thumb ligamentous injury, arthritis | |
| Sling/sling and swathe ( Figs. 19.5 and 19.6 ) | Sling (fabric or foam) holds elbow at 90 degrees and arm adducted against body and extends past the wrist to support the hand. The swathe wraps around the adducted arm and under the unaffected arm to keep the shoulder adducted |
| |
| Knee immobilizer ( Fig. 19.7 ) | Foam wrap with embedded bilateral and posterior rigid stabilizers; may be hinged to allow range of movement or hold knee in locked position; may have patella stabilizer “cut-out” | Cruciate ligament injury, patella or quadriceps tendon rupture, patella fracture or dislocation, arthritis, effusion | |
| Ankle stirrup ( Fig. 19.8 ) | Outer plastic shell with foam surrounded by air bladder that conforms to ankle, prevents inversion and eversion at ankle, ambulatory, can be worn with shoes | Ankle sprain | |
| Walking boot/ CAM (controlled ankle motion) boot ( Fig. 19.9 ) | Rigid posterior lower leg and foot shell with a flexible padded liner, ambulatory | Foot and/or ankle sprain, some stable fractures of foot and ankle | |
| Orthopedic shoe ( Fig. 19.10 ) | Hard-soled, open-toed shoe | Toe fracture, gout, some simple foot fractures |
Finger Immobilization
Finger splints are commonly supplied as prefabricated aluminum with attached foam padding. These can be preformed or come in strips of varying widths and lengths that can be cut and molded to customize the splint. These splints are then held in place by adhesive tape, elastic wrap, or self-adherent wrap ( Table 19.2 ).
| Splint Type | Indication | Position | Finished Splint |
|---|---|---|---|
| Dorsal finger splint ( Fig. 19.11A ) |
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| Mallet finger | * Mallet finger injury (avulsion fracture or rupture of extensor tendon) |
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Buddy Taping
Buddy taping is a form of dynamic splinting that binds the injured digit to an adjacent digit. This method provides stabilization of the injured digit while allowing for some continued mobility. Dynamic splinting is commonly for toe fractures and dislocations, as well as stable finger dislocations and some nondisplaced/nonintraarticular phalanx fractures ( Fig. 19.13 ).
