Splinting/CastingSplinting/Casting

Craig Jamison PA-CCraig Jamison PA-CWest Idaho OrthopedicsWest Idaho OrthopedicsMeridian/CaldwellMeridian/Caldwell459-4511459-4511

ME.ME.

Undergraduate degree from The Undergraduate degree from The College of Idaho.College of Idaho.

Physician Assistant degree from The Physician Assistant degree from The University of Alabama at Birmingham.University of Alabama at Birmingham.

Didn’t know what I was doing until Didn’t know what I was doing until after working several years.after working several years.– Still don’t know everything. Feel free to Still don’t know everything. Feel free to

teach me if you have any additional teach me if you have any additional knowledge.knowledge.

Splint – vs - CastSplint – vs - Cast

Unless working in a orthopedic Unless working in a orthopedic specialty, most people use splinting specialty, most people use splinting more often than casting.more often than casting.– Splinting is effective for support and Splinting is effective for support and

comfort.comfort.– Splinting is easier and safer.Splinting is easier and safer.– Patients are usually sent to an ortho Patients are usually sent to an ortho

specialist for casting and continued specialist for casting and continued care.care.

SplintingSplinting

Splints can be preformed, or custom Splints can be preformed, or custom made.made.– Preformed splints do not always fit properly.Preformed splints do not always fit properly.– Some, such as aluminum with foam, fail to Some, such as aluminum with foam, fail to

wick moisture away and macerate the skin.wick moisture away and macerate the skin.– Some insurance companies will not Some insurance companies will not

reimburse for preformed splints because reimburse for preformed splints because they are durable medical equipment (DME), they are durable medical equipment (DME), and require special billing license.and require special billing license.

– Better than nothing.Better than nothing.

SplintingSplinting

Custom splint could be as simple Custom splint could be as simple as taping a magazine around a as taping a magazine around a broken wrist, or tying sticks up the broken wrist, or tying sticks up the sides of a broken ankle.sides of a broken ankle.– Probably not reimbursable.Probably not reimbursable.– Better than nothing.Better than nothing.– Still provides decreased pain and Still provides decreased pain and

protects soft tissues from additional protects soft tissues from additional traumatrauma

SplintingSplinting

Custom splints:Custom splints:– Usually made from Orthoglass type material Usually made from Orthoglass type material

or OCL. Can also be formed from layers of or OCL. Can also be formed from layers of fiberglass or plaster as long as well padded.fiberglass or plaster as long as well padded.

– Still often improperly fit, but now it is from Still often improperly fit, but now it is from user error.user error.

– A good splint will fit excellent, protect the A good splint will fit excellent, protect the injured area, and decrease pain until further injured area, and decrease pain until further treatment is available or necessary.treatment is available or necessary.

SplintingSplinting

We use splints to support various We use splints to support various injuries.injuries.– Soft tissue traumaSoft tissue trauma– Chronic inflammation/tendonitisChronic inflammation/tendonitis– NeuritisNeuritis– Fractures, occult fractures, stress Fractures, occult fractures, stress

fractures.fractures.

CastingCasting

A good cast has many of the same A good cast has many of the same qualities as a good splint.qualities as a good splint.

-proper fit-proper fit

-good support-good support

-decreased pain-decreased pain

CastingCasting

Casts can be made of fiberglass Casts can be made of fiberglass or plasteror plaster

Casts tend to be stronger and Casts tend to be stronger and more protective.more protective.

Casts are difficult to remove by Casts are difficult to remove by your uncooperative patients.your uncooperative patients.

Casts can be difficult to apply.Casts can be difficult to apply.

Pitfalls of splintingPitfalls of splinting

Very few.Very few. Almost anything is better than nothing.Almost anything is better than nothing. Fashion sometimes pushes toward a Fashion sometimes pushes toward a

smaller, shorter, sleeker splint.smaller, shorter, sleeker splint. In general, patients are more In general, patients are more

comfortable and safer in a well padded comfortable and safer in a well padded splint that is ugly, bulky, and over-splint that is ugly, bulky, and over-protective.protective.– I have never heard of a legal issue from I have never heard of a legal issue from

being over-splinted with an acute injury.being over-splinted with an acute injury.

Pitfalls of CastingPitfalls of Casting

It is difficult for further evaluation It is difficult for further evaluation after referral to a specialist.after referral to a specialist.

Casting often requires more time Casting often requires more time and manipulation of an acute injury.and manipulation of an acute injury.– This yields more pain and risk.This yields more pain and risk.– It is often done safer and easier in a It is often done safer and easier in a

subacute setting by someone more subacute setting by someone more experienced.experienced.

Pitfalls of CastingPitfalls of Casting

Casts can be too tight.Casts can be too tight.– This can arise from applying the This can arise from applying the

material with too much tension.material with too much tension.– This can be from a perfectly rolled This can be from a perfectly rolled

cast, applied before swelling is cast, applied before swelling is under control.under control.

Pitfalls of CastingPitfalls of Casting

A cast that is too tight can be a huge A cast that is too tight can be a huge problem.problem.– It can cause severe pain than may not It can cause severe pain than may not

respond to pain medicine. Hello midnight respond to pain medicine. Hello midnight caller.caller.

– It can cause neurovascular compromise and It can cause neurovascular compromise and perhaps permanent tissue damage if not perhaps permanent tissue damage if not adjusted in time.adjusted in time.

– The person applying the cast is most likely The person applying the cast is most likely liable.liable.

Splint - vs - CastSplint - vs - Cast

For most people:For most people:– Splinting is the answer.Splinting is the answer.

Again, it is easier, it is safer (for you and the Again, it is easier, it is safer (for you and the patient), it is more comfortable and allows patient), it is more comfortable and allows for swelling, it is easily removed for further for swelling, it is easily removed for further evaluation.evaluation.

Splints also allow a bit of adjustability for Splints also allow a bit of adjustability for that midnight caller.that midnight caller.

ApplicationApplication

General rules: General rules: – Support / immobilize the joint above Support / immobilize the joint above

and below the injury.and below the injury.– Protect underlying skin with clean Protect underlying skin with clean

bandage and padding.bandage and padding.– Skin break near the site of the Skin break near the site of the

fracture = open fracture.fracture = open fracture. needs to be seen immediately.needs to be seen immediately.

ApplicationApplication

Splints are often held in place with Splints are often held in place with elastic bandages. These can be pulled elastic bandages. These can be pulled too tight. My usual goal is to have too tight. My usual goal is to have enough tension so that it stays in place enough tension so that it stays in place without a tight stretch. Snug but without a tight stretch. Snug but comfortable.comfortable.

Tape helps to keep bandages in place Tape helps to keep bandages in place around uncooperative areas.around uncooperative areas.

Check NVF before and after placement.Check NVF before and after placement.

ApplicationApplication

Casts are often more fun to put on, but Casts are often more fun to put on, but take more practice. take more practice.

A cast that is too tight is a problem.A cast that is too tight is a problem.– When putting on a cast it is best to strip When putting on a cast it is best to strip

some of the material from the roll, and then some of the material from the roll, and then wrap it around the extremity. wrap it around the extremity.

This decreases the variability that comes from This decreases the variability that comes from different types and ages of casting tape.different types and ages of casting tape.

This is certainly an experience/ feel technique.This is certainly an experience/ feel technique. Usually just enough tension to keep out wrinkles.Usually just enough tension to keep out wrinkles.

ApplicationApplication

Casting is best done with a developed Casting is best done with a developed rolling pattern.rolling pattern.– This is easily and cheaply practiced using This is easily and cheaply practiced using

an elastic bandage.an elastic bandage.– An ugly cast can work well. A pretty cast An ugly cast can work well. A pretty cast

can be useless. Of course your goal is the can be useless. Of course your goal is the best of both, as it will be a multi-week best of both, as it will be a multi-week friend for the patient and advertisement friend for the patient and advertisement (for better or worse) for you.(for better or worse) for you.

ApplicationApplication

A patient should be able to admit A patient should be able to admit the cast is, again, snug but the cast is, again, snug but comfortable.comfortable.

Elevation is the key to controlling Elevation is the key to controlling comfort and fit of a cast. If this comfort and fit of a cast. If this cannot be controlled in this cannot be controlled in this manner, the patient is probably manner, the patient is probably better in a splint.better in a splint.

Protect YourselfProtect Yourself

Amongst others:Amongst others:– Watch for scaphoid fractures.Watch for scaphoid fractures.– Keep LE injuries NWB until further eval.Keep LE injuries NWB until further eval.– Urgently refer pediatric elbow injuries.Urgently refer pediatric elbow injuries.– Do not miss a compartment syndrome.Do not miss a compartment syndrome.

Palor, pulseless, polar, paresthesia, pain, Palor, pulseless, polar, paresthesia, pain, paralysis.paralysis.

– Call somebody or refer uncomfortable Call somebody or refer uncomfortable situations.situations.

Protect YourselfProtect Yourself

Pediatric knee pain warrants eval Pediatric knee pain warrants eval of knee and hip.of knee and hip.

Ortho emergencies: Open Ortho emergencies: Open fracture and neurovascular fracture and neurovascular compromise.compromise.

FutureFuture

Feel free to call.Feel free to call. We have 5 docs and 4 pas.We have 5 docs and 4 pas.

Dr. Charles SchneiderDr. Charles Schneider

Dr. George NicolaDr. George Nicola

Dr. John SmithDr. John Smith

Dr. Robert Hansen.Dr. Robert Hansen.Craig Jamison, Hodaka Abe, Tom Tryon, Bryce Somebody PA-C X 4Craig Jamison, Hodaka Abe, Tom Tryon, Bryce Somebody PA-C X 4