The Procedural Pause

Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, PNP, are teaming up to create a new EMN blog, The Procedural Pause.

The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.

Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

Friday, September 1, 2017

We use splints to help immobilize and stabilize injuries, but it's important to realize splinting also alleviates pain and edema and promotes healing until follow-up. If you are ever concerned that there is a fracture (even if it's not apparent on radiograph, i.e., navicular fractures), splint your patient before discharge. If you have the luxury of orthopedic consult in-house, talk to him before discharge.

Indications for Short Posterior Splint

-Fractures of the distal tibia and/or fibula

-Ankle dislocations

-Severe sprains

-Fractures of the talus

-Fractures of the calcaneus

-Foot fractures such as fractures of the fifth metatarsal

-Fractures of the cuboid, navicular, or cuneiform

Indications for Long Posterior Splint

-If you are discharging a patient, the only true indication for long leg posterior splints is for acute knee injuries and quadriceps tendon rupture. If a femur fracture or hip fracture is the concern, patients should be admitted for further workup and treatment by the orthopedic team in-house or by transfer.

-Temporary application of long posterior leg splinting can be used for distal femur fracture, proximal tibia/fibula fracture, or dislocations of the knee until the patent gets further evaluation from the orthopedic team.

-Associated tibial plateau fractures and patellar fractures

-If you are splinting for a knee injury, keep in mind the knee should be kept at 5-degree flexion and the foot in slight plantar flexion.

Other Indications

-Cellulitis (allows area to heal without movement, decreases pain)

-Deep lacerations across knee or ankle joints (reduces tension, prevents wound dehiscence)

-Tenosynovitis, strains, and sprains (prevents movement, decreases inflammation)

-Areas that are too large for knee or ankle immobilizers (i.e., Velcro knee sleeves or Aircasts)

All leg splints require close follow-up, potential casting, and repeat imaging. The patient must be referred to an orthopedic clinic within the next week and instructed on splint care, including neurovascular status checks. Patients discharged with a long leg posterior splint should be seen again the next day or within 72 hours.

Contraindications of Short and Long Posterior Leg Splints

-Neurovascular compromise

-Neuropathies originating from back injuries or diabetes

-Elderly patients

-Multiple trauma

-Open fractures

ACE vs. Knee Immobilizer vs. Splint

Knee injuries are extremely common in the emergency department. It may be difficult to tell which orthoses are appropriate for which patients. Typically, minor to moderate knee injuries do not require much intervention or surgery, and often heal in two to three weeks. Patients may need to avoid bearing weight, depending on the amount of laxity present in the extremity. It is virtually impossible to get a stat MRI for a knee injury in most EDs, so it is recommended that splinting and non-weight-bearing be completed prior to discharge. Quadriceps and patellar tendon ruptures must be completely immobilized and non-weight-bearing with an indication for immediate follow-up.

How do we know which splint is appropriate? Often patient comfort is the major determining factor. Elderly patients and those prone to DVT with clotting disorders or immobility should be splinted in the least invasive way. Splints should remain on during showers and kept covered. If a patient has a strain or sprain, the splint can be removed if the knee is kept in a neutral position. Far superior to ACE wraps and long leg posterior splints are padded Velcro knee immobilizers, which allow for easy reapplication.

The literature does not provide thorough evidence on whether ACE wraps or knee immobilizers are superior. The bottom line is ACE bandages provide minimal support of the knee. If you really want to achieve immobility, you must apply a long posterior splint or knee immobilizer that goes above and below the knee. The literature also says strains and sprain of the ankle do not benefit from immobilization and the splints are applied primarily for comfort.

Jim weighs in: Long leg posterior splints are bulky and uncomfortable for your patient. If your department does not stock Velcro knee immobilizers, consider investing in this commodity. Velcro splints are much better devices, and can be removed and reapplied by the patient. Lobby to get them in stock!

When in doubt, have an open and frank conversation with your patients about their at-home needs, and admit patients who simply cannot walk or care for themselves in their home.

Watch a lower leg splint being applied in this video.​​



Tuesday, August 1, 2017

Tennis elbow, also known as lateral epicondylitis, is a painful and persistent problem that can be transient or chronic. The syndrome is caused by overuse of the elbow, although not always caused by one too many games of tennis.​

Lateral epicondylitis is an inflammation of the tendons that join the forearm muscles to the outside of the elbow. Overused and abused tendons can be damaged or even destroyed. Performing the same repetitive motions over and over again can irritate and annoy the tendons, resulting in severe pain, tenderness, and even inability to use the affected extremity.

Many treatments are available for lateral epicondylitis, but steroid injections are the gold standard for chronic pain. Supportive treatments such as NSAIDs, RICE, heat, and physical therapy can also tackle the issue. Steroid injections with a long-acting corticosteroid (such as methylprednisolone) combined with 1-2% lidocaine can ease symptoms in two to four days, and can be completed in the emergency department.

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Dr. James Roberts pointing at where the steroid injection is going to be placed.

Presentation

Patients often complain of gradual, slowly increasing pain over their elbow and lateral forearm. They say it has been going on for about a month, but got worse over the past week. Usually no specific injury or insult occurred, but patients feel pain and burning on the outer part of the elbow. The pain has generally gotten so bad that it causes weakness in the grip strength of the hand. Occasionally, patients will say they have trouble shaking hands, and you can test this by extending your hand in introduction when you walk into the room. Patients often find it difficult to grab things off the shelf like a book or a plate in the cabinet.

Steroid Injections

Multiple trials and systematic reviews have found that steroid injection improves many short-term (six- to seven-week) outcome measures, but does not prevent recurrence. (Int J Clin Pract 2007;61[2]:240; Pain 2002;96[1-2]:23.) Steroid injection is reasonable for the quick treatment of severe symptoms and pain in the emergency department. The importance of physical therapy should be stressed, and the patient should follow up with an orthopedist. Splints should be encouraged. (J Orthop Sports Phys Ther 2009;39[6]:484.)

Patients should be instructed not to have repeat injections over a short period of time to avoid damaging the radial nerve. Some studies have shown that injections may lead to higher rates of pain recurrence. Patients who used the counterforce or sleeve splint had fewer repeat episodes of pain than the injection group. (Arch Phys Med Rehabil 2005;86[6]:1081.) It did, however, take longer to achieve the first pain-free period when splinting alone was used.

Another study of steroid injection involved an effective peppering technique where the painful tendon is injected approximately 40 to 50 times (as seen in our video). (Clin Orthop Relat Res 2002;398[5]:127.) The 120 patients in this study were randomly assigned to receive injections of 1 mL of triamcinolone, plus 1-2 mLs of lidocaine. Most patients "had excellent results at one year regardless of the medication or dose," suggesting that the technique played an important role.

Splinting

What about splinting? Are we sending our first-time offenders or even repeat offenders home with a splint? Does it help? The effectiveness of orthoses or splints has been reported as positive, but comparisons of effectiveness among the many different types of orthoses are limited. Many providers (ED and ortho alike) have handed out counterforce braces (see image below) for lateral epicondylitis. They may provide benefit in the first six weeks post-injury, and may prevent recurrence. (Arch Phys Med Rehabil 2005;86[6]:1081.) These cuff-like braces are applied on the forearm about 6-10 cm distal to the elbow joint, and provide support to the elbow. They may even help remodel the muscles in the area, which can decrease pain and persistence.



A lateral counterforce brace, left, and a sleeve brace are used to treat tennis elbow.

Occasionally a full elbow sleeve brace can be used as an at-home splint. Regardless of what you use, studies show the counterforce brace and the sleeve result in an immediate increase in pain-free grip strength. No differences between the two orthoses were found, suggesting that either can be used. A wrist splint produces no immediate change in pain-free or maximum grip strength, indicating that it should not be used as a first-choice orthosis based on those outcome measures. (J Orthop Sports Phys Ther 2009;39[6]:484.)


A wrist splint is not as effective as counterforce and sleeve splints and is much more cumbersome.

Overall, 90 percent of your tennis elbow patients can be managed nonoperatively. (Am J Sports Med 2006;34[12]:1977.) The ED provider can provide fast and effective treatment for tennis elbow by giving an injection of steroids and lidocaine in-house and following up with an orthopedist in a week. A splint should be encouraged, specifically a counterforce or sleeve brace.

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Monday, July 3, 2017

​Simple ankle and wrist sprains and strains still need ACE wraps, Aircasts, Velcro wrist splints, or hard splints. Patients without fractures may still need assistive devices to help control their pain and place their injured extremity in a comfortable position while they heal. Hard splints (like Ortho-Glass) may be unnecessary. Appropriate splinting or hard casting, however, should be used to prevent further injury and decrease pain until follow-up. Strain, sprains, and even contusions do not need hard casting unless there is a high level of suspicion for missed injury, such as a Jones fracture, complicated avulsion injuries, or the nefarious scaphoid fracture.​

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Photo by Martha Roberts

One of the major problems we face is deciding on the right adjunctive therapy for our patients. Depending on the grade of sprain (table), patients may have greater pain or flexibility issues. More intense splinting and prolonged treatment may be indicated. Splinting items are also costly, so it's wise to be prudent with their use. Many devices do not take much time to apply, but it is still an extra step during a patient's visit.

Grading of Sprains

Grade 1Mild damage to a ligament or ligaments without instability of the affected joint.
Grade 2Partial tear to the ligament, in which it is stretched to the point that it becomes loose.
Grade 3Complete tear of a ligament, causing instability in the affected joint. Bruising may occur around the ankle.

Credit: Pain Medicine. Switzerland: Springer International Publishing; 2017.

Inappropriate application may lead to increased injury, such as the dreaded frozen shoulder, which is related to sling use. If a sling is applied and the injury is not a direct shoulder injury, you must instruct patients to do Codman's shoulder exercises to avoid secondary injuries.

ACE Wraps vs. Velcro Splinting

-ACE wraps are difficult to apply yourself for a wrist injury. Dorsal or circumferential Velcro wrists splints may be a better choice.

-ACE wraps assist with swelling and mildly restrict injuries. A Velcro wrist splint inhibits all flexion and extension of the wrist. Keep this in mind with strains and sprains because Velcro splints may not allow for full range of motion and cause muscle atrophy as the injury heals.

-Scaphoid fractures or suspected scaphoid fractures need a thumb spica hard splint. These areas of the scaphoid do not have good blood supply, have difficulty healing, need serial follow-up exams, splint changes, and sometimes OT/PT. A true Velcro thumb spica splint can be used in place of hard casting or Ortho-Glass for these injuries, but a simple dorsal Velcro wrist splint without thumb extension should never be used.

-Evidence Pearl: Grade 1 injuries typically only need two to three weeks of brace time to be fully healed, while grade 2 injuries may need up to six weeks. (Introduction to Splinting: A Clinical Reasoning & Problem-Solving Approach. St. Louis: Mosby Elsevier; 2008.) It is important to remind patients to limit their use of that wrist for up to that amount of time. Any worsening pain or delay in resolution should be seen by an orthopedist.​


Photo by Martha Roberts

ACE Wraps vs. Stirrup Splints

-Stirrup splints (or Aircasts) are meant to stabilize the ankle while the patient is standing. They are not to be worn while sleeping. It should be worn with a supportive shoe, and be sure to caution patients of secondary injury from the sides of the stirrup rubbing on their malleolus.

-An Aircast "boot" is not the same as a stirrup. Be wary of applying boots in the ED, and refer these patients to ortho if you think one is needed.

-ACE wraps should be used while sleeping during the first few days of ankle sprain injuries to help decrease pain and swelling.

-Just like Velcro wrist splints, stirrup Aircasts inhibit ankle rotation. It can cause muscle atrophy if full range of motion is limited.

-Any lower extremity device or cast decreases mobility. Consider patients with risk factors for PE or DVT by avoiding all unnecessary splints.

-Patients can wear ACE wraps under the Aircast (instead of a sock) for the first few days to assist with ankle swelling, but it is not necessary.

-Some patients prefer using the ACE wrap to a sock because it hurts more to put the sock on and off. Give them the option.

-Evidence Pearl: What is the most common sports injury? Lateral ligament ankle sprains. The use of stirrup ankle braces to treat lateral ligament ankle sprains is encouraged. (Br J Sports Med 2005;39[2]:91.) The study reported decreased pain, swelling, ankle girth, and secondary injuries in men and women. The study showed significant improvement in ankle joint function at 10 days and one month compared with standard management with an elastic support bandage alone.​

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Photo by Martha Roberts

Crutches vs. Cane vs. Walkers

-A patient who can bear weight on an injury may use a cane or a walker.

-Jones fractures are non-weight-bearing injuries, and patients with these fractures need to be given crutches.

-Canes can be used instead of crutches depending on the grading and level of pain for ankle sprains or strains. (Table above.)

-Crutches should only be used for the first week (depending on severity of the injury) for acute ankle strains or sprains to avoid secondary axillary injuries.

-Walkers or canes can be given to adolescents, adults, and the elderly if their injuries are appropriate for use.

-Walkers are best suited for any individual who has balance or coordination issues, is elderly, and has difficulty with ambulation at baseline or for when crutches pose too much of a fall risk.

-Evidence Pearl: Some non-weight-bearing injuries include foot and ankle fractures, especially Jones and calcaneal fractures, Achilles tendon rupture, deltoid ligament tears, and tibial stress fractures. (Office Orthopedics for Primary Care: Diagnosis. Philadelphia: Saunders; 2006.)

Common Orthopedic Tips for Patients

-Patients with grade 1 ankle sprains who do not heal within three weeks or those with grade 2 or 3 sprains who do not heal within six weeks should be evaluated by an orthopedic surgeon. Complications include avulsion issues, ligament tears, underlying bone disease, osteoarthritis, osteomyelitis, effusion, and missed fracture. (Office Orthopedics for Primary Care: Diagnosis. Philadelphia: Saunders; 2006.)

-Most adjunctive pieces are needed for only one to two weeks, occasionally longer, depending on the severity of the injury. Patients should wear the assistive device for the first three to seven days, with periods of rest, ice, and compression, and elevation (RICE). Light stretching can be started in a few days, and they can resume normal activities (high-intensity sports or running) when fully healed. Consultation with an orthopedic surgeon may be necessary if patients are not better in two to three weeks.

-Patients can usually remove the splint or wrap to shower, but if it hurts and they have difficulty limiting use in the shower, they should cover it with a plastic bag and not get it wet.

Jim weighs in: Always give the name of a specific person in an orthopedic group to a patient for a referral, not just the group name. Tell them that Dr. Smith is someone at the National Orthopedic Clinic who people like, but everyone in the group is good if you can't get an appointment with Dr. Smith.

Tip of the Week: Instead of tearing the wrapper off an ACE bandage or trying to cut it open and compromising the band if you knick it, simply twist the ends of the wrapper like you're wringing out a towel. The plastic will pop right off.

Watch Ms. Roberts' video on back-to-basics essentials for ACE wrap and Aircast applications.​​​


Thursday, June 1, 2017

Check out this quick video by Martha Roberts, NP, and Carlynne DePolo, EMT, where they show you the basics of splinting in less than five minutes.

Future splinting segments will help you brush up on specialty splints and share pearls to make you a top performing clinician.

Not only will splinting your own patient save you door-to-disposition time, it also guarantees to make your patient happy. Plus, you can position your patients just right, the way you want them to stay, until their follow-up. Read more about splint and cast methods and indications: http://bit.ly/2pWOzhc​.

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Watch Ms. Roberts and Ms. DePolo talk about splinting basics.​


Monday, May 1, 2017

​One of the most important things you can do as a clinician is to fix a patient’s immediate problem. Mastering certain procedures like splinting allows us to provide immediate solutions to patient problems when they arise. We all want to be masters when it comes to splinting, and here is why.



EP splinting a complex distal radial fracture with the help of countertraction. stockinette, fiberglass splinting material, and ACE wrap are utilized.

One of the more common mistakes NPs, PAs, and even MDs make is avoiding splinting their own patients. This means they spend less time at the bedside. If you personally splint your patient, studies show that your added bedside experience may shorten your patient's length of stay and could produce higher patient satisfaction scores. (Am J Manag Care 2014;20[5]:393.) When you skip doing the splint, it can disrupt care and limit your interaction with the patient, which is disliked by patients. Splinting the patient yourself is a great way to expedite care, provide patient teaching, set the mold of the splint the way you want it, and connect with your patient. This is true in emergency care areas and primary care offices. Patients may expect similar interactions with caregivers in the ED as they do in the primary care environment, and the added time at the bedside increases their satisfaction. (Arch Intern Med 2001;161[11]:1437.)

Understandably, you may not always have time to splint a patient yourself. If this is the case, it's important to rely on a team member well-versed in splinting techniques. If the splinting is done incorrectly, it can decrease your satisfaction scores, increase wait time, and impair treatment. Many technicians and nurses are able to apply appropriate splinting, but you as the clinician must always go back into the room and check the splint for accuracy and neurovascular status. Documentation of neurovascular status and splint check is also a billable procedure and recommended by the American Academy of Emergency Medicine. (Acad Emerg Med 2009;16[5]:423.)

The Basics

When you find yourself saying, "Splinting takes too long," we encourage you to attempt a few before coming to that conclusion. The average splint, when done properly, should only take about five minutes. Before you splint, you must know what type of splint is best for the patient's injury or problem.

Casting is a way to immobilize an area circumferentially, and is often reserved for outpatient orthopedic settings. The goals of ED splinting are to protect the injured area, limit the range of motion, and decrease pain, all while providing support and comfort to the patient. Splinting also allows room for swelling, which will occur during the initial healing process of the injury. Surgery, casting or booting, rehabilitation, and reevaluation all come later and should be followed by appropriate orthopedic referral. (Roberts and Hedges' Clinical Procedures in Emergency medicine. Philadelphia, PA: Elsevier Saunders; 2014.)

Complications of Splinting

Be aware of the potential complications of splinting and how to best approach patient concerns. If a patient returns with a splint that is causing more pain or impairs neurovascular status, simply remove and reapply the splint. Potential splinting issues are listed in the table. Keep in mind, all minor problems can turn to severe problems if left untreated.

MinorModerateSevere

Infection (mild)

Dermatitis

Joint stiffness

Pain

Heat injury

Skin breakdown

Burns

Pressure sores

Muscle atrophy

Chronic pain

 

Ischemia

Gangrene

Neurologic injury

Compartment syndrome

Splinting requires an understanding of the materials used during application. The most common splinting material used in the ED is a fiberglass padding that is moistened, applied, and set to dry. Plaster can also be used, but it's more difficult to work with and can be a lot messier. Plaster and fiberglass splints will be very hard once dried. All splinted extremities should be in a position of function, and a stockinette (or protective covering against the skin) should be used prior to covering with fiberglass. (Am Fam Physician 2009;80[5]:491.) This can help prevent minor, moderate, or even severe complications. The splint should have a padding folded over molded contours to provide a smooth edge, and the final splint should be wrapped with an elastic bandage in a "distal to proximal" direction. (Am Fam Physician 2009;80[5]:491.)


Photo of a thumb spica splint after application of a plaster splint in the emergency department. Notice the ring on the patient's middle finger; all jewelry should be removed before splinting and remain off during the healing process because of associated distal joint swelling. Photo courtesy of Larry Mellick, MD.

Managing Splint Application

Maintaining good anatomic fracture alignment throughout the splinting process is important to prevent the injury from getting worse. Stable fractures should be seen one to two weeks after splint application, although hand and forearm fractures are often reevaluated within the first week of injury. (Am Fam Physician 2009;80[5]:491.) Displaced and unstable fractures should be followed more closely, and if proper reduction cannot be achieved, orthopedic surgery consult or surgery may be indicated. (Hand Clin 2000;16[3]:323.)

Why Your Splints Matter

Patients are more likely to follow up with appropriate referrals when they leave your department with a splint. The type of bracing or splinting applied influenced the "no-show" rates for orthopedic follow-up, according to a 2014 study in The Journal of Bone and Joint Surgery. (2014;96[19]:1650.) Patients with splints that were easier to remove or were poorly applied were less likely to follow up with the orthopedic clinic. The better you apply the splint and the more time you spend with your patient, the more likely they are to receive proper follow-up care. The study found that assault victims had the highest no-show rate, and by anatomic region, patients with spine or back complaints had the highest no-show rate. "The easier it was to remove the splint, the worse the follow-up," the authors wrote, noting that patients who were morbidly obese and who currently used tobacco were also less likely to follow up. These factors may influence your disposition and management decisions for these patients.

Pearls

-Splinting should be completed after all radiographs and reductions.

-All jewelry should be removed, especially rings, as soon as possible after injury.

-Keep all patients in the ED until the splint is fully hardened.

-Teach patients the signs of ischemia, i.e., coloring, pain, numbness.

-Complete neurovascular checks before and after splinting.

-Splint in position of function (unless otherwise indicated).

-Do the splint yourself, whenever possible.

-Consult an orthopedic surgeon for all unstable or displaced fractures.

Patients will have less pain, fewer complications, and better outcomes when splints are applied appropriately and cautiously.​