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.

Monday, July 3, 2017

Back-to-Basics for Strains and Sprains: ACE Wraps, Aircast, and Velcro

​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.​

PP aircast velcro 1.jpg

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.​

PP aircast velcro 3.jpg

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.​​​