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SPLINTING AND BRACING WORKSHOP

31st Annual Hal Wanger Family Medicine Conference

Dept of Family Medicine Division of Sports Medicine West Virginia University School of Medicine [email protected] I. Materials A. General principles B. Plaster C. Fiberglass D. Pre-made splinting material

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II.

Common Splints A. Upper extremity 1. Thumb spica splint 2. Volar cock-up splint 3. Thumb spica splint 4. Ulnar gutter splint

B.

Lower extremity 1. Posterior leg splint

III.

A.

Common Off-the-Shelf Splints

IV.

Appropriate Billing

I.

Materials A. General Principles of Casting A few basic principles of casting should be covered. The goals of casting and splinting are immobilization and protection. Before casting tape material is placed, the skin should be prepared with padding, such as stockinette and cotton or synthetic webril. Allow enough of overhang of the stockinette and webril to roll back over the first layer of casting tape. This ensures that the casting material does not come in direct contact with the skin leading to skin irritation and maceration. This also allows for a more aesthetically appealing cast when completed. · Stockinette: add extra on either side (finger side and elbow side) of cast. Remove

Hal Wanger 2005

SPLINTING AND BRACING WORKSHOP

31st Annual Hal Wanger Family Medicine Conference

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Dept of Family Medicine Division of Sports Medicine West Virginia University School of Medicine [email protected] wrinkles at ankle, elbow. Webril: Overlap approximately one third to one half of the cotton padding (webril) diameter. Consider using special webril with fiberglass that decreases moisture between casting tape and skin. This should lead to less skin maceration. More padding should be placed over areas of bony prominence (ie: radial and ulnar styloids, lateral and medial epicondyles, malleoli). Keep this padding as smooth as possible since gathered webril or ridges may produce pressure areas and increase risk of skin breakdown. Use ~ 1-2 layers. Cast tape: see below for details. Use cool water. The warmer the water, the quicker the drying of the cast tape. In addition, the mixture of water to cast tape produces an exothermic reaction that is responsible for plaster and fiberglass setting. This results in the release of heat that is intensified with warmer water. There is the small, but definite, risk of skin burns to the patient. At the very least the increased heat may not be tolerated by the patient. Ace bandage: Wrapping the "finished product" in an moistened elastic wrap will help solidify the multiple layers of cast tape and smooth out rough edges.

B. Plaster of Paris This product is the "old stand-by." It is the cheapest material and easiest to mold into desired form. This porous material is air permeable- allowing passage of body fluids to the surface. Plaster sets in 10-15 minutes and dries completely within 24 hours. It does, however, require a special plaster trap to be installed in the plumbing of the sink since plaster can damage ordinary plumbing. In addition, plaster may interfere with radiography, especially if postreduction films are necessary. 1. The width of the plaster tape depends upon the size of the patient and location of fracture. Common widths of plaster include 2-6 inches. 2. Unroll dry plaster onto the patient to measure the proper length. Allow approximately 1 cm extra to accommodate for shrinkage when wet. 3. Utilize approximately 4-8 layers of cast tape (depending upon the cast type/location). 4. Submerge in cool water. The warmer the water, the quicker the setting/drying; also, recall risk of thermal injury to skin. The plaster is saturated with water when no bubbles rise to the surface. Smooth wet plaster to get rid of most of the water. Excessive wringing of the plaster is not necessary. 5. Wrap the wet plaster around the previously placed cotton padding. Do not wrap under tension. Smoothing the plaster with the palms of the hands will consolidate the layers into one mass. Considerable care should be maintained to avoid creating pressure points and indentations in the drying plaster.

Hal Wanger 2005

SPLINTING AND BRACING WORKSHOP

31st Annual Hal Wanger Family Medicine Conference

Dept of Family Medicine Division of Sports Medicine West Virginia University School of Medicine [email protected] 6. Wrap in wet elastic (ace wrap) bandage. Again, do not use tension. 7. Plaster will set in 10-15 minutes and will be dry in 24 hours. 8. Avoid exposure to water since this will cause plaster breakdown. If cast gets slightly wet, a hair dryer can help avoid major damage. 9. Patient should be counseled regarding risk of skin maceration, infection, neurovascular compromise. The patient should be instructed to observe for these potential complications and told to return if they occur. The cast should be removed and reapplied.

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C. Fiberglass cast material This cast tape is knitted fiberglass impregnated with a polymer resin and silicone. This creates a much lighter cast, but is not as moldable. The exothermic reaction of fiberglass gives off a larger amount of heat as compared to plaster. However, fiberglass is more durable than plaster. Application of fiberglass requires the use of gloves to prevent resin from adhering to the skin. Fiberglass sets within 4-5 minutes, and dries completely in one hour. It does not interfere with radiography. 1. The width of the plaster tape depends upon the size of the patient and location of fracture. Common widths of plaster include 2-6 inches. 2. Apply stockinette and webril as above. Use a synthetic webril (not cotton) that wicks moisture away from the skin to decrease risk of maceration. This synthetic webril has a higher incidence of dermatitis. 3. Open the cast tape foil package. Avoid opening the foil package until ready to place the cast. The moisture in the air will immediately start the exothermic reaction that initiates hardening. Submerge the cast tape into cold water. Shake to remove extra water. 4. Apply the tape overlapping tape approximately one-third to one-half of the diameter. On either end, leave a margin of ~ 1cm between the webril and where you start the cast tape. This will create that beautiful look to the cast when done. 5. After application of the first layer (~ 1 roll), roll back extra stockinette at either end and apply a second layer. As the cast tape begins to harden, it may become difficult to unravel. Do not pull harder to unravel cast tape since this may tighten the cast. If the tape is too hard, dispose of the remaining tape and start a new roll. 6. Wrap in wet elastic (ace wrap) bandage. Again, do not use tension. 7. Plaster will set in 4-5 minutes and will be dry in 1 hour. 8. Patient should be counseled regarding risk of skin maceration, infection, neurovascular compromise. The patient should be instructed to observe for these potential complications and told to return if they occur.

Hal Wanger 2005

SPLINTING AND BRACING WORKSHOP

31st Annual Hal Wanger Family Medicine Conference

Dept of Family Medicine Division of Sports Medicine West Virginia University School of Medicine [email protected] MATERIALS Plaster

· · · ·

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ADVANTAGES

Porous Very moldable, conforming Inexpensive Nonirritating · · · · · · ·

DISADVANTAGES

Heavy May interfere with radiography Messy Requires plaster trap in sink Dries in 24 hrs Average durability Not waterproof

Fiberglass

· · · · · ·

Lightweight Radiolucent No special prep or disposal Very strong, durable 3-4 year shelf life Sets in 4-5 min, dries in 1 hr

· · · ·

Nonporous Not as conforming Expensive Synthetic padding may irritate

D. Pre-made splinting material Plaster and fiberglass splinting material is available on rolls. Their convenience and ease of applicability make them well-suited to busy office practice. Special templates are available: thumb spica, ulnar gutter, posterior leg, etc. These will be discussed later. II. Common Casts A. Upper extremity 1. Short-arm cast- indications: Distal radius fracture Ulnar fracture 2. Long-arm cast- indications: Some carpal fractures, especially if pain with supination/pronation Distal humerus fracture 3. Short-arm thumb spica cast- indications: Scaphoid fracture Some thumb fractures

B. Lower extremity 1. Short leg nonweight-bearing cast Jone's fracture (base of the 5th metatarsal) Some distal fibular fractures Some tibial stress fractures 2. Short leg weight-bearing cast

Hal Wanger 2005

SPLINTING AND BRACING WORKSHOP

31st Annual Hal Wanger Family Medicine Conference

Dept of Family Medicine Division of Sports Medicine West Virginia University School of Medicine [email protected] Some grade 3 ankle sprains Some distal tibial fractures III.

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Common splintsThese splints may be used as a final treatment option or a temporary measure. In elderly patients with significant swelling, splints decrease the risk of neurovascular compromise possible with a circumferential cast. In very young (mobile) patients splints may only provide support until definitive therapy can be performed. Remember, maximum swelling may take up to 72 hrs to occur. If a circumferential cast is applied at 24 hrs, neurovascular compromise may occur. Note, the elderly and very young (vascular) may be especially at risk groups for continued swelling. Prefabricated splinting material is available (ie: Ortho-Glass, OCL splinting, 3-M, etc.). This material comes with the cast material and padding in one set-up. It usually comes in rolls of either plaster or fiberglass polymer. Templates are available for assistance with special splints (thumb spica, radial gutter, etc.). Select appropriate width and length. This should then be wrapped with a wet ACE bandage to further laminate the layers. Drying and hardening times the same as for casting as above. Ensure no motion while drying to avoid "hinging" of cast material in areas of caution (eg: the thumb in thumb spica splints; the foot in posterior leg splints). A. Upper extremity 1. Volar cock-up splint Carpal tunnel syndrome Some tendinitis Wrist sprain 2. Thumb spica splint Distal radius fracture Scaphoid fracture- initial immobilizing splint Ligamentous injuries to the thumb, UCL sprain 3. Ulnar gutter splint Metacarpal fractures, especially 4th and 5th metacarpals 4. Posterior elbow splint Elbow fractures Occult elbow fractures B. Lower extremity 1. Posterior leg splint

Hal Wanger 2005

SPLINTING AND BRACING WORKSHOP

31st Annual Hal Wanger Family Medicine Conference

Dept of Family Medicine Division of Sports Medicine West Virginia University School of Medicine [email protected] Some ankle sprains Avulsion fractures of either malleoli

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IV. Appropriate Billing: Enclosed are CPT codes for application of splints or taping:

Strapping: UHA Fee Schedule 29540 Ankle $100 29280 Finger, Hand 135 29550 Toes 95 29260 Wrist 135 Application of Splint: 29125 Short arm splint 170 29105 Long arm splint 225 29130 Finger splint, static 100 29131 Finger splint, dynamic 135 29590 Foot splint 135 29515 Short leg splint 170 29505 Long leg splint 200

Below are CPT treatment codes for the global care of selected fractures:

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23540

Treatment of Fractures Tx AC Dx

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28470

Tx metatarsal fx, each

Hal Wanger 2005

SPLINTING AND BRACING WORKSHOP

31st Annual Hal Wanger Family Medicine Conference

Dept of Family Medicine Division of Sports Medicine West Virginia University School of Medicine [email protected]

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 28400 25630 23500 27780 28490 23600 23620 24530 28660 26770 27786 27760 26700 28630 26600 Tx calcaneal fracture Tx carpal bone fracture Tx clavicle fracture Tx fibular fx, proximal, shaft Tx great toe/hallux fracture Tx humerus fx, proximal Tx humerus fx, greater tuber Tx humerus fx, supracondyl Tx IP joint Dx Toe Tx IP Dx Toe w/ manip Tx lateral malleolus fx Tx medial malleolus fx Tx MCP Dx Tx MTP Dx Tx metacarpal fx, each ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 27560 27520 26720 26750 25600 24640 24650 21800 23650 23620 22305 28430 28510 25530 22310 Tx patellar dislocation Tx patellar fracture Tx phalanx fx, prox/middle Tx phalanx fx, distal Tx radius fracture, distal Tx radius head, subluxation Tx radial head fracture Tx Rib fracture, each Tx shoulder Dx, no fracture Tx shldr Dx, fx gr tuberosity Tx spinous process fx Tx talus fracture Tx toe fracture, each Tx ulna fracture, proximal Tx vertebral body fx

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Hal Wanger 2005

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