Medicine for the Outdoors
Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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Immobilization Techniques After Wrist Fracture Reduction

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After a person breaks (fractures) a bone, the treating clinician may attempt to straighten (reduce) the fracture in order to correct the deformity and restore the anatomy. This preserves function, facilitates healing, reduces pain, may reduce bleeding, and in the case of fractures in children, may allow continued proper growth.

After the bone is put into proper position, it must be prevented from moving or slipping out of position. This is accomplished with an immobilization device, most commonly a splint (non-circumferential). Circumferential (completely enclosing the limb) casts are usually applied only after an adequate period of time (usually at least a few days and up to a week or more) has passed to allow swelling to cease so that pressure inside the constrictive cast does not cut off circulation or cause the pressure to injure the soft tissues.

In an article by E. Grafstein entitled “A prospective randomized controlled trial comparing circumferential casting and splinting in displaced Colles fractures” (CJEM 2010;12:292), outcomes were similar at 8 weeks and 6 months when one of two splinting techniques (top-bottom or modified “sugar tong”) or circumferential casting were used to immobilize first-time distal (at the end near the wrist) radius bone (arm) fractures in adults and who did not show any neuromuscular deficits after the fractures were reduced. The parameters studied included anatomic position, disability, and pain.

What is the message here? The most important message, and the one we should take away, is that the splints performed as well as the circumferential casts in terms of providing proper positioning for healing and leading to acceptable outcomes. There did not appear to be any loss of proper bone positioning.

A message that is implied is that there were not any complications with using the circumferential casts. I think that this would be a dangerous message to take away from this study, particularly for field use of that technique, away from regular evaluation and perhaps away from an easy ability to remove the cast (such as a cast saw). There may not have been enough persons in the study to generate someone with the potentially devastating complication of pressure within a circumferential cast causing elevated tissue pressure and damage. So, it cannot be assumed that this complication would never occur. I have seen it happen – it leads to disability and to unnecessary law suits.

One might make the counter argument that perhaps there were not enough patients in this trial to identify one for whom the splinting technique failed. Fair enough. However, I know that a splint properly applied, with sufficient room for swelling to occur without taking the chance of a pressure-induced injury, can hold a wrist in perfect position and withstand a great deal of abuse. So, until further notice, please take away the ‘good message’ and learn how to apply proper splints, and do not use circumferential casts for an acute bony injury.

 

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Tags: General Interest

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Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.

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