Pediatric emergency medicine trisk 1117
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be flexed to 90 degrees at the elbow with no rotation of the forearm. The hand is
dorsiflexed minimally (have the patient hold a small roll of tape or Webril).
With the arm positioned as described, measure from the midpalm around the
elbow to the knuckles dorsally (add 1 to 2 in to allow for shrinkage). The
splinting material should be wide enough to support the arm along the volar and
dorsal surfaces but not so wide as to overlap. Prepare and apply the materials as
described in the “General Splinting” section. Ensure sufficient padding is placed
over the elbow to prevent pressure ulcers. A properly measured splint allows 90
degrees of flexion of the fingers and approaches, but does not cover, the knuckles
dorsally. An assistant is helpful when applying this splint. Ensure the thumb is
free to move in all directions.
Discharge the patient with a sling with the hand slightly above the level of the
elbow.
Thumb Spica Splint
Indications
1. Nonrotated, nonangulated, nonarticular fractures of the thumb metacarpal or
phalanx
2. Ulnar collateral ligament injuries (gamekeeper’s thumb)
3. Suspected or documented scaphoid fracture
Procedure
The splint extends in a U-shaped manner along the radial side of the thumb and
forearm from the thumbnail to the midforearm ( Fig. 130.49H ). The proper
splinting position maintains the wrist in slight dorsiflexion, the thumb in some
flexion and abduction, and the interphalangeal joint in slight flexion. The final
position is as though the patient were holding a glass or catching a ball, and will
allow apposition of the index finger and thumb.
Determine the appropriate length of splint material by measuring from the
patient’s thumbnail to the midforearm. The splint should be wide enough to
completely encircle the thumb. Prepare and apply the splint materials as described
in the “General Splinting” section. The Webril should cover the thumb, hand, and
forearm. Mold the splint so the thumb is maintained in the position previously
described.
A sling is usually unnecessary but may assist in reminding the patient to keep
the site elevated.
Dorsal Extension Finger Splint
Indications
1. Nonrotated, nonangulated fractures of the phalanges, not involving greater than
10% of the joint line
2. Immobilization after laceration or tendon repair
3. Sprains of the phalangeal ligaments
Note: Mallet and boutonniere fingers require an alternative splinting method
Equipment
1. Commercially available foam splints with aluminum backing
2. ½- and 1-in adhesive tape
Procedure
A dorsal splint is preferred to a volar splint because tactile sensation is
maintained, it is more comfortable for the patient, and it is more protective of the
injury as the splint lies between the patient and outside surfaces during
ambulation.
The splint extends from the dorsum of the wrist to the end of the finger ( Fig.
130.49I ). The appropriate width will be equal to the diameter of the finger. Cut
the splint to the proper length and place tape on the sharp edges. Tape the splint
with 1-in tape to the dorsum of the hand and wrist. Bend the splint to obtain 50 to
90 degrees of flexion at the metacarpophalangeal joint and 15 to 20 degrees of
flexion at the interphalangeal joints. Secure the splint of the finger with ½-in tape,
making sure not to cover the joint lines.
REDUCTION OF NURSEMAID’S ELBOW
Indications
Radial head subluxation (nursemaid’s elbow), which is an injury that probably
represents interposition of the annular ligament between the radial head and the
capitellum ( Fig. 130.50A ).
FIGURE 130.50 Reduction of a nursemaid’s elbow (radial head subluxation).
Complications
Vascular or musculoskeletal damage if the maneuver is performed on a child with
a fracture (e.g., supracondylar fracture of the humerus)
Procedure
Radiographs are not necessary if the suspicion for radial head subluxation is high,
but are helpful to be certain that no bony injury exists when the history and
examination are equivocal. Suspicion for radial head subluxation is based on (i) a
history that is suggestive of a mechanism that would lead to radial head
subluxation, such as excessive axial traction placed across the elbow joint during
a fall while holding hands with an adult ( Fig. 130.50 ); (ii) observation of the
affected arm, which is generally held at the child’s side, slightly flexed at the
elbow and with the forearm in pronation; (iii) absence of point tenderness along
the length of the arm and shoulder during examination of the affected arm; (iv)
absence of swelling (which could indicate a supracondylar fracture); and (v)
tenderness with supination of the forearm. An adequate examination requires that
the child be comfortable and may entail some distraction. It may be useful to have
the caregiver palpate the entire arm to assess for tenderness while the medical
provider observes from across the room because young children may be
frightened and may cry when the medical provider approaches or attempts to
touch the child. Oral analgesia with acetaminophen or ibuprofen may be also
useful.
Generally, it takes less than 10 to 15 minutes after a successful reduction before
the child uses the arm normally. Rarely, when a prolonged period has elapsed
before reduction, it will take somewhat longer for the child to regain normal
function after the maneuver is performed. Repeat or try an alternative approach if
unsatisfied with the child’s use of the arm.
Supination and Flexion Approach
After explaining the procedure to the parent, have the parent or assistant gently
restrain the child in the sitting position. As shown in Figure 130.50B , grasp the
palm of the child’s hand as if to shake it. Encircle the elbow with the other hand
placing the thumb over the radial head and annular ligament and position the
elbow in some flexion. Gently distract the elbow joint and then supinate the palm
of the hand ( Fig. 130.50C ), and in a continuous motion, flex the elbow bringing
the patient’s hand up to their shoulder ( Fig. 130.50D ). During the flexion
maneuver, a “pop” should be felt with the thumb that overlies the radial head.
Hyperpronation
