Article, Orthopedics

A modified thumb spica splint for thumb injuries in the ED

Clinical Notes

A modified thumb spica splint for thumb injuries in the EDB

Raymond G. Hart MD, MPHa,b,*, Harold E. Kleinert MDc, Kathleen Lyons RNd

aDepartment of Emergency Medicine, University of Louisville School of Medicine, Louisville, KY 40202, USA

bhand injury Prevention and Research, Christine M. Kleinert Institute for Hand and Microsurgery, Inc,

Louisville, KY 40202, USA

cDepartment of Surgery, University of Louisville School of Medicine, Louisville, KY 40202, USA

dChristine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY 40202, USA

Accepted 16 March 2005

Abstract There are a significant number of hand and upper extremity injuries treated in US emergency departments (EDs) each year. Many of these involve the thumb and wrist. These injuries encompass the range from fractures, strains, and sprains to more specific injuries such as gamekeeper thumb and de Quervain tenosynovitis. These injuries often require diagnosis, splinting, and referral to a hand or Orthopedic surgeon. The splint described in this article is presently being used for patients with de Quervain tenosynovitis, but it may have more widespread application in emergency medicine. It is a safe and simple splint that is underused in EDs for splinting thumb injuries.

D 2005

Introduction

There were 110.2 million emergency department (ED) patient visits in the United States in 2002 [1]. Of those visits, hand and Finger injuries were estimated to be 4.8 million [2]. The thumb is estimated to be more than 20% of those injuries or nearly 1 million ED visits per year.

Work-related Musculoskeletal disorders of the hand and upper extremity have become more common [3,4]. A reported 588000 persons complained of prolonged hand discomfort and were given a diagnosis of trigger finger, ganglion cyst, tendonitis, epicondylitis, synovitis, de Quer- vain disease, or tenosynovitis by a medical person [5]. Of

B The authors did not receive funding or outside support for this study. T Corresponding author. Hand Injury Prevention and Research, Christine M. Kleinert Institute for Hand and Microsurgery, Inc, Louisville,

KY 40202, USA. Tel.: +1 502 562 0310; fax: +1 502 562 0326.

E-mail address: [email protected] (R.G. Hart).

these, 28% were thought to be work-related. Each of these injuries must be carefully diagnosed, splinted when neces- sary, and appropriately referred.

There are a number of varied injuries that may result from trauma to the thumb. A sprain or strain is common and can be painful and debilitating. A thumb fracture will definitely need follow-up evaluation and care. An intra-articular fracture at the first carpometacarpal (CMC) joint, called a Bennett or Rolando fracture, is a particular example. These injuries can lead to pain, weakness, and instability of the thumb. There are also several specific thumb injuries that require splinting and referral. A gamekeeper thumb, which is an injury to the ulnar collateral ligament at the thumb metacarpophalangeal (MCP) joint, requires a splint and referral. De Quervain tenosynovitis, which usually results from overuse, causes a painful thumb and improves with appropriate splinting. In addition, dislocation of any joint of the thumb requires reduction, splinting, and follow-up care. Other injuries to the thumb include nail-bed and fingertip

0735-6757/$ - see front matter D 2005 doi:10.1016/j.ajem.2005.03.004

Fig. 1 See text for description. Fig. 3 See text for description.

injuries, soft tissue injuries, and lacerations. Furthermore, possible flexor or extensor tendon lacerations and neuro- vascular bundle injuries that may require exploration by a hand surgeon will need splinting from the ED.

There are choices the emergency physician must consider for splinting. A soft dressing may be adequate for some injuries, perhaps with an elastic bandage added for support. There are prefabricated splints that can adequately immo- bilize a thumb injury. There are also volar or dorsal foam- backed splints that can be fashioned and applied to the thumb. However, when immobilization is needed, the most effective splint for the thumb is the thumb spica splint. The thumb spica provides support to the wrist and thumb. The immobilization will promote healing, protect the injured thumb, and decrease pain.

Methods

The splint recommended is presently being used in the hand surgery practice for patients with de Quervain

Fig. 2 See text for description.

tenosynovitis. Patients seen with the diagnosis may have radiographs and may begin nonsteroidal anti-inflammatory drugs. They will likely also receive a steroid injection and will have a splint placed for 3 to 4 days. It is fashioned specifically to the patient’s thumb, wrist, and forearm. It is inexpensive and lightweight and can be removed without difficulty. It also allows for possible swelling of the digit.

The splint is simple to make and apply. First, obtain about 4 sheets of 4-in plaster. These 4-in strips should be folded longitudinally in half, with an accompanying 12-in-long x 2-in-wide stockinet prepared (Fig. 1). The plaster is then slipped into the stockinet, and the entire splint is dipped in water (Fig. 2). Warm water provides rapid setting of the plaster; thus, cool or only lukewarm water is suggested to allow the physician time to fashion the splint appropriately. A dressing of 4-in Webril can be applied initially as with other plaster splints, but it is not mandatory with this particular splint. The patient’s thumb should be positioned in a comfortable, neutral position. Take the wet splint from the basin of water, and with 2

Fig. 4 See text for description.

Fig. 5 See text for description. Fig. 7 See text for description.

fingers, strip the excess water; then, apply the splint, supporting the volar surface of the thumb first (Fig. 3). Apply the splint in a cross fashion around the dorsum of the thumb at approximately the MCP joint. The splint will cross the wrist and provide 8 to 10 cm of support proximally, with the wrist in a neutral position (Figs. 4 and 5). After the thumb and wrist have been positioned comfortably, the splint can be adjusted and straightened to provide maximal comfort and no opportunity for sharp or hard edges. An elastic bandage can then be applied to ensure support for the splint, thumb, and wrist (Fig. 6). The splint can be fashioned to accommodate swelling and, if necessary, in such a way that the elastic bandage and splint may be quickly and easily removed if the patient experiences excessive pain or swelling (Fig. 7).

Discussion

hand injuries are common in the ED. Thumb injuries, in particular, can be subtle, and the emergency physician must

Fig. 6 See text for description.

be aware of potential complicated injuries. These injuries are overlooked at great risk to the patient and can be devastating because the thumb is crucial to the dexterity of the human hand. One of its most important functional aspects is its extensive mobility, and it is the most vital and important digit of the hand.

The CMC joint is the most important joint of the thumb from a functional standpoint [6,7]. The thumb interphalan- geal joint and MCP joints both flex and extend. The CMC joint, however, allows palmar abduction and adduction, as well as radial abduction and adduction. The thumb also can move in opposition and reposition. Its movements allow the complexity of human prehension.

Unfortunately, some hand injuries can ultimately lead to disability. Instability, pain, and loss of function at the CMC joint can lead to a lifetime of pain and disability. It is incumbent on the emergency physician to properly diagnose, treat, and refer these injuries; part of the treatment must include the appropriate splint. It is essential to know which of these injuries require referral and the urgency of follow-up with a hand or orthopedic surgeon.

The CMC joint of the thumb is a common site for degenerative arthritis [8 - 10]. The degeneration of first CMC osteoarthritis generally occurs in the fifth decade of life and affects women more than men. There are tremendous functional demands placed on this highly mobile joint [6]. In addition, it must be stable enough to allow for powerful pinching loads. The CMC joint has a relatively large and loose capsule to accommodate the extensive range of motion, and it is reinforced by at least 5 ligaments. In addition, patients with rheumatoid arthritis have a significantly higher incidence of related hand pathology [11].

De Quervain tenosynovitis is an inflammation of the extensor pollicis brevis and abductor pollicis longus tendons [12]. This also includes the layers of the tendon sheaths. It occurs commonly in women aged between 30 and 50 years. It can occur from a variety of causes including bathing, grinding, polishing, and screwdriver use. It has

recently been described as a postpartum/newborn condition [13,14]. These patients complain of pain and tenderness along the radial aspect of the wrist, with swelling dorsally over the first extensor tendon compartment. It may be possible to palpate the swelling at the anatomic snuffbox near the radial styloid, and any motion of the thumb or the wrist may be painful. These patients benefit greatly from the splint described.

Correct splinting is critical in all cases but particularly with the hand and thumb. A splint must provide support and protection, and the splint material chosen should be inexpensive but secure. It should immobilize the thumb to decrease pain, rest the injured part, and prevent further injury. Splints can be made static for immobilization or dynamic to allow controlled mobility. It is essential that the chosen splint applied does not cause its own complica- tions. The most frequent are itching, pain, stiff joints, and pressure sores.

A splint misapplied to the thumb can lead to a digital neuropathy similar to a Bowler thumb lesion [15,16]. This is a compression neuropathy caused by extra neural mechan- ical pressure applied to the ulnar digital nerve of the thumb. This nerve is susceptible to injury for 4 reasons: it is immediately beneath the skin, it travels directly over bony structures, it has a fixed position with minimal excursion, and there is no pain associated with the nerve trauma, only resulting numbness.

Poorly chosen and designed splints can lead to these complications. These complications may occur more fre- quently in prefabricated splints in that they are inflexible, made to standard sizes, and do not allow uniform contact with the tissues [16]. Custom-made splints allow better molding, individual variability, and careful specific tissue contact.

The splint applied must provide joint protection. Joint protection is defined as minimizing or eliminating stress placed on the joint during the performance of activities of daily living [7]. Regardless of design, a static splint applied to the thumb should position the base of the thumb in relative palmar abduction and incorporate slight flexion and medial rotation. Staged splinting has also proven effective for thumb conditions in infants [17].

There are splints specifically designed for the MCP joint of the thumb [18]. The goal stated for these splints is to maintain the thumb in a stable position, minimize compres- sion over the dorsal surface of the MCP joint, and enhance overall function of the hand. These splints stabilize the thumb MCP joint in approximately 158 to 208 of flexion with slight opposition.

Spica (Latin for bear of wheat Q) is defined as ba figure of eight bandage with turns that cross one another regu- larly like the letter V, usually applied to anatomic areas of quite different dimensions,Q such as the thumb [19]. The proposed splint is a modified thumb spica splint. It has a stand-alone unit of removable plaster with only a single cross or turn of the material and is supported with an elastic bandage.

The thumb splint described supports multiple joints and will afford maximal protection to the entire thumb and radial wrist region. This is especially desirable for an acutely injured, painful thumb in an active person. The wrist should be immobilized in about 108 to 208 extension, the CMC joint in relative palmar abduction, the MCP joint in 308 flexion, and the interphalangeal joint in a neutral position.

The splint described is used to treat patients in this hand surgery practice with de Quervain tenosynovitis who require a steroid injection and splinting. It was initially devised and popularized by Dr Bruce Butler. The splint has proven itself over the years to be inexpensive, patient-specific, comfort- able but secure, durable, and effective. Many of the thumb injuries seen in the US EDs require splinting. The splint described is an option that may have widespread application for just those injuries.

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