Orthopedic Emergencies: Expert Management for the Emergency Physician 1st Ed.

Chapter 10. Immobilization and splinting

Michael C. Bond and Michael K. Abraham

Orthopedic Emergencies, ed. Michael C. Bond, Andrew D. Perron, and Michael K. Abraham. Published by Cambridge University Press. © Cambridge University Press 2013.

General

Splint material (Figures 10.1 and 10.2)

·        Stockinette (Figure 10.1C) – a cloth sleeve that helps provide protection to the skin, and helps to hold the splint in place during application. Also gives a cleaner appearance to the splint/cast.

·        Plaster of Paris (Figure 10.2B) – available in sheets or rolls. Sheets typically come 5 inches wide in 30- or 45-inch lengths. Eight to ten sheets typically needed for upper-extremity splints, and 15–20 sheets for lower-extremity splints. Width and length can easily be adjusted to the patient’s needs by ripping or cutting the sheets. Plaster of Paris takes approximately 20 minutes to cure and a full day to reach maximum strength. The curing process is an exothermic reaction, so patients may complain of significant heat and can suffer burns. The risk of excessive heat production increases with the number of sheets used and if the water used to wet the plaster of Paris is hot

·        Fiberglass (Figure 10.1D) – (e.g., Orthoglass®, Scotchcast®) sold as rolls of fiberglass wrapped in cotton padding. Supplied in predetermined widths (2″, 3″, 4″, 5″, and 6″). Fiberglass requires minimal water to aide the activation process, will cure and reach maximum strength in about 20–30 minutes. Not as moldable as plaster of Paris. Care needs to be made to trim or cover the cut edges in order to prevent fiberglass barbs from poking the patient. Orthoglass® has the same padding on both sides of the splint, whereas Scotchcast® has padding on one side and a breathable backing on the other

·        Cast padding (e.g., WebrilU+2122) (Figure 10.1A and Figure 10.2C) – rolls of cotton padding that must be used with plaster of Paris. Care should be taken to prevent creases or lumps as this can lead to pressure points that can result in skin breakdown and pain. Typically two to three layers provide enough padding. Additional layers should be used on bony prominences

·        Elastic bandage (Figure 10.1B and Figure 10.2D) – used to hold the splint in place. Do not apply with excessive force as this can lead to numbness and reduced blood flow



Figure 10.1 Typical supplies used for splinting: A – cotton padding. B – elastic bandage. C – stockinette. D – fiberglass splinting material.



Figure 10.2 Typical supplies used for splinting. A – stockinette. B – plaster of Paris sheets. C – cotton padding. D – elastic bandage. Ensure the cotton padding is wider and longer than the plaster of Paris to ensure that the plaster is completely covered.

Sugar tong splint (Figure 10.3)

Indications

·        Radius and ulna fractures

·        Supracondylar humeral fractures

·        Carpal bone fractures

PEARL: The sugar tong splint prevents flexion and extension at the wrist, supination, pronation, and greatly inhibits flexion and extension at the elbow. Can be combined with a second sugar tong splint (double sugar tong) that starts at the axilla and wraps around the elbow to the shoulder. This double sugar tong will prevent all flexion and extension at the elbow.



Figure 10.3 Traditional sugar tong splint. Used for fractures of the radius, ulna, carpal bones, and supracondylar fractures. Note the final hand position.

Materials

·        Stockinette

·        Plaster of Paris or fiberglass splint

·        Cast padding

·        Elastic bandages

Application

·        Two methods possible

o   Traditional sugar tong (Figure 10.3)

§  Apply stockinette from the hand to mid-bicep

§  Measure splinting material (plaster of Paris, or fiberglass) from the dorsum of the hand, around the elbow, to the volar surface of the hand

§  Ensure that the width is thin enough that it does not come up the sides of the forearm, which would essentially form a circumferential cast. Most splints will be 2 or 3 inches wide (5 to 7.5 cm)

§  If using plaster of Paris, roll out two to three layers of cast padding. Consider adding additional padding over areas of bony prominence

§  Wet the plaster of Paris, or slightly dampen the fiberglass splinting material

§  Apply the cast padding to the wet splint material, and apply to the arm as one unit starting at the hand, wrapping around the elbow and returning to the hand (Figure 10.4). Splinting material can bunch up at the elbow (Figure 10.5)

§  Starting at the hand, apply elastic bandages to hold the splint in place. Make sure not to to apply the elastic bandages too tightly

§  Once the splint is applied, the hand and wrist should be placed in the position of function



Figure 10.4 Traditional sugar tong splint with the fiberglass placed over the stockinette. The splint should go from the dorsal side of the hand, wrap around the elbow, and return to the volar side of the hand.



Figure 10.5 Demonstrates the bunching that can occur with the splinting material at the elbow.

Double sugar tong splint

Indications

·        Humerus fractures

·        Supracondylar fractures

·        Radius and ulna fractures

·        Carpal bone fractures

PEARL: Prevents flexion and extension at the wrist, and elbow and metacarpal joint if extended into the fingers. Also prevents supination and pronation of the forearm.

Materials

·        Stockinette

·        Plaster of Paris or fiberglass splint

·        Cast padding

·        Elastic bandages

Application

·        Apply stockinette from the hand to axilla

·        Measure 2 pieces of splinting material (plaster of Paris, or fiberglass). The first will go from the axilla, around the elbow and wrap back up the arm to the shoulder. The second piece will go from the dorsum of the hand, wrap around the elbow, to the volar surface of the hand

·        Most splints will be 2 or 3 inches wide (5 to 7.5 cm)

·        If using plaster of Paris, roll out 2–3 layers of cast padding. Consider adding additional padding over areas of bony prominence

·        Wet the plaster of Paris, or slightly dampen the fiberglass splinting material

·        Apply the cast padding to the wet splint material, and apply to the arm as two units. The first unit will be applied from the axilla, wrap around the elbow, and extend back up to the shoulder. The second unit will extend from the dorsum of the hand, wrap around the elbow, and extend back to the volar surface of the hand

·        Starting at the hand, apply elastic bandages to hold the splint in place. Make sure not to apply the elastic bandages too tightly

·        Once the splint is applied, the hand and wrist should be placed in the position of function, and the elbow flexed at 90°

Reverse sugar tong splint (Figure 10.6)

·        Apply stockinette from the hand to mid-bicep

·        Measure splinting material (plaster of Paris, or fiberglass) from the dorsum of the hand, around the elbow, to the volar surface of the hand

·        Ensure that the width is thin enough that it does not come up the sides of the forearm, which would essentially form a circumferential cast. Most splints will be 2 or 3 inches wide (5 to 7.5 cm)

·        If using plaster of Paris, roll out two to three layers of cast padding. Consider adding additional padding over areas of bony prominence

·        Fold the splint in half, and in the middle, cut through the splinting material except for a small piece (U+223C1/2 inch [1 cm]) (Figure 10.7)

·        Wet the plaster of Paris, or slightly dampen the fiberglass splinting material

·        Apply the cast padding to the wet splint material, and apply to the arm as one unit starting at the hand. The area that was not cut should be placed in the webspace of the first and second digits of the hand, with the splint hanging down from the hand (Figure 10.8)

·        Starting at the hand, apply elastic bandages to hold the splint in place. Make sure not to apply the elastic bandages too tightly

·        Once the splint is applied, the hand and wrist should be placed in the position of function



Figure 10.6 A reverse sugar tong splint. The splinting material is cut so that it can rest in the first and second web space, and then drapes down the arm, where the ends can be wrapped around the elbow. More easily held in place while wrapping with elastic bandages than a traditional sugar tong, and prevents some of the bunching of splint material at the elbow.



Figure 10.7 Fold the splinting material in half and cut through the material, leaving about 1 cm uncut.



Figure 10.8 Reverse sugar tong shown in place with the uncut splint material resting in the first and second web space.

Volar splint (Figure 10.9)

Indications

·        Carpal bone fractures

·        Metacarpal bone fractures

·        Carpal tunnel syndrome

·        Soft-tissue injuries of wrist

PEARL: A volar splint prevents flexion and extension at the wrist and metacarpal joint if extended into the fingers.



Figure 10.9 A volar splint used for the treatment of fractures of the carpal bones, metacarpals, carpal tunnel syndrome, and soft-tissue injuries of the wrist.

Materials

·        Stockinette

·        Plaster of Paris or fiberglass splint

·        Cast padding

·        Elastic bandages

Application

·        Apply stockinette from the hand to mid-forearm

·        Measure splinting material (plaster of Paris, or fiberglass) along the volar side of the hand from the mid-fingers to the mid-forearm

·        Most splints will be 2 or 3 inches wide (5 to 7.5 cm)

·        If using plaster of Paris, roll out two to three layers of cast padding. Consider adding additional padding over areas of bony prominence

·        Wet the plaster of Paris, or slightly dampen the fiberglass splinting material

·        Apply the cast padding to the wet splint material, and apply to the arm as one unit starting at the distal hand along its volar surface (Figure 10.10)

·        Starting at the hand, apply elastic bandages to hold the splint in place. Make sure not to apply the elastic bandages too tightly

·        Once the splint is applied, the hand and wrist should be placed in the position of function



Figure 10.10 A volar splint being placed. The stockinette is in place and the splinting material is placed on the volar surface of the hand/wrist.

Dorsal splint (Figure 10.11)

Indications

·        Carpal bone fractures

·        Metacarpal bone fractures

·        Carpal tunnel syndrome

·        Soft-tissue injuries of wrist

PEARL: A dorsal splint prevents flexion and extension at the wrist and metacarpal joint if extended into the fingers.



Figure 10.11 A dorsal splint used for the treatment of fractures of the carpal bones, metacarpals, carpal tunnel syndrome, and soft-tissue injuries of the wrist.

Materials

·        Stockinette

·        Plaster of Paris or fiberglass splint

·        Cast padding

·        Elastic bandages

Application

·        Apply stockinette from the hand to mid-forearm

·        Measure splinting material (plaster of Paris, or fiberglass) along the dorsal side of the hand from the mid-fingers to the mid-forearm

·        Most splints will be 2 or 3 inches wide (5 to 7.5 cm)

·        If using plaster of Paris, roll out two to three layers of cast padding. Consider adding additional padding over areas of bony prominence

·        Wet the plaster of Paris, or slightly dampen the fiberglass splinting material

·        Apply the cast padding to the wet splint material, and apply to the arm as one unit starting at the distal hand along its dorsal surface (Figure 10.12)

·        Starting at the hand, apply elastic bandages to hold the splint in place. Make sure not to apply the elastic bandages too tightly

·        Once the splint is applied, the hand and wrist should be placed in the position of function

PEARL: Dorsal and volar splints do not prevent supination and pronation. If concerned about this movement you can place both dorsal and volar splints (sandwich splint) and the combination will prevent supination and pronation.



Figure 10.12 A dorsal splint being placed. The stockinette is in place and the splinting material is placed on the dorsal surface of the hand/wrist.

Posterior long-arm splint (Figure 10.13)

Indications

·        Supracondylar fractures

·        Radius and ulna fractures

·        Carpal bone fractures

·        Soft-tissue injuries of elbow

PEARL: A posterior long-arm splint prevents flexion and extension at the elbow, and flexion and extension at the wrist. Does not prevent supination or pronation of the forearm.



Figure 10.13 Posterior long-arm splint is shown. Used for supracondylar, radius, ulna, and carpal bone fractures.

Materials

·        Stockinette

·        Plaster of Paris or fiberglass splint

·        Cast padding

·        Elastic bandages

Application

·        Apply stockinette from the hand to mid-forearm

·        Measure splinting material (plaster of Paris, or fiberglass) along the posterior side of the arm, forearm to the hand

·        Most splints will be 2 or 3 inches wide (5 to 7.5 cm)

·        If using plaster of Paris, roll out two to three layers of cast padding. Consider adding additional padding over areas of bony prominence

·        Wet the plaster of Paris, or slightly dampen the fiberglass splinting material

·        Apply the cast padding to the wet splint material, and apply to the arm as one unit starting at the distal hand along its posterior surface (Figure 10.14)

·        Starting at the hand, apply elastic bandages to hold the splint in place. Make sure not to apply the elastic bandages too tightly

·        Once the splint is applied, the hand and wrist should be placed in the position of function



Figure 10.14 A posterior long-arm splint shown with the stockinette and plaster in place awaiting placement of elastic bandage.

Posterior leg splint (Figure 10.15)

Indications

·        Ankle sprains

·        Tibia and fibula fractures

·        Tarsal and metatarsal fractures

·        Achilles tendinopathy or rupture

·        Soft-tissue injuries of ankle or foot

PEARL: A posterior leg splint prevents dorsiflexion and plantar flexion of the ankle. If extended to the mid-thigh will prevent extension and flexion of the knee.



Figure 10.15 Posterior leg splint is shown. Used for the treatment of ankle sprains, tibia, fibula, tarsal, and metatarsal fractures, and Achilles tendinopathy or rupture.

Materials

·        Stockinette

·        Plaster of Paris or fiberglass splint

·        Cast padding

·        Elastic bandages

Application

·        Apply stockinette from the foot to mid-calf or mid-thigh (if splinting a tibia or fibula fracture you need to extend to thigh) (Figure 10.16)

·        Measure splinting material (plaster of Paris, or fiberglass) along the dorsal side of the leg from the toes to the mid-calf or mid-thigh

·        Most splints will be 3 to 5 inches wide (7.5 to 12.5 cm)

·        If using plaster of Paris, roll out two to three layers of cast padding. Consider adding additional padding over areas of bony prominence

·        Wet the plaster of Paris, or slightly dampen the fiberglass splinting material

·        Apply the cast as a single unit from the plantar surface of the foot along the posterior surface of the leg (Figure 10.17)

·        Consider cutting the plaster/fiberglass near the heel of the foot to allow the material to be folded with less bulk (Figure 10.18)

·        Starting at the foot, apply elastic bandages to hold the splint in place. Make sure not to apply the elastic bandages too tightly

·        Once the splint is applied, the ankle should be placed at 90°, unless the specific injury requires different positioning (e.g., Achilles tendon rupture – often splinted with ankle in plantar flexion)



Figure 10.16 Stockinette shown in place in preparation of placement of posterior leg splint.



Figure 10.17 Posterior leg splint with stockinette and splinting material in place.



Figure 10.18 Splinting material is cut at the heel in order to facilitate folding it and preventing it from bunching up at the heel.

Stirrup splint (Figure 10.19)

Indications

·        Tibia and fibula fractures

·        Ankle sprains

·        Tarsal bone fractures

PEARL: A stirrup splint prevents inversion and eversion of the ankle joint.



Figure 10.19 A stirrup splint is shown. Used in the treatment of ankle sprains and fractures of the tibia, fibula or tarsal bones. Prevents inversion and eversion at the ankle.

Materials

·        Stockinette

·        Plaster of Paris or fiberglass splint

·        Cast padding

·        Elastic bandages

Application

·        Apply stockinette from the foot to mid-calf

·        Measure splinting material (plaster of Paris, or fiberglass) from mid-calf, around foot to the opposite side of the mid-calf (Figure 10.20)

·        Most splints will be 3 or 4 inches wide (7.5 to 10 cm)

·        If using plaster of Paris, roll out two to three layers of cast padding. Consider adding additional padding over areas of bony prominence

·        Wet the plaster of Paris, or slightly dampen the fiberglass splinting material

·        Apply the cast padding to the wet splint material, and apply to the leg as one unit starting with the middle of the splint at the foot, and extending up both sides of the leg (Figure 10.21)

·        Starting at the foot, apply elastic bandages to hold the splint in place. Make sure not to apply the elastic bandages too tightly

·        Once the splint is applied, the ankle should be placed at 90°



Figure 10.20 Splinting material shown in proper position with the stockinette in place.



Figure 10.21 Another view of the splinting material in place, awaiting the placement of elastic bandage.

Thumb spica splint (Figure 10.22)

Indications

·        First metacarpal and phalangeal fractures

·        Scaphoid fractures

·        Lunate fractures

·        DeQuervain’s syndrome

·        Soft-tissue injuries of first digit

PEARL: A thumb spica splint prevents flexion, extension, abduction and adduction of the first finger.



Figure 10.22 A thumb spica splint is shown. This splint is used to treat first metacarpal and phalangeal fractures, scaphoid fractures, lunate fractures, and soft-tissue injuries of the first digit.

Materials

·        Stockinette

·        Plaster of Paris or fiberglass splint

·        Cast padding

·        Elastic bandages

Application

·        Apply stockinette from the hand to mid-forearm (Figure 10.23)

·        Measure splinting material (plaster of Paris, or fiberglass) from the tip of the thumb to the mid-forearm

·        The splint material can be wrapped around the thumb, or cuts can be made in the material in the shape of two triangles to prevent the bulking up of the splinting material, and allowing it to circumferentially wrap around the first digit (Figure 10.24)

·        Most splints will be 2 or 3 inches wide (5 to 7.5 cm)

·        If using plaster of Paris, roll out two to three layers of cast padding. Consider adding additional padding over areas of bony prominence

·        Wet the plaster of Paris, or slightly dampen the fiberglass splinting material

·        Apply the cast padding to the wet splint material, and apply to the arm as one unit starting at the thumb and lying along the radial side of the forearm (Figure 10.25)

·        Starting at the hand, apply elastic bandages to hold the splint in place. Make sure not to apply the elastic bandages too tightly

·        Once the splint is applied, the thumb should be placed in anatomical position with the thumb in its natural position



Figure 10.23 A stockinette is applied to the arm in preparation of the splint. Cut a hole in it to allow the thumb to poke through.



Figure 10.24 Cuts are made in the splinting material, as shown, to allow the material to wrap around the thumb more easily.



Figure 10.25 Thumb spica splint shown in place with stockinette, awaiting the placement of elastic bandage.

Ulnar gutter splint (Figure 10.26 and Figure 10.27)

Indications

·        Fourth and fifth digit phalanx and metacarpal fractures

·        Soft-tissue injuries of fourth and fifth digits

PEARL: An ulnar gutter splint prevents flexion and extension of the distal interphalangeal, proximal interphalangeal, metacarpophalangeal and wrist joints.



Figure 10.26 An ulnar gutter splint is shown – side view. This splint is used for the treatment of fractures and soft-tissue injuries of the fourth and fifth digits.



Figure 10.27 An ulnar gutter splint is shown – front view. This splint is used for the treatment of fractures and soft-tissue injuries of the fourth and fifth digits.

Materials

·        Stockinette

·        Plaster of Paris or fiberglass splint

·        Cast padding

·        Elastic bandages

Application

·        Apply stockinette from the hand to mid-forearm

·        Measure splinting material (plaster of Paris, or fiberglass) along the ulnar side of the hand from the distal fingers to distal forearm

·        Most splints will be 3 or 4 inches wide (7.5 to 10 cm)

·        If using plaster of Paris, roll out two to three layers of cast padding. Consider adding additional padding over areas of bony prominence

·        Apply a piece of cast padding between the fourth and fifth digits (Figure 10.28)

·        Wet the plaster of Paris, or slightly dampen the fiberglass splinting material

·        Apply the cast padding to the wet splint material, and apply to the hand along the ulnar side of the hand making sure the splinting material wraps around the fourth and fifth digits (Figure 10.29)

·        Starting at the distal fingers, apply elastic bandages to hold the splint in place. Make sure not to apply the elastic bandages too tightly. The ace wrap should not wrap around the second and third digits

·        Once the splint is applied, the hand and wrist should be placed in the position of function



Figure 10.28 A piece of cast padding is placed between the fourth and fifth digits in order to prevent skin maceration while in the splint.



Figure 10.29 An ulnar gutter splint is shown with the splinting material and stockinette in place awaiting the placement of the elastic bandage. Be sure to wrap the fourth and fifth digits separately in order to allow maximum movement of the second and third digits.

Radial gutter splint (Figure 10.30)

Indications

·        Second and third digit phalanx and metacarpal fractures

·        Soft-tissue injuries of second and third digits

PEARL: A radial gutter splint prevents flexion and extension of the distal interphalangeal, proximal interphalangeal, metacarpophalangeal and wrist joints.



Figure 10.30 A radial gutter splint is shown. This splint is used for the treatment of fractures and soft-tissue injuries of the second and third digits.

Materials

·        Stockinette

·        Plaster of Paris or fiberglass splint

·        Cast padding

·        Elastic bandages

Application

·        Apply stockinette from the hand to mid-forearm

·        Measure splinting material (plaster of Paris, or fiberglass) along the dorsal side of the hand from the mid-fingers to the mid-forearm

·        Most splints will be 3 or 4 inches wide (7.5 to 10 cm)

·        If using plaster of Paris, roll out two to three layers of cast padding. Consider adding additional padding over areas of bony prominence

·        Apply a piece of cast padding between the second and third digits

·        Consider cutting a notch out of the material to allow the thumb to sit into the splint without excess contact with the splinting material (Figure 10.31). Make sure to pad the edges (Figure 10.32)

·        Wet the plaster of Paris, or slightly dampen the fiberglass splinting material

·        Apply the cast padding to the wet splint material, and apply to the hand along the radial side of the hand making sure the splinting material wraps around the second and third digits. The thumb should remain out of the splint (Figure 10.33)

·        Starting at the distal fingers, apply elastic bandages to hold the splint in place. Make sure not to apply the elastic bandages too tightly. The ace wrap should not wrap around the fourth and fifth digits

·        Once the splint is applied, the hand and wrist should be placed in the position of function



Figure 10.31 A notch is cut into the splinting material in order to prevent the thumb from becoming splinted too.



Figure 10.32 The notch is padded in order to prevent plaster or fiberglass from rubbing on the thumb and causing irritation.



Figure 10.33 The radial gutter splint is shown with splinting material and stockinette in place awaiting the placement of the elastic bandages. Only the second and third digits should be wrapped in the elastic bandage in order to allow maximum movement of the fourth and fifth digits.

Immobilization devices

PEARL: In addition to splinting, various immobilization devices can be utilized by the ED provider to facilitate patient comfort and healing, while stabilizing the injured area. These include hinged knee braces, figure-of-8 braces, boot immobilizers, and arm slings.

PEARL: Instructing the patient on the proper use of immobilization devices is crucial to prevent further complications, i.e., DVT or nerve palsies.

Knee braces

·        There are two types: hinged “braces” and unhinged “immobilizers”

·        Can be used in both acute and chronic injuries

·        Knee immobilizers will be more readily available in the ED compared to hinged braces

·        Hinged knee braces should be used in consultation with orthopedic or sports medicine consultants

·        Hinged braces can be used for rehabilitation and protection from re-injury during sports participation

·        Hinged knee braces can be used for isolated mid-grade MCL injuries that do not require operative repair

·        Immobilizers are used for a litany of ED complaints but are rarely used properly

·        Immobilizers can be used when instability in one of the knee ligaments is detected on examination, or when the patient is unable to co-operate for a full exam and there is concern for a ligamentous injury

·        Knee immobilizers can cause DVTs; therefore patients should not remain in them for a prolonged period and should have close follow-up to determine the continued necessity of the immobilizer

·        Both knee braces and immobilizers can be used with or without crutches

Arm slings

·        Indications include clavicle and humeral fractures, AC joint separation, rotator cuff injuries, wrist and forearm fractures, and after upper-extremity dislocation reduction

·        Arm slings provide upper-extremity immobilization and patient comfort

·        Mainly used to immobilize the shoulder and elbow joints

·        They can be used with or without an underlying brace or splint

·        Unless contraindicated because of the injury, i.e., proximal humerus fracture, patients should be instructed to perform shoulder range of motion exercises

·        Range of motion exercises will prevent complications including adhesive capsulitis or “frozen shoulder”

·        Proper sizing of the arm sling will prevent excessive ulnar deviation of the wrist as the forearm rests on the sling. This deviation can cause significant ulnar neuropathy if not adjusted. The sling should extend to the MCP jointof the immobilized arm

PEARL: A properly fitted arm sling extends to the MCP joint of the affected arm in order to prevent an ulnar neuropathy that can develop with excessive ulnar deviation of the wrist.

CAM walking boots

·        Indication – isolated distal fibular fractures, Achilles tendon injuries, and severe ankle sprains

·        Can be hinged or fixed depending on the injury

·        Provides similar immobilization as a posterior splint

·        When used for Achilles tendon rupture the patient should be placed in approximately 15° of plantar flexion

·        Can be used for weight-bearing injuries or with crutches when the injury is non-weight-bearing

·        Unless contraindicated because of the injury, the patient should be instructed on proper removal of the boot to allow calf massage in order to prevent DVTs

Other devices

·        There are many different devices available for immobilization, comfort, or protection

·        Dynamic splinting and figure-of-8 braces are examples of advanced immobilization devices

·        These should only be used in conjunction with orthopedic consultation and if the ED provider feels comfortable fitting the devices, and instructing the patient on their use

References

Mercier LR. Practical Orthopedics. 6th edn. Philadelphia, PA: Mosby/Elsevier. 2008.

Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. Philadelphia, PA: Saunders/Elsevier. 2010.

Simon RR, Sherman SC, Koenigsknecht SJ. Emergency Orthopedics: The Extremities. New York, NY: McGraw-Hill, Medical Pub. Division. 2007.


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