Splinting is an important part of the trauma resuscitation process. No patient should leave your trauma resuscitation room without splinting of all major fractures. It reduces pain, bleeding, and soft tissue injury, and can keep a closed fracture from becoming an open one.
But what about imaging? Can’t the splint degrade x-rays and hamper interpretation of the fracture images? Especially those pre-formed aluminum ones with the holes in them? It’s metal, after all.
Some of my orthopedic colleagues insist that the splint be removed in the x-ray department before obtaining images. And who ends up doing it? The poor radiographic tech, who has no training in fracture immobilization and can’t provide additional pain control on their own.
But does it really make a difference? Judge for yourself. Here are some knee images with one of these splints on:
Amazingly, this thin aluminum shows up only faintly. There is minimal impact on interpretation of the tibial plateau. And on the lateral view, the splint is well posterior to bones.
On the tib-fib above, the holes are a little distracting on the AP view, but still allow for good images to be obtained.
Bottom line: In general, splints should not be removed during the imaging process for acute trauma. For most fractures, the images obtained are more than adequate to define the injury and formulate a treatment plan. If the fracture pattern is complex, it may be helpful to temporarily remove it, but this should only be done by a physician who can ensure the fracture site is handled properly. In some cases, CT scan may be more helpful and does not require splint removal. And in all cases, the splint should also be replaced immediately at the end of the study.
In my next post, I’ll look at the use of CT scans when this type of splint is in use.
A 3-year-old girl presented to the emergency department after she had ingested a metal pendant. She had not vomited and had no pain in her chest. A physical examination was unremarkable. A radiograph of the chest confirmed a heart-shaped foreign body in the proximal thoracic esophagus. Ingestions of foreign bodies are most commonly reported in children 1 to 3 years of age. Ingested items that warrant immediate endoscopic removal from the esophagus include sharp objects, button batteries, and foreign bodies that have been present for longer than 24 hours. Asymptomatic children who have ingested items that do not have potentially dangerous features may be observed without intervention to allow the foreign body to pass spontaneously. In this patient, the position of the foreign body appeared to be unchanged on repeat radiographs of the chest. The patient was taken to the operating room to undergo rigid endoscopy, and a gold heart-shaped pendant was removed (inset). Reinspection of the esophagus showed minor abrasions of the esophageal mucosa. After the procedure, the patient recovered well and was discharged home.
A 46-year-old man presented to the emergency department with worsening chronic left knee pain. Fourteen years before presentation, he had sustained a gunshot wound to the left knee. Radiographs obtained at the time of that injury showed a metallic bullet embedded in the posterior weight-bearing surface of the lateral femoral condyle and metallic debris within the joint (Panel A). No surgery was performed to remove the bullet at that time. At the current presentation, the physical examination was notable for a large effusion in the left knee. Repeat radiographs showed that, in addition to changes consistent with arthritis in the joint, the bullet had fragmented into metallic particles throughout the joint and synovium (Panel B). Laboratory studies revealed microcytic anemia, with a hemoglobin level of 9.1 g per deciliter (normal range, 12.9 to 16.8), and an elevated blood lead level (182 μg per deciliter [8.8 μmol per liter]). The Mini–Mental State Examination score was 24 (scores range from 0 to 30, with lower scores indicating poorer cognitive performance). The patient showed no other symptoms of chronic lead poisoning. Intraarticular bullets should be removed surgically at the time of the injury. In addition to causing joint damage, intraarticular bullets can fragment and dissolve in synovial fluid, leading to lead absorption and delayed symptomatic lead poisoning. The patient received chelation therapy. Surgical management with a left knee synovectomy was planned, but the patient left the hospital before surgery and was lost to follow-up.
Splinting is an important part of the trauma resuscitation process. No patient should leave your trauma resuscitation room without splinting of all major fractures. It reduces pain, bleeding, and soft tissue injury, and can keep a closed fracture from becoming an open one.
But what about imaging? Can’t the splint degrade x-rays and hamper interpretation of the fracture images? Especially those pre-formed aluminum ones with the holes in them? It’s metal, after all.
Some of my orthopedic colleagues insist that the splint be removed in the x-ray department before obtaining images. And who ends up doing it? The poor radiographic tech, who has no training in fracture immobilization and can’t provide additional pain control on their own.
But does it really make a difference? Judge for yourself. Here are some knee images with one of these splints on:
Amazingly, this thin aluminum shows up only faintly. There is minimal impact on interpretation of the tibial plateau. And on the lateral view, the splint is well posterior to bones.
On the tib-fib above, the holes are a little distracting on the AP view, but still allow for good images to be obtained.
Bottom line: In general, splints should not be removed during the imaging process for acute trauma. For most fractures, the images obtained are more than adequate to define the injury and formulate a treatment plan. If the fracture pattern is complex, it may be helpful to temporarily remove it, but this should only be done by a physician who can ensure the fracture site is handled properly. In some cases, CT scan may be more helpful and does not require splint removal. And in all cases, the splint should also be replaced immediately at the end of the study.
In my next post, I’ll look at the use of CT scans when this type of splint is in use.
Many trauma patients require implantable hardware for treatment of their orthopedic injuries. One of the concerns they frequently raise is whether this will cause a problem at TSA airport screening checkpoints (Transportation Safety Administration).
The answer is probably “yes.” About half of implants will trigger the metal detectors, and these days that usually means a pat down search. And letters from the doctor don’t help. It turns out that overall, 38% are detected when the scanner is set to low sensitivity and 52% at high sensitivity.
Here is a more detailed breakdown:
Lower extremity hardware is detected 10 times more often than upper extremity or spine implants
90% of total knee and total hip replacements are detected
Upper extremity implants such as shoulder, wrist and radial head replacements are rarely detected
Plates, screws, IM nails, and wires usually escape detection
Cobalt-chromium and titanium implants trigger alarms more often than stainless steel
If your patient knows that their implant triggers the detectors, they have two options: request a patdown search, or volunteer to go through the full body millimeter wave scanner. This device looks at everything from the skin outwards, and will not “see” the implant and is probably the preferred choice. If they choose to go through the metal detector and trigger it, they are required to have a patdown. Choosing to go through the body scanner after setting off the detector is no longer an allowed option.
Reference: Detection of orthopaedic implants in vivo by enhanced-sensitivity, walk-through metal detectors. J Bone Joint Surg Am. 2007 Apr;89(4):742-6.
