Immobilisation - Collar and cuff sling

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Indications

Fracture of proximal or surgical neck of humerus

Contraindications (absolute in bold)

None

Alternatives

Open reduction internal fixation

Shoulder immobiliser

Informed consent

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Abrasions and pressures sores (with risk of infection)

Joint stiffness (including the neck)

Procedural hygiene

Standard precautions

PPE: sterile gloves

Area

Anywhere with chair or stool

Staff

Procedural clinician

Equipment

Collar and cuff sling

Velcro strap, cable tie or tape

Positioning

Seated with arm supported on pillow for comfort

Shoulder: adducted and internally rotated with palm of hand facing trunk

Elbow: flexed so that hand is pointing upwards towards opposite shoulder

Sequence

Ensure adequate analgesia prior to procedure

Loop one end of sling around the proximal forearm and secure with cable tie, tape or Velcro

Maintain arm position and pass sling around the back to the opposite shoulder

Wrap sling over the top of the shoulder and down to the wrist

Loop under the wrist and secure with cable tie, tape or Velcro

Sequence (alternative method for greater elbow flexion)

Ensure adequate analgesia prior to procedure

Secure the cuff material around the wrist of the injured limb with cable tie, tape or Velcro

Bring the sling around the neck and back down to the wrist

Cut the cuff material to the required length secure with cable tie, tape or Velcro

Shorten the sling to increase elbow flexion

Post-procedure care

Confirm loop is not too tight around wrist

Confirm hand is pointing towards opposite shoulder with adequate traction at fracture site

Advise patient to support arm with pillow when sleeping and avoid getting sling wet

Advise patient to remove sling and move elbow, wrist and hands regularly (to prevent stiffness)

Advise patient to follow up with orthopaedic surgeon in approximately two weeks

Tips

Consider the forces acting on the injured bones and joints when choosing sling type

A collar and cuff uses the arm’s weight as traction helping to reduce the humerus fracture

The greater the amount of elbow flexion the greater the force reducing the fracture

Discussion

Greater elbow flexion applies more traction at the fracture site and is preferred if pain allows. On first application, pain may limit elbow flexion. Over time, this often improves, and the patient may be able to adjust the sling to increase elbow flexion.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

NSW Agency for Clinical Innovation. Orthopaedic/musculoskeletal. Sydney: ACI; 2020. Available from https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/orthopaedic-and-musculoskeletal

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Eiff MP, Hatch R. Fracture management for primary care. 3rd ed. Philadelphia PA: Saunders; 2011.

Stracciolini A. Basic techniques for splinting of musculoskeletal injuries In: UpToDate. Waltham (MA): UpToDate. 2019 April 18. Available from: https://www.uptodate.com/contents/basic-techniques-for-splinting-of-musculoskeletal-injuries

Liverpool hospital emergency department: Plaster booklet (2019)

© Agency for Clinical Innovation 2021

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