FIGURE 130.48 Peripheral nerve block for regional anesthesia A Digital and metacarpal B Supraorbital nerve C Infraorbital nerve D Mental nerve Procedure The supraorbital nerve exits the skull at the foramen just above the supraorbital ridge The supratrochlear nerve exits just medial to the supraorbital nerve Locate the foramen by palpating over the medial aspect of the supraorbital ridge ( Fig 130.48B , top) Cleanse the area with antiseptic solution Insert a 27- or 30-gauge, 1- to 1.5-in needle just medial to the foramen, directed toward the foramen ( Fig 130.48B , bottom) After inserting the needle and advancing the tip, inject 1% lidocaine with epinephrine in a fan-like distribution along the superior orbital rim If paresthesia of the forehead is noted in the verbal patient during advancement of the needle, redirect the needle to avoid injecting directly into the nerve Infraorbital Nerve Block (Intraoral Approach) Indications Lacerations within sensory distribution of the nerve ( Fig 130.48C , part A)— midface (skin of the upper lip, nose, and lower eyelid) Removal of a foreign body Procedure The infraorbital nerve exits its foramen just below the infraorbital ridge Locate the foramen by palpating for the notch along the inferior orbital rim Don gloves and place a finger over the infraorbital ridge while using the index finger to hold up the upper lip Numb the upper gum near the canine with a topical anesthetic such as viscous lidocaine Insert a 27-gauge, 1.5-in needle on a syringe with 1% lidocaine Puncture the gum line along the long axis of the canine and advance until the needle tip is located just inferior to the foramen where the infraorbital nerve exits ( Fig 130.48C , part B) The needle is inserted to about a depth of cm in a full-grown teenager Inject 1% lidocaine in a fanlike distribution inferior to the foramen Wait minutes for anesthesia to occur Mental (Infraoral) Nerve Block Indications Lacerations of the lower lip and chin Removal of a foreign body Procedure The mental nerve is a branch of the alveolar nerve with sensory distribution of the lower lip and chin ( Fig 130.48D , top) It exits its foramen in the mandible at the level of the premolar Locate the foramen by palpating over the mandible in line with the supraorbital and infraorbital foramen ( Fig 130.48D , bottom) Cleanse the area with antiseptic solution Insert a 27- or 30-gauge, 1- to 1.5-in needle just medial to the foramen directed toward the foramen Depending on the size of the child, insert the needle approximately 0.5 cm and inject to mL of 1% lidocaine with epinephrine in a fan-like distribution around the foramen If paresthesia of the lower lip is noted in the verbal patient during advancement of the needle, redirect the needle to avoid injecting directly into the nerve SPLINTING OF MUSCULOSKELETAL INJURIES General Splinting Indications To provide short-term stabilization and/or protection of musculoskeletal injuries (fractures, tendon injuries, lacerations, or tenosynovitis) Complications Neurovascular compromise Pressure ulcers Contact dermatitis Contracture if prolonged splint or not in position of function Equipment Cotton undercast padding (e.g., Webril) Plaster slabs or rolls (2-, 3-, 4-, and 6-in widths) or prepadded material (e.g., Orthoglass) of same widths Room temperature tap water Elastic bandage Adhesive tape or bandage clip Procedure Determine the style of splint needed based on anatomic considerations of the injury The injured extremity should be splinted in a position of function to minimize the risk of contractures Skin lesions and wounds should be cleansed, repaired, and dressed in the usual manner before the application of a splint Open fractures should be evaluated emergently by an orthopedic surgeon Neurovascular status should be documented before and after the splint is applied Before applying the splint, it is important to completely expose the extremity to be splinted and anticipate the child’s ability to remove his/her clothing once the splint is applied Plaster Splint Measure and cut the appropriate length of plaster It is better to cut the length slightly longer than necessary to account for any shrinkage If the cut length is too long, the end can be folded on itself The upper extremity requires to 10 layers; the lower, 12 to 14 layers to withstand some weight bearing In general, the width of the material should cover approximately one-half of the circumference of the extremity but should not be so wide that it completely encircles the extremity or overlaps itself Next, prepare the padding If toes or fingers are to be incorporated within the splint, place padding between the digits to prevent maceration Roll the cotton undercast padding (e.g., Webril) around the injured extremity in a distal to proximal manner, making sure to overlap each turn by 50% Extend the padding to cm distally and proximally beyond the area to be splinted Wrinkles in the padding can create pressure points and are best avoided by stretching and/or partially tearing the padding during application Bony prominences require additional padding to minimize pressure injury Stockinette may be used under the padding if desired An alternative method is to pad the splint material itself prior to applying to the patient This is achieved by layering the cotton undercast padding along the aspect of the splint that will come into contact with the patient’s extremity The padding is unrolled back and forth along the length of the splint to achieve enough cushion to prevent pressure injury Immerse the plaster slab in room-temperature water until bubbling stops Because setting plaster elaborates heat, room temperature water is recommended to minimize risk of heat injury to the patient’s skin Remove the slab from the water and on an absorbent surface such as a towel; smooth the plaster to remove excess moisture and wrinkles and to laminate the layers The setting time of the plaster is determined by the temperature of the water and the overall moisture content of the plaster, with warmer water and drier plaster shortening the set time Properly position the splint onto the extremity Using your palms, smooth and contour the splint to the extremity, taking care not to leave indentations Indentations create pressure points that will be uncomfortable and cause skin breakdown Fold the exposed cotton padding back over the ends of the splint Next, an optional layer of gauze or a single layer of cotton padding may be placed over the splint to prevent the elastic bandage from adhering to the plaster as it sets Roll the elastic bandage over the splint in a distal to proximal manner and secure with tape or clips The extremity should be maintained in the desired position until the splint is sufficiently hard Fiberglass Splint