Public Service Announcement: Splinting & Cellulitis

After seeing mutliple cases of upper & lower limb cellulitis that had “failed” oral antibiotics last week, some referred from GP’s, and some who had treatment started in my ED, I have to vent… (Sorry for those Registrars at RDH that have had to listen to me go on about this already). This may not come up in your exam, but it is one of the most poorly done aspects of ED patient referral/management that I see, and it does my head in.

If you diagnose someone with cellulits in the upper limb, who is otherwise well and suitable for outpatient antibiotic treatment, you MUST immobilise the limb. For infections above the elbow that means a broad-arm sling, for forearm and hand infections that means a volar plaster slab down to the fingertips and a sling, for infections at the elbow (eg bursitis) use a foam collar & cuff sling. For lower limb infections in a compliant adult patient, you may get away with just using crutches. For everyone else, a plaster backslab is necessary. Don’t use circumferential padding, just make a padded slab, and wrap it on with a crepe bandage.

The commonest reason I see people “fail” oral antibiotics is that they are not adequately immobilised. Your hands are constantly moving, even with your arm in a sling, your fingers will move, a lot. This pumps your lymphatics, expands & contracts your soft tissues, and makes soft tissue infections spread. Walking on a celulitic lower limb does the same thing. Ever referred a nasty limb infection to a plastic surgeon? What do they ask you to do? “Put a slab on please”. People that get admitted get splints/slabs, why don’t outpatients?

I can’t find any published literature on this, (although here’s a chapter from “Practical Plastic Surgery for Nonsurgeons” that backs me up) but at the risk of using dogma/common sense over science, please don’t send anyone home from your ED with limb cellulits without immobilising them. And if you know anyone who is a GP in Australia, please send them a link to this article. For the GP’s, please don’t refer anyone to ED with “failed oral antibiotics, needs IV” for limb cellulitis if they haven’t had at least 48hours of oral antis and proper immobilisation, unless they have other signs like a fever or systemic symptoms that would mandate IV antis.

And on that note, DON’T USE FIBREGLASS to make your splints/slabs, for cellulitis or fractures. Use plaster. Especially in kids, the elderly, diabetics, the congnitively impaired, the immunocompromised, and those with sensory impairment (neuropathy/post nerve block). This article outlines some of the scary complications that can result from those little scracthes you get from fibreglass slabs. One kid had his arm amputated after a 1cm abrasion got infected. Yikes.

Alright, that’s my rant on splinting and cellulitis. Now get back to your exam study!

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2 Responses to Public Service Announcement: Splinting & Cellulitis

  1. doncuan January 1, 2012 at 1:17 am #

    Commonest reason I see ‘failed oral ABs’ is that they are treated with keflex rather than fluclox for simple cellulitis. Immobilisation I agree with however – seems much more common practice in the UK than here.

    Literature seems to support keflex being efficacious for all sorts of things but repeated personal anecdote makes me wonder if there was some drug company influence in generating that evidence.

  2. Andy B January 1, 2012 at 1:31 am #

    Thanks Duncan
    The Antibiotic Guidelines in Australia recommend Di/Flucloxacillinas first line, and Cephalexin if pencillin “hypersensitivity” (for penicillin “immediate hypersensitivity” – which I guess means anaphylaxis – Clindamycin/Lincomycin is recommended).
    They mention that Cepahlexin may be “better tolerated” in children and the oral solution is more “palatable”.
    I think this has been extrapolated to adult medicine. Contributing to this trend as well is another Cephalosporin, Cefazolin, which is widely used intravenously in Australia for cellulitis as it can be given (with probenecid) once or twice daily, which makes it the drug of choice for “Hospital in the Home” programs (rather than Flucloxacillin, which mus be given 4 times a day), as nurses visit the patients at home to administer the medication, saving hospital beds.
    I think they are both meant to have adequate Staph/Strept cover, but I take your point that in the absence of contraindications, Di/Flucloxacillin should be first line treatment.
    Any microbiological people out there with an opinion?

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