chapter 32: splints for orthopedic injuries

what is a splint? what does it help prevent?

• splint: flexible or rigid device used to protect and maintain position of an injured extremity

  • preventing movement reduces pain and makes it easier to transport and transfer pt

• helps prevent:

  • further damage to muscles, spinal cord, peripheral nerves, and blood vessels from broken bone ends

  • laceration of skin by broken bone ends [prevents conversion: closed fractures becoming open]

  • restriction of distal blood flow from pressure of bone ends on vessels

  • excessive bleeding at injury site due to broken bone ends

  • increased pain from movement of bone ends

what are the 13 principles of splinting?

1. remove clothing from area of suspicion and look for DCAP-BTLS

2. note and record neurovascular status distal to injury site [pulse, sensation, movement] and continue to monitor

3. cover open wounds with dry, sterile dressing before splinting and follow standard precaustions. do not intentionally replace protruding bones

4. do not move pt before splinting an extremity unless there is an immediate danger to pt or you

5. in suspected shaft fractures, stabilize joints above and below fracture

6. with injuries in and around the joint, stabilize bones above and below

7. pad all rigid splints to prevent local pressure and pt discomfort

8. maintain manual stabilization to minimize movement and support injury site

9. if fracture of a long bone shaft results in severe deformity, use constant, gentle manual traction to align limb so it can be splinted. especially important if distal part is cyanotic or pulseless

10. if there’s resistance to limb alignment, splint limb in deformed position

11. immobilize all suspected spinal injuries in a neutral in-line position on a backboard

12. if pt has signs of shock, align limb in normal anatomic position and provide transport with total body immobilization

13. when in doubt, splint

what are the three basic types of splints? what are examples of rigid splints?

• 3 types:

  • rigid

  • formable

  • traction

• common examples of rigid splints:

  • padded board splints

  • molded plastic and metal splints

  • padded wire ladder splints

  • folded cardboard splints

steps to applying a rigid splint?

1. provide gentle support and in-line traction for the limb. assess distal pulse and motor and sensory function

2. place splint alongside or under the limb. pad the limb and the splint as needed to ensure even pressure and contact

3. secure splint to limb with bindings

4. assess and record distal neurovascular function

when should splint in a position of deformity?

• you must splint limb in position of deformity if:

  • deformity is severe

  • you encounter resistance or extreme pain when applying gentle traction to fracture of a long bone shaft

• apply padded board splints to each side of the limb and secure with soft roller bandages

• most dislocations should be splinted as found but follow local protocols

what are formable splints that will be used by EMTs? what are other types of formable splints? what are SAM splints?

• formable splints that are likely to be used as an EMT are:

  • structural aluminum malleable [SAM] splints

  • vacuum splints

• other formable splints include:

  • air splints

  • pillow splints

  • sling and swathe bandages

  • pelvic binders

• SAM splints consist of a moldable aluminum core encased in layers of foam padding

  • can be quickly shaped, folded, or cut to serve numerous splinting needs

  • there are several ways to use it depending on the area to be splinted, so familiarity will application in a variety of scenarios is vital

steps to applying vacuum splints?

1. assess distal pulse and motor and sensory function. your partner should stabilize and support the injury

2. place the splint and wrap it around the limb

3. draw air out of the splint through suction valve, then seal the valve. assess distal pulse and motor and sensory function

what is a pelvic binder used for? why are they often used by EMTs?

• pelvic binder: used to splint the bony pelvis to reduce hemorrhage from bone ends, venous disruption, and pain

  • lightweight, made of soft material, and can easily be applied by one EMT

  • be familiar with manufacturer’s instructions

what are the hazards of improper splinting?

• compression of nerves, tissues, and blood vessels

• delay in transport of pt with life-threatening injury

• reduction of distal circulation

• aggravation of the injury

• injury to tissue, nerves, blood vessels, or muscles as a result of excessive movement of bone or joint

what are the rules of transportation decisions when pt has a pulseless limb?

• pts with pulseless limbs should be given higher priority

• if treatment facility is an hour or more away, pt with a pulseless limb should be transported by helicopter or immediate ground transportation

• if circulation in the distal limb is impaired, notify medical control so proper steps can be taken quickly once pt arrives in the eD

who commonly experiences clavicle fractures? what are the differences between adult and young children’s reports from a clavicle fracture? what are the 2 common signs of a clavicle fracture? why is a clavicle fracture so dangerous?

• fractures of clavicle occur commonly in:

  • children when they fall on an outstretched hand

  • pts with crush injuries of the chest

• pts with fracture of the clavicle will report pain in shoulder and hold arm across front of their body

  • young children often report pain throughout entire arm and won’t use it

• common signs:

  • swelling and point tenderness occur over the clavicle

  • skin may “tent” over the fracture fragment

• clavicle lies directly over major arteries, veins, and nerves → risk of neurovascular compromise

fractured scapulae are almost always the result of what? during what activity does the acromioclavicular joint dislocate and how?

• fractures of scapula are almost always the result of a forceful, direct blow to the back, which may also injure thoracic cage, lungs, and heart

• acromioclavicular [AC] joint: frequently separates during sports when a player falls and lands on the point of the shoulder, driving the scapula away from the outer end of the clavicle

  • distal end of clavicle will often stick out

  • pt will have pain, including point tenderness over AC joint

what is a sling? how do you make sure it is effective? how do you prevent creating pressure on cervical spine? what is a swathe? how tight should it be? how do you account for neurovascular function reassessments?

• sling: any bandage or material that helps support the weight of an injured upper extremity, relieving the downward pull of gravity on the injured site

  • to be effective, sling must apply gentle upward support to the olecranon process of the ulna

  • tie the knot of the sling to one side of the neck so that it does not press uncomfortably on the cervical spine

• swathe: bandage that passes completely around the chest to bind the arm to the chest wall, fully stabilizing the shoulder region

  • should be tight enough to prevent arm from freely swinging, but not so tight that it compresses the chest and compromises breathing

  • leave pt’s fingers exposed to assess neurovascular function at regular intervals

what is the glenohumeral joint? what is the MOI of shoulder dislocations and how will a pt react to one? what secondary issues can arise as a sign? how do shoulder dislocations affect the ligaments? is posterior dislocation possible?

• glenohumeral joint: where the glenoid fossa [part of scapula] joints with the humeral head → injury is a shoulder dislocation

• in shoulder dislocations, the humeral head dislocates anteriorly, coming to lie in front of the scapula due to forced abduction and external rotation of the arm

  • pt will guard shoulder and try to protect it by holding dislocated arm in a fixed position away from chest wall

  • axillary nerve may be compressed, causing a numb patch on outer aspect of the shoulder → document this finding!

• shoulder dislocations disrupts the supporting ligaments of anterior aspect of the shoulder

  • often, these ligaments do not heal properly and dislocation recurs

  • surgical repair may be required

• posterior dislocation is less common

  • arm will often be locked in adduction so it cannot be rotated

  • reducing the dislocation requires medical supervision

how do you splint a dislocated shoulder?

• splint joint in a position most comfortable for the pt

  • if necessary, place and pillow or rolled blankets/towels between arm and chest to fill space between them

• once arm is stabilized, elbow can usually be flexed to 90° without pain

• apply sling to forearm and wrist to support weight of the arm

• secure arm in sling to the pillow and chest with a swathe

• transport pt in seated or semi-seated position

where do fractures of humerus typically occur? which type is more common in older people? which type is more common in younger people?

• fractures of humerus occur either prixmally, in the midshaft, or distally at the elbow

• fractures of proximal humerus from falls are common in older people

• fractures of midshaft from violent injury are more common in young pts

what are the characteristics and treatment of proximal humeral fractures?

• characteristics:

  • significant swelling without significant deformity

  • neurovascular compromise is uncommon

    • if present, any or all of brachial plexus may be affected depending on degree of displacement

    • concurrent soft tissue injuries are possible

    • possible rotator cuff injury [if radiograph films show no fracture, especially if pt cannot rotate the arm

• treatment:

  • stabilize in a sling and swathe or a shoulder stabilizer

  • use chest wall as a splint and secure injured arm to chest wall

  • place short, padded board splint on lateral side of arm under the sling and swathe for additional support

what are the characteristics and treatment of midshaft humeral fractures?

• characteristics:

  • gross angulation of the arm

  • marked instability and crepitus of fragments

  • possible neurovascular compromise

  • possible entrapment of radial nerve [inability to extend or dorsiflex the wrist or fingers with possible numbness on dorsum of hand; classic wrist drop]

• treatment:

  • stabilize with sling and swathe or shoulde rstabilizer

  • use chest wall as a splint and secure injured arm to chest wall

  • place a short, padded board splint on lateral side of the arm under the sling and swathe of additional support

what are the characteristics and treatment of distal humeral fractures?

• characteristics:

  • significant swelling at the elbow

  • possible neurovascular compromise

  • possible injury to the ulnar or median nerve [document nerve status before and after any attempt to reduce or stabilize fracture]

• treatment:

  • stabilize in a splint, in addition to a sling and swathe or shoulder stabilizer

how do you treat a fracture of the humerus? what are children with humeral fractures at risk for?

• support site of the fracture with one hand, and with the other, grasp the two humeral condyles [lateral and medial protrusions] just above the elbow

• pull gentle in line with the normal axis of the limb

• once limb is realigned, splint the arm with sling and swathe, supplemented with a padded board splint on lateral aspect of the arm

• if pt reports significant pain or resists gentle traction:

  • splint the fracture in the deformed position with a padded wire ladder or a padded board splint, using pillow to support injured limb

• children are at risk for compartment syndrome from these fractures

what is a fracture of the distal humerus? what is the main complication?

• fracture of the distal humerus is also known as a suprecondylar or intercondylar fracture

  • common in children

• fracture fragments rotate significantly, producing deformity and causing injuries to nearby vessels and nerves

  • swelling occurs rapidly and is often severe

who commonly experiences dislocation of the elbow? what is nursemaid’s elbow? how are the radius and ulna displaced from the distal humerus? how is the joint locked? what does this injury result in?

• dislocation of the elbow typically occurs in athletes

  • can occur in toddlers when they are lifted or pulled by the arm [nursemaid’s elbow], although it is not technically a joint dislocation [it is a soft tissue impingement condition]

• radius and ulna are most often displaced posteriorly relative to the humerus

  • posterior displacement makes the olecranon process of the ulna much more prominent

  • joint is usually locked, with forearm moderated flexed → any attempt at motion is extremely painful

  • results in swelling and significant potential for vessels or nerve injury

what causes a fracture of the olecranon process of the ulna and what does it result in? what causes a fracture of the radial head and what does it result in? what injury is an elbow joint sprain often mistakenly applied to and why?

• fracture of the olecranon process of the ulna can result from direct or indirect forces, causing an inability to actively extend the elbow

  • often associated with lacerations and abrasions

• fracture of the radial head often occurs as a result of a fall on an outstretched arm or a direct blow to the lateral aspect of the elbow

  • attempts to rotate forearm will cause discomfort

  • often missed during diagnosis

• elbow joint sprain is often mistakenly applied to an occult, non-displaced fracture because it can be difficult to distinguish between sprains and fractures

how do you take care of/treat an elbow injury? what indicates injury to blood vessels and what should you do? what should you do if limb is pulseless and significantly deformed at the elbow? what should you do for all pts with impaired distal circulation?

• 2 ways:

  • two padded board splints usually are enough to stabilize the arm

    • board should extend from shoulder joint to wrist joint

  • you can mold a padded wire ladder split or a SAM splint to the shape of the limb

• a cold, pale hand or a weak or absent pulse with poor capillary refill indicates that blood vessels have been injured

  • notify medical control immediately

  • if within 10-15 mins of the hospital, splint the limb in the position you found it and provide transport

• if limb is pulseless and significantly deformed at the elbow, apply gentle manual traction in line with long axis of the limb to decrease deformity

  • if no pulse returns after one attempt, splint the limb in comfortable position for the pt

  • if pulse returns, splint the limb in whatever position allows the strongest pulse

• provide prompt transport for all pts with impaired distal circulation

what are growth plate injuries and where do they often occur? why is it important to recognize these injuries and treat them? when should you suspect growth plate injury?

• growth plate injuries in children are common, especially at wrist, elbow, knee, and ankle

  • these cartilaginous growth centers are inherently weaker than surrounding bone

• longitudinal bone is dependent upon function of the growth plate

  • you must recognize growth plate injuries, stabilize injured limb, and transport pt to an appropriate care center

• any deformity close to a joint in children younger than 16 should be assumed to be a growth plate injury

what is a nightstick fracture? what is a colles fracture? what is a silver fork deformity and why is it risky for children? how do you stabilize forearm or wrist fractures?

• nightstick fracture: isolated fracture of the shaft of the ulna, likely occurring as the result of a direct blow

• colles fractures: fractures of distal radius, which are especially common in older people with osteoporosis

• silver fork deformity: describes the distinctive appearance of the pt’s arm

  • in children, this fracture may occur through the growth plate and can have long-term consequences

• to stabilize forearm or wrist fractures:

  • use padded board, air, vacuum, or pillow splint

  • include elbow joint in splint if shaft of the bone has been fractured

  • add a sling or pillow for more support to increase pt comfort, although elbow splinting is not essential for fractures near wrist

• elevate injured extremity above the heart to help with swelling

when should you splint the hand and wrist? should you attempt to reset a finger yourself? what should you do with amputated body parts?

• any questionable wrist sprain or fracture should be splinted and evaluated by a physician

• dislocations are usually associated with a fracture → fracture dislocation

• do not attempt to “pop” a dislocated finger back in place

• take any amputated parts to hospital with the patient

  • wrap amputated part in dry or moist sterile dressing and place in a dry plastic bag

  • put bag in a cooled container; do not soak the part in water or allow it to freeze

steps to splinting hand and wrist

1. support injured limb and move hand into position of function [hand position where the wrist is slightly dorsiflexed and all finger joints are moderately flexed]. place a soft roller bandage in the palm

2. apply padded board splint on the palmar side with fingers exposed

3. secure the splint with a roller bandage

what causes pelvic fractures? when should you suspect a pelvic fracture? what is the main risk with pelvic fractures? though uncommon, how can a pelvic fracture become an open fracture? what is the most reliable sign of pelvic fracture?

• fractures of pelvis often result from direct compression in the form of a heavy blow

  • injuries can also be caused by indirect forces

  • suspect a pelvic fracture on any pt who has sustained high-velocity injury and reports discomfort in lower back or abdomen

• up to several liters of blood can drain into pelvic and retroperitoneal space

  • results in significant hypotension, shock, and sometimes death → immediate treat shock, even if there is only minimal swelling

• open fractures of pelvis are uncommon

  • pelvic fracture fragments can lacerate the rectum and vagina, creating an open fracture that os often overlooked

  • bladder may be lacerated by pelvis bone fragments, or it may tear as a result of direct pressure on bladder itself or tension in urethra

• most reliable sign of fracture of pelvis is simple tenderness or instability on firm compression and palpation

  • firm compression on 2 iliac crests will produce pain at a fracture site in the pelvic ring

how do you assess tenderness in the pelvis? what signs will a pt have if there’s injury to bladder or urethra? how can you stabilize isolated pelvic fractures?

• to assess tenderness

  1. place palms of hands over lateral aspect of each iliac crest and apply firm but gentle inward pressure on pelvic ring

  2. with pt lying supine, place a palm over anterior aspect of each iliac crest and apply firm downward pressure

  3. use palm of hand to firmly but gently palpate the pubic symphysis, the firm cartilaginous joint between the two pubic bones. this area will be tender if there is injury to anterior portion of ring

• if there is injury to bladder or urethra, pt will have lower abdominal tenderness and may have hematuria or blood at urethral opening

• pts in stable condition can be secured to backboard or a scoop stretcher to stabilize isolated fractures of pelvis

where do most hip locations occur? what does the sciatic nerve control? what happens when a hip dislocation compresses the sciatic nerve? how are pts with hip dislocations typically found?

• most dislocations of the hip are posterior → femoral head is displaced posteriorly to lie in muscles of buttock

• sciatic nerve controls:

  • the activity of muscles in the posterior thigh and below the knee

  • the sensation in most of the leg and foot

• when head of the femur is forced out of hip socket, it can compress/stretch the sciatic nerve, leading to partial or complete paralysis of the nerve

  • decreased sensation in leg and foot

  • weakness in the foot muscles

  • dorsiflexors involved may cause “foot drop” characteristic of damage to peroneal portion of the sciatic nerve

• pts with hip dislocation typically lie with hip joint flexed [knee joint draw up toward the chest] and the thigh rotated inward toward midline of body over the top of the opposite thigh

what are the distinctive signs of hip dislocation? how can you check for sciatic nerve injury? when should you reduce dislocated hip in field? how should you splint and transport a pt with a hip dislocation?

• look for the distinctive signs of hip dislocation:

  • severe pain in the hip, accompanied by strong resistance to any movement of the joint

  • tenderness of lateral and posterior aspects of hip region upon palpation

• check for sciatic nerve injury by carefully assessing sensation and motor function in the lower extremity

• do not attempt to reduce the dislocated hip in the field unless medical control directs you to

• to splint and transport a pt with a hip dislocation:

  • splint dislocation in position of deformity and place pt supine on backboard

  • support affected limb with pillows and roller blankets, particularly under the flexed knee

  • secure entire limb to backboard with long straps so hip region will not move, then promptly transport

where do fractures of the proximal femur occur? how are pts with displaced fractures typically found? what are the main signs of fractures of the proximal femur?

• fractures of proximal femurs are called hip fractures, but they rarely involve the hip joint. instead the break goes through:

  • neck of femur

  • interochanteric [middle] region

  • proximal shaft of the femur [subtrochanteric fractures]

• pts with displaced fractures of proximal femur lie with the leg externally rotated, and the injured leg is usually shorter than uninjured limb

• with any kind of hip fracture, pts are usually unable to walk or move the leg because of pain in hip, groin, or inner aspect of the thigh

  • hip is tender on palpation, and gentle rolling of the leg will cause pain but will not do further damage

  • sometimes, pain is referred to knee

to do you assess fractures of the proximal femur? when should you splint lower extremities of older pts? how should you stabilize fracture of geriatric pts?

• assess pelvis for any soft-tissue injury and bandage appropriately

• assess pulses and motor and sensory functions for signs of vascular and nerve damage

• splint lower extremities of older pts who have fallen and reports pain in either the hip or the knee even if there is no deformity, then transport to ED

• geriatric pts with an isolated hip fracture do not require a traction splint

  • you can stabilize the fracture by placing pt on a backboard or scoop stretcher

  • use pillows or rolled blanket to support the injured limb in the deformed position

  • secure injured limb carefully to device with long straps

• treat with high-flow oxygen, monitor vitals frequently, and be alert for shock

what are femoral shaft fractures? what are main complications? how much blood is usually lost?

• fractures of femoral shaft may be open, and fragments of bone may protrude through the skin → do not attempt to push bone back in

• often a significant amount of blood loss [as much as 500-1000 mL]

  • with open fractures, the amount of blood may be even greater

  • not unusual for hypovolemic shock to develop

how do you treat a femoral shaft fracture?

• to treat:

  • handle pts with extreme care to prevent extra blood loss and damage from bone fragments penetrating/pressing on nerves and vessels

  • carefully and periodically assess distal neurovascular function

  • remove any clothing from the affected limb to inspect injury site for any open wounds

  • follow standard precautions when blood or body fluids are present

  • monitor pt’s vitals closely, watch for onset of shock, rapidly transport

  • cover open wounds with dry, sterile dressing

  • if foot or leg below level of fracture have signs of impaired circulation, apply gentle longitudinal traction to deformed limb

    • gradually turn leg from deformed position to restore overall alignment

  • best stabilized with a traction splint, such as a Sager splint

what is traction? what are the goals of traction? what are the 4 different types of lower extremity traction splints? what injuries should you not use traction splints for?

• traction: most effective way to realign a fracture of the shaft of a long bone so the limb can be splinted more easily

• goals of in-line traction:

  • stabilize fracture fragments to prevent excessive movement

  • align the limb sufficiently to allow it to be placed in a splint

  • avoid potential neurovascular compromise

• several different types of lower extremity traction splints are commercially available:

  • hare traction splint

  • sager splint

  • reel splint

  • kendrick splint

• do not use traction splints for:

  • injuries of upper extremity

  • injuries close to or involving the knee

  • injuries of the pelvis

  • partial amputations or avulsions with bone separation

  • lower leg, foot, or ankle injuries

how do you apply a traction splint?

• before application, control any external bleeding

• amount of traction requires varies, but often does not exceed 15 lbs

  • use least amount of force necessary

• grasp foot or hand at the end of the injured limb firmly; once you start pulling, do not stop until limb is fully splinted

  • releasing manual traction before limb is secures causes muscles to contract, allowing bone fragments to cause more damage

• always apply the direction of traction along the long axis of the limb

• grasp the foot or hand and the initial pull usually causes discomfort as bone fragments move, so second EMT should support the injured limb directly under site of the fracture

  • initial discomfort quickly subsides, and you can then apply further gentle traction

• if pt strong resists traction or if it causes more pain that persists, stop and splint the limb in the deformed positon

steps to applying a hare traction splint

1. expose the injured limb and check the pt’s pulse and motor and sensory function. place splint beside uninjured limb, adjust splint to proper length, and prepare the straps

2. support the injured limb as your partner fastens the ankle hitch about the foot and ankle

3. continue to support the limb as partner applies gentle in-line traction to ankle hitch and foot

4. slide the splint into position under injured limb

5. pad the groin and fasten the ischial strap

6. connect the loops of the ankle hitch to the end of the splint as your partner continues to maintain traction. carefully tighten the ratchet to the point that the splint holds adequate traction

7. secure and check support straps. assess pulse and motor and sensory functions

8. secure pt and splint to the backboard in a way that will prevent movement of the splint during pt movement and transport

steps to applying a sager traction splint

1. after exposing the injured area, assess distal motor, sensory, and circulatory function. position splint against the medial aspect of the injured leg, with the perineal cushion resting against the ischial tuberosity. adjust the thigh strap so that it lies anteriorly when secured

2. secure the thigh strap

3. apply padded ankle harness just above the ankle. attach the harness to the crossbar

4. extend the splint’s inner shaft to apply traction of about 10% of body weight, up to a max of 15 pounds

5. secure the splint with elasticized cravat bandages, and with a figure-of-eight configuration, use the pedal pinion strap to secure the feet together

6. secure pt to backboard. reassess distal motor, sensory, and circulation function

who is primarily affected by ligament injuries and how do they occur? what will pt with this injury report? what do you usually find upon examination?

• ligament injuries are often seen in recreational and competitive athletes

  • ligaments on medial side of knee are most frequently injured, typically when foot is fixed to the ground and the lateral aspect is struck by a heavy object

• pt with knee ligament injury will report pain in the joint and be unable to use the extremity

• upon examination, you will generally find:

  • swelling

  • occasional ecchymosis

  • point tenderness at injury site

  • joint effusion [excess fluid in the joint]

when should you splint a knee ligament injury? what splints are preferred? which ones can be used but are less effective? what if a pt can’t straighten their knee?

• splint all suspected knee ligament injuries

  • splint should extend from hip joint to the foot, stabilize the bone above and below the knee

• variety of splints can be used, including padded rigid long leg splint or two padded board splints applied to medial and lateral aspects

  • backboard, pillow splint, or simple binding the injured limb to its uninjured mate is an acceptable [but less effective] technique

• pt is usually able to straighten the knee to allow you to apply the splint

  • if there’s resistance or pain, splint it in the flexed position

• continue to monitor distal neurovascular function during transport

what is the more urgent injury associated with a knee dislocation and what causes it? what should you check first? what knee dislocations are most common, and what structures are damaged? medial dislocations are caused by what? lateral dislocations are caused by what?

• substantial ligament damage occurs with a knee dislocation, but the more urgent injury is often to the popliteal artery, which is frequently lacerated or compressed by displaced tibia

• always check distal circulation first

  • if distal pulses are absent, contact medical control for stabilization and transport instruction

• posterior knee dislocations are most common, occuring in almost half of all cases

  • anterior and posterior crucial ligaments are damaged [ACL and PCL]

  • high risk of injury to popliteal artery

• medial dislocations result from a direct blow to the lateral part of the leg

  • high likelihood of injury to the medial ligaments

• lateral dislocations result when when force is applied from medial direction, stretching the lateral part of the knee apart and injuring the lateral ligament

• lateral and medial dislocations happen less commonly and are less likely to injure popliteal artery

what are possible complications from knee dislocations? what should you do if there’s an adequate distal pulse? what should you do if limb is straight with a good pulse? what should you do if knee is bent with a good pulse? how do you eliminate any motion during transport?

• complications:

  • limb-threatening popliteal artery disruption

  • injuries to the nerves

  • joint instability

• do not confuse dislocation with a relatively minor patella dislocation

• if there’s an adequate distal pulse, splint knee in position in which you found it, and transport pt promptly

  • do not attempt to manipulate or straighten any severe knee injury if there are good distal pulses

• if limb is straight, apply standard rigid long leg splints to at least 2 sides of the limb to stabilize it

• if knee is bent and foot has a good pulse, splint the joint in the bent position, using parallel padded board splints secured at hip and ankle joint to provide a stable A-frame

• secure the limb to a backboard or stretcher with pillows and straps to eliminate any motion during transport

what should you do if medical control instructs you to align a dislocated knee?

• if medical control instructs you to align a limb:

  • straighten limb by applying gentle longitudinal traction in the axis of the limb

  • once you apply manual traction, maintain it until limb is fully splinted

  • if traction significantly increases the pt’s pain, do not continue

  • as you apply traction, monitor the posterior tibial pulse to see whether it returns

  • splint the limb in the position in which you feel the strongest pulse

  • if you are unable to restore distal pulse, splint in position that is most comfortable for pt, and promptly transport

• notify medical control of status of distal pulse

what should you do if there’s adequate distal pulse and no significant deformity on a nondisplaced/minimally displaced fracture? what about if there’s an adequate pulse and significant deformity? what about if the pulse is absent below the level of the injury

• manage nondisplaced and minimally displaced fractures about the knee as follows:

  • if there’s an adequate distal pulse and no significant deformity, splint the limb with the knee straight

  • if there is an adequate pulse and significant deformity, splint the joint in the position of deformity

  • if the pulse is absent below the level of the injury, suspect possible vascular and nerve damage, and contact medical control immediately

  • never use traction splint it you suspect a fractured knee

who is most at risk for dislocated patella? how does the knee appear? how should you splint a dislocated patella? what should you do if the knee spontaneously returns to its normal position?

• dislocated patella most commonly occurs in teens and young adults that play sports → can be recurrent

  • usually displaces to lateral side

• displacement produces deformity in which the knee is held in a moderately flexed position, and the patella is displaced to the lateral side of the knee

• splint the knee in the position you found it

• add padded board splints to medial and lateral aspects of the joint, extending from the hip to the ankle. use pillows to support the limb on the stretcher

• occasionally, the patella will return to its normal position spontaneously

  • stabilize limb as for a knee ligament injury in a padded long leg splint and transport

  • report spontaneous reduction as soon as you arrive to hospital

what can fracture of tibia or fibula result in? how should you stabilize a fracture? what is the goal when correcting severe deformity prior to splinting? why should the limb be realigned?

• fracture of the shaft of the tibia or fibula may occur at any place between the knee joint and the ankle joint → often both fracture at the same time

  • can result in severe deformity, with significant angulation or rotation

  • since tibia is located just beneath the skin, open fractures are common

• stabilize fracture with padded rigid long leg splint or an air splint that extends from foot to upper thigh

  • once splinted, secure affected leg to opposite leg

• traction splints are not indicated for isolated tibial fractures

• correct severe deformity before splinting by applying gently longitudinal traction → goal is to restore a position that will take a standard splint

• sometimes associated with vascular injury, so realigning the limb frequently restores adequate blood supply to the foot

  • if it does not, transport pt promptly and notify medical control

who is most at risk for ankle injuries? how does severity range? when should a physician evaluate an ankle injury? what is the most frequency MOI for ankle injury? how should you manage ankle injuries?

• ankle injuries appear in people of all ages and range in severity from simple sprain, which heals after a few days of rest, to severe fracture-dislocations

  • sometimes hard to tell a nondisplaced ankle fracture from a simple sprain without radiograph exam

• any ankle injury that produces pain, swelling, localized tenderness, or inability to bear weight must be evaluated by a physician

• most frequent mechanism of ankle injury is twisting

  • more extensive twisting may result in fracture of one or both malleoli

  • dislocation of ankle is usually associated with fractures of one or both malleoli

• manage injuries as follows:

  • dress all open wounds

  • assess distal neurovascular function

  • correct any gross deformity by applying gentle longitudinal traction to the heel

  • before releasing traction, apply a splint

    • can use padded rigid splint, air splint, or pillow splint

    • make sure it includes entire foot and extends up the leg to level of knee

what can injuries to the foot result in? what bone is most frequently fractures and why? what should you do if a pt jumps or falls from a height and reports heel pain? what should you do if you suspect a foot dislocation and pulses are present? what about when they’re absent?

• injuries to foot can result in dislocation or fracture of one or more tarsals, metatarsals, or phalanges

  • calcaneus is most frequently fractured, usually from falls or jumps from a height → can also be other fractures with great enough impact

• if a pt has jumped or fallen from a height and reports heel pain, ask about back pain and check spine for tenderness/deformity

  • use a backboard to immobilize any suspected spinal injury and splint foot

• if you suspect a foot dislocation, assess pulses and motor and sensory function

  • if pulses are present, stabilize extremity using a splint or a pillow splint, leaving toes exposed so you can assess neurovascular function

  • if pulses are absent, contact medical control and discuss reduction of dislocation if local protocol permits

what are injuries to the foot associated with and not associated with? what are some common complications from lacerations and puncture wounds? what are the steps to splinting a foot?

• injuries of foot are associated with significant swelling, but rarely with gross deformity

• vascular injuries are uncommon

• lacerations about the ankle and foot may damage important nerves and tendons

• puncture wounds are common and may cause serious infection is not treated early

• to splint the foot:

  • apply a rigid padded board splint, air splint, or pillow splint, stabilizing ankle joint and foot

  • leave toes exposed to assess neurovascular function

  • elevate foot approximately 6 inches off stretcher to minimize swelling

  • transport in supine position to allow for elevation

  • never allow foot and leg to dangle off stretcher onto floor/ground

how should you view a severe sprain to remain on the side of caution? what is RICES and what does it stand for? what else should you do to treat a pt with a sprain or strain?

• because it may be difficult to differentiate various types of injuries, you should treat every severe sprain as if it were a fracture

• general treatment of sprains and strains is similar to fractures and includes RICES:

  • rest

  • ice

  • compression

  • elevation

  • splinting

• in addition:

  • reduce or protect limb from weight bearing activity

  • manage pain as soon as is practical

what should you first do with a traumatic amputation? why would a complete traumatic amputation have reduced blood loss? how should you stabilize partial amputations? how do you transport body part after complete amputation?

• you must control bleeding and treat for shock

• complete traumatic amputations may occasionally not bleed much if cut vessels go into spasm, reducing blood loss

• partial amputations, make sure to stabilize with bulky compression dressings and a splint to prevent further injury

  • do not sever any partial amputations

• hemorrhage from complete or incomplete amputations can be severe and life threatening

• control any bleeding from the stump → if severe, apply tourniquet

• with complete amputation, wrap clean part in sterile dressing and place in plastic bag

  • follow local protocols on how to preserve amputated parts

  • put bag in cool container filled with ice

  • lay wrapped part on a bed of ice, but do not pack it in [can freeze or develop frostbite]

  • transport amputated part with pt to hospital

what is compartment syndrome and how long does it take to develop. what are the signs/symptoms? what should you do if it is suspected? what should you do if symptoms of compartment syndrome appear after splinting an injured extremity?

• compartment syndrome: limb-threatening condition characterized by localized tissue swelling within a compartment

  • often develops within 6-12 hours after injury

• characterized by:

  • pain out of proportion to injury

  • pain on passive stretch of muscles within the compartment

  • pallor

  • decreased sensation

  • decreased power [ranging from decreased strength and movement of limb to complete paralysis]

• must be managed surgically

• if compartment syndrome is suspected:

  • splint affected limb, keeping it at level of the heart

  • provide immediate transport

  • reassess neurovascular status frequently during transport

• after splinting an injured extremity, if signs or symptoms of compartment syndrome appear during transport, loosen knots or other potentially constricting elements of the splint