Extremity Injuries and Splinting

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Extremity Injuries and Splinting

• Dr. Esmailian mehrdad
• Assistant Professor of Emergency Medicine
• M_esmailian_at_med.mui.ac.ir

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Skeletal System
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Functions of theMusculoskeletal System

• Gives the body shape
• Protects internal organs
• Provides for movement
• Consists of more than 600 muscles

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Splinting

• Movement may worsen musculoskeletal injury and
  cause more pain
• Splint injured arm or leg if risk of area being
  moved (unless help expected quickly)
• Always splint an extremity before transporting
  victim

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Splinting

• Helps prevent further injury
• Reduces pain
• Minimizes bleeding and swelling

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Mechanism of Injury

• Force may be applied in several ways

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• Significant force is generally required to cause
  fractures or dislocations
• This force may be applied to the limb in any of
  the following ways
• Direct blows
• Indirect forces
• Twisting forces
• High-energy injury

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• A direct blow fractures the bone at the point of
  impact
• Indirect force may cause a fracture or
  dislocation at a distant point
• Twisting injuries are a common cause of
  musculoskeletal injury, especially to the knee

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• High-energy injuries produce severe damage to the
  skeleton, surrounding soft tissues, and vital
  internal organs
• a. Automobile crashes
• b. Falls from heights
• c. Gunshot wounds

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• Trauma is not necessary to fracture a bone
• a. Slight force can easily injure a weakened
  bone
• b. In geriatric patients with osteoporosis, minor
  falls, simple twisting, or even a muscle
  contraction may cause a fracture

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Injuries from Falls

• Frequently after a fall, the force of the injury
  is transmitted up the legs to the spine,
  sometimes resulting in a fracture of the lumbar
  spine

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Types of Musculoskeletal Injuries

• Fracture
• Broken bone
• Dislocation
• Disruption of a joint
• Sprain
• Joint injury with tearing of ligaments
• Strain
• Stretching or tearing of a muscle

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Splinting

• Splints can be improvised when needed and tied
  with bandages, belts, neckties, strips of cloth
• Always check breathing and care for
  life-threatening conditions first
• Consider mechanism of injury and possibility of
  spinal injury

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Fractures

• Closed fracture
• A fracture that does not break the skin
• Open fracture
• External wound associated with fracture
• Nondisplaced fracture
• Simple crack of the bone
• Displaced fracture
• Fracture in which there is actual deformity

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Signs and Symptomsof a Fracture

• Deformity
• Tenderness
• Guarding
• Swelling
• Bruising

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• Crepitus
• False motion
• Exposed fragments
• Pain
• Locked joint

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Signs and Symptomsof a Dislocation

• Marked deformity
• Swelling
• Pain
• Tenderness on palpation
• Virtually complete loss of joint function
• Numbness or impaired circulation to the limb and
  digit

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Signs and Symptoms of a Sprain

• Point tenderness can be elicited over injured
  ligaments.
• Swelling and ecchymosis appear at the point of
  injury to the ligaments.
• Pain
• Instability of the joint is indicated by
  increased motion.

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Severity of Injury

• Critical injuries can be identified using
  musculoskeletal injury grading system

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Minor Injuries

• Minor sprains
• Fractures or dislocations of digits

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Moderate Injuries

• Open fractures of the digits
• Nondisplaced long bone fractures
• Nondisplaced pelvic fractures
• Major sprains of a major joint

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Serious Injuries

• Displaced long bone fractures
• Multiple hand and foot fractures
• Open long bone fractures
• Displaced pelvic fractures
• Dislocations of major joints
• Multiple digit amputations
• Laceration of major nerves or blood vessels

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Severe Life-Threatening Injuries (Survival Is
Probable)

• Multiple closed fractures
• Limb amputations
• Fractures of both long bones on the leg
  (bilateral femur fractures)

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Critical Injuries (Survival Is Uncertain)

• Multiple open fracture of the limbs
• Suspected pelvic fractures with hemodynamic
  instability

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Rapid Physical Exam forSignificant Trauma

• If you find no external signs of injury, ask
  patient to move each limb carefully, stopping
  immediately if this causes pain
• Skip this step if the patient reports neck or
  back pain. Slight movement could cause permanent
  damage to spinal cord

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Focused Physical Exam for Nonsignificant Trauma

• Evaluate circulation, motor function, sensation
• If two or more extremities are injured, transport
• Severe injuries more likely if two or more bones
  have been broken
• Recheck neurovascular function before and after
  splinting
• Impaired circulation can lead to death of the
  limb

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Assessing Neurovascular Status

• If anything causes pain, do not continue that
  portion of exam
• Pulse
• Palpate the radial, posterior tibial, and
  dorsalis pedis pulses

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• Capillary refill
• Note and record skin color
• Press the tip of the fingernail to make the skin
  blanch. If normal color does not return within 2
  seconds, you can assume that circulation is
  impaired

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• Sensation
• Check feeling on the flesh near the tip of the
  index finger
• In the foot, check the feeling on the flesh of
  the big toe and on the lateral side of the foot

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• Motor function
• Evaluate muscular activity when the injury is
  near the patients hand or foot
• Ask the patient to open and close his or her fist
• Ask the patient to wiggle his or her toes

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Emergency Medical Care

• Completely cover open wounds
• Apply the appropriate splint
• If swelling is present, apply ice or cold packs
• Prepare the patient for transport
• Always inform hospital personnel about wounds
  that have been dressed and splinted

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Splinting

• Flexible or rigid device used to protect
  extremity
• Injuries should be splinted prior to moving
  patient, unless the patient is critical
• Splinting helps prevent further injury
• Improvise splinting materials when needed

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General Principles of Splinting

• Remove clothing from the area
• Note and record the patients neurovascular
  status
• Cover all wounds with a dry, sterile dressing
• Do not secure splint on open wound
• Do not move the patient before splinting
• Splint only if it doesnt cause more pain

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• Immobilize the joints above and below the injured
  joint
• Pad all rigid splints
• Elevate splinted extremity if possible
• Apply cold packs if swelling is present
• Maintain manual immobilization

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• Use constant, gentle, manual traction if needed
• If you find resistance to limb alignment, splint
  the limb as is
• Check circulation
• Swelling, bluish color, tingling, numbness, cold
  skin are signs and symptoms of reduced
  circulation
• If reduced circulation, remove splint

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• Immobilize all suspected spinal injuries in a
  neutral in-line position
• If the patient has signs of shock, align limb in
  normal anatomic position and transport
• When in doubt, splint

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Types of Splints

• Rigid splints
• Soft splints
• Anatomic splints

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Rigid Splint

• Board
• Plastic or metal
• Rolled newspaper or magazine
• Thick cardboard

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Applying a Rigid Splint

• Provide gentle support and in-traction of the
  limb
• Another EMT-B places the rigid splint alongside
  or under the limb
• Place padding between the limb and splint as
  needed

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• Secure the splint to the limb with bindings
• Assess and record distal neurovascular function

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Soft Splint

• Pillow
• Folded blanket or towel
• Triangular bandage folded into sling

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Anatomic Splint

• Bandage injured leg or finger to uninjured one

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In-line Traction Splinting

• Act of exerting a pulling force on a bony
  structure in the direction of its normal
  alignment
• Realigns fracture of the shaft of a long bone
• Use the least amount of force necessary
• If resistance is met or pain increases, splint in
  deformed position

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Securing Splints

• Use bandages, strips of cloth (cravats), Velcro
  straps around splint and extremity
• Use knots that can be untied
• Do not secure with tape

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Hazards of Improper Splinting

• Compression of nerves, tissues, and blood vessels
• Delay in transport of a patient with a
  life-threatening condition
• Reduction of distal circulation
• Aggravation of the injury
• Injury to tissue, nerves, blood vessels, or
  muscle

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Upper Extremity Injuries

• Clavicle and Scapula
• Shoulder
• Upper arm
• Elbow
• Lower arm
• Wrist
• Hand

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Clavicle and Scapula Injuries

• Clavicle is one of the most fractured bones in
  the body
• Scapula is well protected
• Joint between clavicle and scapula is the
  acromioclavicular (A/C) joint
• Splint with a sling and swathe

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• Pad hollow between body and arm
• Apply sling and binder to support arm and
  immobilize against chest
• if this causes pain use larger soft splint

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A/C Separation

• With A/C separation, the distal end of the
  clavicle usually sticks out

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Dislocation of the Shoulder

• Most commonly dislocated large joint
• Usually dislocates anteriorly
• Is difficult to immobilize
• A patient with a dislocated shoulder will guard
  the shoulder, trying to protect it by holding the
  arm in a fixed position away from the chest wall

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• Splint the joint with a pillow or towel between
  the arm and the chest wall
• Apply a sling and a swathe

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Guidelines for Slings

• Use sling to prevent movement of arm and shoulder
  and to elevate extremity
• Splint injury first, when appropriate
• If you splint injury in position found and this
  position makes use of sling difficult do not
  use sling

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Guidelines for Slings

• Do not move arm into position for sling if it
  causes pain
• A cold pack can be used inside sling
• Do not cover fingers inside sling

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Fractures of the Humerus

• Occurs either proximally, in the midshaft, or
  distally at the elbow
• Consider applying traction to realign a severely
  angulated humerus, according to local protocols
• Splint with sling and swathe, supplemented with a
  padded board splint

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• Apply rigid splint along outside of arm
• Tie above injury and at elbow
• Support wrist with sling
• Apply wide binder to support arm and immobilize
  it against chest
• If it causes pain to raise wrist for sling, use a
  long rigid splint

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Elbow Injuries

• Fractures and dislocations often occur around the
  elbow
• Injuries to nerves and blood vessels common
• Assess neurovascular function carefully
• Realignment may be needed to improve circulation

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• If elbow bent, apply rigid splint from upper arm
  to wrist
• If more support needed, use sling at wrist and
  binder around chest

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Elbow Injuries

• If elbow straight, apply rigid splint from upper
  arm to hand
• If more support needed, use binders around chest
  and upper arm and lower arm and waist

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Fractures of the Forearm

• Usually involves both radius and ulna
• Use a padded board, air, vacuum, or pillow splint
• A fracture of the distal radius produces a
  characteristic silver fork deformity

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Secure point of bandage at elbow
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Position triangular bandage
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Bring lower end of bandage to opposite side of
neck
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Tie the ends
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Tie binder bandage over sling and around chest
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Injuries to the Wrist and Hand

• Follow BSI precautions
• Cover all wounds
• Form hand into the position of function
• Place a roller bandage in palm of hand
• Apply padded board splint
• Secure entire length of splint
• Apply a sling and swathe

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• Apply rigid splint on palm side of arm from
  forearm past fingertips
• Tie above and below wrist
• Leave fingers uncovered
• Support forearm and wrist with sling and apply
  binder around upper arm and chest

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Support arm. Check circulation
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Position arm on rigid splint
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Secure splint
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Check circulation
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Put arm in sling. Tie binder over sling and
around chest
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Finger Injuries

• Fractures and dislocations
• Often splint not required
• Use rigid splint or anatomic splint

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Lower Extremity Injuries

• Pelvic and Hip
• Upper leg
• Knee
• Lower leg
• Ankle
• Foot

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Fractures of the Pelvis/Hip

• May involve life-threatening internal bleeding
• Assess pelvis for tenderness
• Stable patients can be secured to a long
  backboard or scoop stretcher to immobilize
  isolated fractures of the pelvis

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Assessment of Pelvic/Hip Fractures

• If there is injury to the bladder or urethra, the
  patient may have lower abdominal tenderness
• They may have blood in the urine (hematuria) or
  at the urethral opening

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Stabilizing Pelvic/Hip Fractures

• A stable patient with a pelvic fracture may be
  placed on a long board
• If the patient is unstable, consider using a PAGS
  with the patient stabilized on the long board
  (consult your local protocols)

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• Do not move victim
• Immobilize leg and hip in position found
• Pad between legs and bandage together (unless
  this causes more pain)
• Treat victim for shock but do not elevate legs

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Dislocation of the Hip

• Hip dislocation requires significant mechanism of
  injury
• Posterior dislocations lie with hip joint flexed
  and thigh rotated inward
• Anterior dislocations lie with leg extended
  straight out, and rotated, pointing away from
  midline
• Splint in position of deformity and transport

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Femoral Fractures

• Presents with very characteristic deformity
• Fractures from trauma injuries best managed with
  traction splint or PASG and a backboard
• Isolated fracture in geriatric patients can be
  managed with long backboard or a scoop stretcher

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• A proximal femur fracture will be rotated
• Splint the injured leg to the uninjured leg and
  secure the patient to a scoop stretcher or
  backboard

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• Rigid splint may be unnecessary
• Provide additional support with folded blankets
  or coats
• Can use an anatomic splint
• Check circulation and sensation in foot and toes

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• Put rigid splint on each side of leg
• Pad body areas and voids
• Inside splint should extend from groin past foot
• Outside splint should extend from armpit past
  foot

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Splinting a Femur Fracture

• Tie splints with cravats or bandages
• Check circulation periodically

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Injuries of Knee Ligaments

• Knee is very vulnerable to injury
• Patient will complain of pain in the joint and be
  unable to use the extremity normally
• Splint from hip joint to foot
• Monitor distal neurovascular function

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Dislocation of the Knee

• Produces significant deformity
• More urgent injury is to the popliteal artery,
  which is often lacerated or compressed
• Always check distal circulation

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Fractures About the Knee

• If there is adequate distal pulse and no
  significant deformity, splint limb with knee
  straight
• If there is adequate distal pulse and significant
  deformity, splint joint in position of deformity
• If pulse is absent below level of injury, contact
  medical control immediately

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Dislocation of the Patella

• Usually dislocates to lateral side
• Produces significant deformity
• Splint in position found
• Support with pillows

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• If possible, put rigid splint on both sides of
  leg
• Pad body areas and voids
• Check circulation and sensation in foot and toes
  first and periodically after splinting

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Splinting the Knee

• If knee is straight apply two splints along both
  sides of knee
• If knee is bent, splint in position found
• Tie splints with cravats or bandages

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Injuries to Lower Leg

• Usually, both bones fracture at the same time.
• Open fracture of tibia common
• Stabilize with a padded rigid long leg splint or
  an air splint that extends from the foot to upper
  thigh
• Because the tibia is so close to the skin, open
  fractures are quite common

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• Rigid splint applied the same as for knee injury
• Three-sided cardboard splint can be used

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Check circulation. Gently slide four to five
strips of bandages under both legs
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Pad between legs
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Gently slide uninjured leg next to injured leg
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Tie bandages. Check circulation
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Ankle Injuries

• Most commonly injured joint
• 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

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Ankle Injuries

• Position foot in middle of soft pillow
• Fold pillow around ankle
• Tie pillow around foot and lower leg

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Foot Injuries

• Usually occur after a patient falls or jumps.
• Immobilize ankle joint and foot
• Leave toes exposed to assess neurovascular
  function

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• Elevate foot
• Also consider possibility of spinal injury from a
  fall
• A pillow splint can provide excellent
  stabilization of the foot

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