Trauma: Orthopedic Injuries
This quarter we will review the field management of orthopedic
injuries. We will start with a review of the City of Cleveland Medical
Protocol “Trauma -4: Extremity Trauma”. Reassess some splinting tips;
and finally look at the Sam Splint and its applications. The Sam Splint is
one of the most versatile splinting tools we carry. To demonstrate the
Sam Splint we have included a video presentation and written
instructional guide to show and explain its many uses.
( City of Cleveland Trauma Protocol 4 Extremity trauma) INSERT
TRAUMA -4 PLEASE
Field management for fractures, dislocations, sprains, and strains is
essentially the same: Prevent further injury, reduce the risk of infection,
minimize pain, and reduce the risk of long-term disability. Because it
can be difficult to differentiate between the different types of
orthopedic injuries, it is necessary to provide the same emergency care
to all, which includes control of bleeding, followed by splinting. Longbone injuries can be immobilized with a padded board splint, an air
splint, or other similar device. Isolated femoral fractures should be
managed using a traction splint. If a pelvic injury is suspected, a pelvic
binder should be applied. Clavicle and shoulder injuries can be
immobilized using a sling and swathe.
Managing life threats to the patient’s ABCs is the primary concern
with any traumatic emergency. The MOI that caused the injury may
also have caused a spinal injury or other fracture, and these must be
managed at the appropriate time following local protocol. Remove any
jewelry the patient is wearing on injured extremities. Choose the
correct type and size splint for the injury. Splints for long-bone
fractures should be long enough to stabilize the injured bone and the
joint above and below the injury. If swelling is present, a cold pack can
be applied to the injured area. In all of the following specific injuries,
perform the following:
1. Ensure scene safety.
2. Determine the MOI.
3. Consider the need for spinal stabilization.
4. Open, clear, and maintain the patient’s airway.
5. Ensure adequate ventilation.
6. Administer high-concentration oxygen via a nonrebreathing mask or
bag-mask device as appropriate.
7. Control bleeding, and treat for shock. Cover open wounds with a
dry, sterile dressing and apply pressure to control bleeding.
8. Apply a splint, and elevate the extremity about 6” (slightly above the
level of the heart).
9. Apply cold packs if there is swelling, but do not place them directly
on the skin.
10. Position the patient for transport, and transport to the appropriate
treatment facility.
Splinting Tips
Skeletal or voluntary muscle attaches to bone and forms the major muscle
mass of the body. This muscle contains veins, arteries, and nerves.
2. There are 206 bones in the human body. When this living tissue is fractured, it
can produce bleeding and significant pain.
3. A joint is a junction where two bones come into contact. Joints are stabilized in
key areas by ligaments.
4. A fracture is a broken bone, a dislocation is a disruption of a joint, a sprain is a
stretching injury to the ligaments around a joint, and strain is a stretching of
the muscle.
5. Depending on the amount of kinetic energy absorbed by tissues, the zone of
injury may extend beyond the point of contact. Always maintain a high index
of suspicion for associated injuries.
6. Fractures of the bones are classified as open or closed. Both are splinted in a
similar manner, but remember to control bleeding and apply a sterile dressing
to the open extremity injury before splinting.
7. Fractures and dislocations are often difficult to diagnose without an x-ray
examination. You will treat these injuries similarly. Stabilize the injury with a
splint, and transport the patient.
8. Signs of fractures and dislocations include pain, deformity, point tenderness,
false movement, crepitus, swelling, and bruising.
9. Signs of sprain include bruising, swelling, and an unstable joint.
10. Compare the unaffected extremity with the injured extremity for differences
whenever possible.
11. There are three main types of splints used by EMTs: rigid splints, traction
splints, and formable splints.
12. Remember to splint the injured extremity from the joint above to the joint
below the injury site for complete stabilization.
13. A sling and swathe is used commonly to treat shoulder dislocations and to
secure injured upper extremities to the body. Lower extremities can be
secured to the unaffected limb or to a long backboard.
14. The most common life-threatening musculoskeletal injuries are multiple
fractures, open fractures with arterial bleeding, pelvic fractures, bilateral
femur fractures, and limb amputations.
15. Types of muscle include cardiac, smooth or skeletal
1.
16.
Motor function or movement, sensation and pulses and capillary refill (MSP)
should be checked and documented before and after splinting.
05/2/11
Trauma-4
Extremity Trauma
Extremity Trauma and Traumatic Amputation
Indications:
Trauma of any type that results in injury to one or more extremities.
Routine Trauma Care Protocol (Routine-2)

EMT-B Refer to the specific protocol if the patient has a life threatening injury, or fits the
NOTS Trauma-(Trauma-9).

EMT-B If injured extremity is to the hand and the patient has s/s of crushing, wound, etc.
transport patient to hospital with Hand Specialist available.
EMT-B Stop any bleeding with direct pressure, elevation (if no s/s of a fracture or
dislocation) or by compressing the pressure point above the injured extremity.

EMT-B Consider the Arterial Tourniquet Procedure-(Procedure-18), remember using a
tourniquet to control severe life threatening bleeding as a LAST RESORT.

EMT-B Splint the injured extremity if the patient has s/s of a fracture, dislocation, sprain,
or strain.

EMT-B Consider the Hypovolemic Shock Protocol (Medical-18).

EMT-B Consider the Pain Management Protocol (Trauma-10).

Reassess

Contact Med Command for further assistance if an injured extremity appears pale
with no palpable pulses. Gentle reduction maybe indicated.
Extremity Trauma Key Points
In cases of major trauma, the backboard can work as a whole body splint.
DO NOT take the time to splint injured extremities in major trauma patients unless
it does not delay the scene time and does not prevent you from performing more
pertinent patient care.
Splint the extremity if the patient has signs and symptoms of a fracture or
dislocation.
Treat all suspected sprains or strains as fractures until proven otherwise.
Splint the joint above and below for all suspected fractures.
Splint the bone above and below for all suspected joint injuries.
Check and document the patient’s MPS before and after splinting.
A traction splint with a backboard is the preferred splint to use for femur fractures.
Refer to the Hospital Transport Guide (Appendix-1) for listing of hand specialist.
TOC
05/2/11
Trauma-4
Extremity Trauma
Traumatic Amputation Key Points
Care of the amputated extremity include:
o Cleanse an amputated extremity with normal saline or sterile water.
o DO NOT place any amputated tissue directly on ice or cold pack. Instead,
place the amputated limb into a plastic bag. Put the bag into a container of
cool water with a few ice cubes (if available).
Contact the receiving hospital with the patient information, and include the status of
the amputated limb.
Focus on patient care and not on the amputated extremity.
Remember to calm and reassure the patient. Do not give the patient or their family
members false hope of re-attachment of the affected limb. This decision is made by
a medical team at the receiving hospital.
Delegate someone to do an on scene search for the amputated part when it cannot be
readily found and continue with patient care.
Tourniquets are a LAST resort.
Before you move the patient make sure that the arterial tourniquet is secured.
Pulling the arterial tourniquet band snugly will ensure less work that the device will
have to do.
Frequently reassess your patient and the arterial tourniquet.
DO NOT USE an arterial tourniquet unless direct pressure, elevation, and pressure
points or dressing does not stop the bleeding.
Hand Specialty Hospitals:
o Cleveland Clinic Hospitals – Cleveland Clinic Main Campus, Euclid
Hospital, Fairview Hospital, Lakewood Hospital, South Pointe Hospital,
Hillcrest Hospital
o University Hospitals – University Hospital, Rainbow Babies and Children’s
Hospital, Bedford Medical Center, Richmond Heights Medical Center,
St. John’s Medical Center
o Sister of Charity Hospitals – St. Vincent Charity Medical Center, St. John
Medical Center
o Independent Hospital - MetroHealth Medical Center
TOC
THE CONCEPT: THE BASIC BEND
A SAM Splint in its virgin state (without any bends) is completely
malleable. When a curve or fold is placed anywhere across its longitudinal axis, it becomes rigid and suitable for splinting almost any bone
on the body. Always use curves to add strength and rigidity to the
SAM Splint. The basic C-Curve meets most splinting needs.
STRONG
The C-Curve
To create the C-Curve, place both thumbs in the center of the SAM
Splint. Using your thumbs as a brace, pull the edges of the splint
toward you to create a shallow C-Curve. This curve immediately adds
strength and rigidity to the splint. For greater strength, deepen the
bend.
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SAM Splint User Guide: Basic Instructions & General Information
ADVANCED BENDS
STRONGER
The Reverse C-Curve
First, form a C-Curve. Then add additional strength by bending the
edges of the C-Curved splint back in the reverse direction.
STRONGEST
The T-Curve
This bend adds exceptional strength to the splint. To create the
T-Curve, fold the outer edges of the splint together. Next, bend half
of each side of the fold in the opposite direction to create a “T”
shaped beam.
SAM Splint User Guide: Basic Instructions & General Information
13
UPPER BODY & EXTREMITIES
FINGER SPLINT
1
Step 1: To create a simple finger
splint or fingertip guard, first
form a SAM Finger Splint into the
C-Curve.
2
Step 2: Place the finger in the
curved surface of the splint.
Squeeze the end of the splint to
create a fingertip guard.
3
Step 3: Secure with your wrap
of choice.
Applications
t Fingertip injuries
t Finger fractures
t Finger lacerations
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SAM Splint User Guide: Upper Body & Extremities
1
Step 1: Roll the end of a 9-inch
(for children) or 18-inch (for
adults) SAM Splint over to
provide comfort for fingers.
2
Step 2: Apply a C-Curve.
3
Step 3: Using your own right or
left hand and wrist as a template,
mold the splint into the position
of function.
4
Step 4: Be sure to create a
generous curve for the base of
the thumb.
SAM Splint User Guide: Upper Body & Extremities
15
UPPER BODY & EXTREMITIES
VOLAR WRIST
UPPER BODY & EXTREMITIES
VOLAR WRIST
(CONTINUED)
5
Step 5: Obtain additional
strength by folding up the ulnar
(little finger) side of the splint.
6
Step 6: Apply to patient.
7
Step 7: Make fine adjustments as
necessary. Secure with your wrap
of choice.
Applications
t
t
t
t
16
Wrist fractures/pains
Lacerations
Carpal Tunnel Syndrome
Night splints
SAM Splint User Guide: Upper Body & Extremities
1
Step 1: Using your own right
or left thumb and wrist as a
template, mold the thumb spica
shape into the selected SAM
Splint. A 9-inch splint works well
for this.
2
Step 2: Be sure to create a
generous curve for the base of
the thumb.
3
Step 3: You may add Reverse CCurves on the edges as needed
for additional strength if desired.
SAM Splint User Guide: Upper Body & Extremities
17
UPPER BODY & EXTREMITIES
THUMB SPICA
UPPER BODY & EXTREMITIES
THUMB SPICA (CONTINUED)
4
Step 4: Apply to the patient.
Make fine adjustments as
necessary.
5
Step 5: Secure with your wrap
of choice.
Applications
t
t
t
t
18
Navicular/scaphoid fractures
Thumb dislocations or fractures
Ulnar collateral ligament sprains
Tendonitis
SAM Splint User Guide: Upper Body & Extremities
1
Step 1: Fold a 9-inch SAM Splint
length-wise.
2
Step 2: Using the ulnar side of
your own hand and wrist as a
template, mold the splint into the
desired shape.
3
Step 3: Apply to the patient.
4
Step 4: Make fine adjustments
as needed and secure with your
wrap of choice.
Applications
t Fifth metácarpel fractures
t Little finger injuries
t Ring finger injuries
SAM Splint User Guide: Upper Body & Extremities
19
UPPER BODY & EXTREMITIES
ULNAR GUTTER
UPPER BODY & EXTREMITIES
DOUBLE LAYER WRIST
1
Step 1: Fold a 36-inch SAM
Splint in half upon itself.
2
Step 2: Roll the end over to
provide more comfort for the
fingers.
3
Step 3: Add strength by
creating a C-Curve.
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SAM Splint User Guide: Upper Body & Extremities
Step 4: Using your own right or
left arm as a template, mold the
splint to the general shape of the
wrist and forearm.
Step 5: Make adjustments to
fit the injury and apply to the
patient. Only small adjustments
should be made once the splint is
in place. Secure with your wrap
of choice.
5
Applications
t Wrist fractures or sprains
t Tendonitis
t Lacerations
SAM Splint User Guide: Upper Body & Extremities
21
UPPER BODY & EXTREMITIES
4
UPPER BODY & EXTREMITIES
HUMERAL SHAFT (UPPER ARM)
1
Step 1: Fold one third of a
36-inch SAM Splint upon itself
to create a 12-inch section of
double-layered splint.
2
Step 2: Curve the double
layer into a fishhook shape and
secure the double layer with your
wrap of choice.
3
Step 3: Form a C-Curve along the
shank of the fishhook for strength
and fit.
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SAM Splint User Guide: Upper Body & Extremities
UPPER BODY & EXTREMITIES
4
Step 4: Apply the splint to the
patient. Fold any excess splint
over the patient’s shoulder or
back upon itself.
5
Step 5: Secure with your wrap of
choice. Apply a sling and swath
for additional support.
Applications
t Humeral shaft fractures
SAM Splint User Guide: Upper Body & Extremities
23
UPPER BODY & EXTREMITIES
SUGAR TONG
1
Step 1: Fold a 36-inch SAM
Splint in half.
2
Step 2: To obtain the correct
length use the patient’s arm as a
template. Place the folded splint
around the elbow so the end of
the top half stops at the knuckles. Fold the bottom half down
even with the top.
3
Step 3: Form a C-Curve in each
half. Extend the C-Curve no
further than two-thirds the
distance down each half. If you
extend the curve farther, it will
limit your ability to fold the splint
around the elbow.
4
Step 4: Using your own right or
left arm as a template, shape the
splint to fit.
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SAM Splint User Guide: Upper Body & Extremities
Step 5: Pad any bony
prominences about the wrist
and elbow.
6
Step 6: Fit the splint to the
patient.
7
Step 7: Secure splint with your
wrap of choice.
UPPER BODY & EXTREMITIES
5
Applications
t Dislocated elbow
t Maintaining elbow extension
SAM Splint User Guide: Upper Body & Extremities
25
UPPER BODY & EXTREMITIES
DISLOCATED ELBOW
1
Step 1: Using the patient’s nonaffected arm, extend a 36-inch
SAM Splint from just below the
patient’s armpit to the knuckles.
2
Step 2: Fold over any portion of
the splint that extends beyond
the knuckles.
3
Step 3: Form a C-Curve down the
entire length of the splint.
4
Step 4: Using your own right or
left arm as a template, shape the
splint to fit.
26
SAM Splint User Guide: Upper Body & Extremities
Step 5: You may create Reverse
C-Curve bends on the edges as
needed for strength.
6
Step 6: Apply the splint to the
patient.
7
Step 7: Secure with your wrap
of choice.
Applications
t Dislocated elbow
t Maintaining elbow extensions
SAM Splint User Guide: Upper Body & Extremities
27
UPPER BODY & EXTREMITIES
5
In this common dislocation, the patient’s arm is typically most comfortable when supported in the abducted (sitting away from the body)
position. The arm can be supported in this manner with a rolled ski
parka, blanket, pillow or SAM Splint “triangle”. To create a “triangle”
your splint is first folded into thirds. This produces three equal 12w
sections of splint.
Step 1: Fold the outer sections
along the longitudinal axis,
leaving the middle section flat.
Hook the outer folded ends
together, producing a triangle.
1
A more rounded, gentler curve
or half-circle is then folded along
the longitudinal axis of the flat
section of the triangle. This curve
is formed to contour to the shape
of the arm.
Step 2: The triangle is then
placed in the axilla and used to
support the abducted arm. The
arm triangle is held in place by
the patient or secured to the
patient’s trunk with your wrap of
choice.
2
Applications
t Shoulder dislocation
SAM Splint User Guide: Upper Body & Extremities
31
UPPER BODY & EXTREMITIES
ANTERIOR DISLOCATION
OF THE SHOULDER
LOWER EXTREMITIES
ANKLE STIRRUP
If a patient has to walk in rough terrain on the injured limb, you may
choose to leave footwear in place.
1
Step 1: If footwear is removed or
when the ankle is exposed, place
padding above and around the
boney prominences on each side
of the ankle.
2
Step 2: Fold a 36-inch SAM
Splint to create two equal halves.
3
32
Step 3: Apply C-Curves twothirds of the distance down each
half. Add Reverse C-Curves on
the edges if needed for strength.
Do not extend the curves further
or they will stiffen the splint and
limit your ability to fold it around
the foot and ankle.
SAM Splint User Guide: Lower Extremities
LOWER EXTREMITIES
4
Step 4: Fold the stirrup splint
around the foot and ankle.
5
Step 5: Secure with your wrap
of choice.
Applications
t Ankle fractures and sprains
t Lower leg fractures
SAM Splint User Guide: Lower Extremities
33
LOWER EXTREMITIES
FIGURE EIGHT
If a patient has to walk in rough terrain on the injured limb, you may
choose to leave footwear in place.
1
Step 1: If footwear is removed or
when the ankle is exposed, place
padding above and around the
boney prominences on each side
of the ankle.
2
Step 2: Lay a 36-inch SAM Splint
flat. Place the patient’s foot in the
middle of the splint so that the
splint lies just forward of the heel.
3
Step 3: Conform one half of the
splint snugly around the ankle.
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SAM Splint User Guide: Lower Extremities
LOWER EXTREMITIES
4
Step 4: Fold the second half of
the splint around the first in a
Figure Eight position. Crimp as
necessary to fit.
5
Step 5: Secure with your wrap
of choice.
Applications
t Ankle fractures and sprains
SAM Splint User Guide: Lower Extremities
35
LOWER EXTREMITIES
COMBO ANKLE STIRRUP
& FIGURE EIGHT
1
Step 1: First apply a Figure Eight
Splint, as shown in the previous
section of this training manual.
2
Step 2: Next, prepare an
Ankle Stirrup Splint as shown in
previous section of this training
manual.
3
Step 3: Apply the Ankle Stirrup
Splint over the Figure Eight
Splint.
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SAM Splint User Guide: Lower Extremities
LOWER EXTREMITIES
4
Step 4: Secure with your wrap
of choice and crimp as needed
to fit.
Front
Back
Applications
t Ankle fractures and sprains where greater immobilization is needed
SAM Splint User Guide: Lower Extremities
37
LOWER EXTREMITIES
SINGLE LONG LEG
1
2
Step 1: If footwear is removed or
when the ankle is exposed, place
padding above and around the
boney prominences on each side
of the ankle.
Step 2: Apply a C-Curve to
approximately 30 inches of a 36inch SAM Splint. Leave the last 6
inches of the splint flat and soft
to fold under the foot.
3
Step 3: For extra strength, apply
Reverse C-Curves on the edges
where necessary.
4
38
Step 4: Place the splint against
the outside of the leg and fold the
soft portion of the splint under
the foot to create a foot-plate.
SAM Splint User Guide: Lower Extremities
LOWER EXTREMITIES
5
Step 5: Adjust splint to fit
the leg.
6
Step 6: Secure with your wrap
of choice.
Applications
t Leg fractures (tibula or fibula)
SAM Splint User Guide: Lower Extremities
39
LOWER EXTREMITIES
DOUBLE LONG LEG
1
Step 1: If footwear is removed or
when the ankle is exposed, place
padding above and around the
boney prominences on each side
of the ankle.
2
Step 2: Create a long leg splint
as shown in the Single Long Leg
segment of this manual.
3
Step 3: Apply the long leg splint
to the outer aspect of the leg.
4
Step 4: Prepare a second splint,
identical to the first. Apply this
splint to the inner aspect of the
leg.
40
SAM Splint User Guide: Lower Extremities
LOWER EXTREMITIES
5
Step 5: Fold the soft, flat end
over the first footplate.
6
Step 6: Secure both splints to leg
with your wrap of choice.
Applications
t Leg fractures (tibula or fibula) where greater immobilization is needed
SAM Splint User Guide: Lower Extremities
41
LOWER EXTREMITIES
KNEE IMMOBILIZER
1
Step 1: Fold a 36-inch SAM
Splint in the center to create 2
equal halves. Spread the two
halves to produce a fan-shaped
splint, wider at the top for the
thigh and narrower at the bottom
for the calf.
2
Step 2: Apply tape to the top and
middle portions of the splint to
maintain the fan shape.
3
Step 3: Create a second fan
shaped splint.
4
Step 4: Form a C-Curve in each
SAM Splint.
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SAM Splint User Guide: Lower Extremities
LOWER EXTREMITIES
5
7
Step 5: The C-Curves should
appear as above.
6
Step 6: Place one splint on each
side of the knee and make fine
adjustments to fit.
Step 7: Secure with your wrap
of choice.
Applications
t Knee injuries
t Sprains
t Strains
SAM Splint User Guide: Lower Extremities
43