Extremity Injuries
and Splinting
Dr. Esmailian mehrdad
Assistant Professor of
Emergency Medicine
M_esmailian@med.mui.ac.ir
4-1
Skeletal System
42
Functions of the
Musculoskeletal System
 Gives the body shape
 Protects internal organs
 Provides for movement
 Consists of more than 600 muscles
43
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
44
Splinting
 Helps prevent further injury
 Reduces pain
 Minimizes bleeding and swelling
45
Mechanism of Injury
 Force may be applied in several ways:
46
 Significant force is generally required to cause
fractures or dislocations
 This force may be applied to the limb in any of
the following ways:
1) Direct blows
2) Indirect forces
3) Twisting forces
4) High-energy injury
47
1) A direct blow fractures the bone at the point of
impact
2) Indirect force may cause a fracture or
dislocation at a distant point
3) Twisting injuries are a common cause of
musculoskeletal injury, especially to the knee
48
4) 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
49
 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
410
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
411
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
412
Splinting
 Splints can be improvised when needed and tied
with bandages, belts, neckties, strips of cloth
 Always check breathing and care for lifethreatening conditions first
 Consider mechanism of injury and possibility of
spinal injury
413
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
414
Signs and Symptoms
of a Fracture
 Deformity
 Tenderness
 Guarding
 Swelling
 Bruising
415
 Crepitus
 False motion
 Exposed fragments
 Pain
 Locked joint
416
Signs and Symptoms
of a Dislocation
 Marked deformity
 Swelling
 Pain
 Tenderness on palpation
 Virtually complete loss of joint function
 Numbness or impaired circulation to the limb
and digit
417
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.
418
Severity of Injury
 Critical injuries can be identified
musculoskeletal injury grading system
419
using
Minor Injuries
 Minor sprains
 Fractures or dislocations of digits
420
Moderate Injuries
 Open fractures of the digits
 Nondisplaced long bone fractures
 Nondisplaced pelvic fractures
 Major sprains of a major joint
421
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
422
Severe Life-Threatening Injuries
(Survival Is Probable)
 Multiple closed fractures
 Limb amputations
 Fractures of both long bones on the leg (bilateral
femur fractures)
423
Critical Injuries
(Survival Is Uncertain)
 Multiple open fracture of the limbs
 Suspected pelvic fractures with hemodynamic
instability
424
Rapid Physical Exam for
Significant 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
425
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
426
Assessing Neurovascular Status
 If anything causes pain, do not continue that
portion of exam
 Pulse
Palpate the radial, posterior tibial, and
dorsalis pedis pulses
427
 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
428
 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
429
 Motor function
Evaluate muscular activity when the injury is
near the patient’s hand or foot
Ask the patient to open and close his or her
fist
Ask the patient to wiggle his or her toes
430
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
431
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
432
General Principles of Splinting
 Remove clothing from the area
 Note and record the patient’s 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 doesn’t cause more pain
433
 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
434
 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
435
 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
436
Types of Splints
 Rigid splints
 Soft splints
 Anatomic splints
437
Rigid Splint
 Board
 Plastic or metal
 Rolled newspaper or magazine
 Thick cardboard
438
439
440
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
441
 Secure the splint to the limb with bindings
 Assess and record distal neurovascular function
442
Soft Splint
 Pillow
 Folded blanket or towel
 Triangular bandage folded into sling
443
Anatomic Splint
 Bandage injured leg or finger to uninjured one
444
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
445
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
446
Hazards of Improper Splinting
 Compression of nerves, tissues, and blood
vessels
 Delay in transport of a patient with a lifethreatening condition
 Reduction of distal circulation
 Aggravation of the injury
 Injury to tissue, nerves, blood vessels, or muscle
447
Upper Extremity Injuries
 Clavicle and Scapula
 Shoulder
 Upper arm
 Elbow
 Lower arm
 Wrist
 Hand
448
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
449
 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
450
A/C Separation
 With A/C separation, the distal end of the
clavicle usually sticks out
451
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
452
 Splint the joint with a pillow or towel between the
arm and the chest wall
 Apply a sling and a swathe
453
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
454
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
455
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
456
 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
457
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
458
 If elbow bent, apply rigid splint from upper arm to
wrist
 If more support needed, use sling at wrist and
binder around chest
459
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
460
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
461
Secure point of bandage at
elbow
462
Position triangular
bandage
463
Bring lower end
of bandage to
opposite side
of neck
464
Tie the ends
465
Tie binder
bandage over
sling and around
chest
466
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
467
 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
468
Support arm. Check
circulation
469
Position arm on rigid
splint
470
Secure splint
471
Check circulation
472
Put arm in sling. Tie
binder over sling and
around chest
473
Finger Injuries
 Fractures
and
dislocations
 Often
splint
not
required
 Use rigid splint or
anatomic splint
474
Lower Extremity Injuries
 Pelvic and Hip
 Upper leg
 Knee
 Lower leg
 Ankle
 Foot
475
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
476
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
477
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)
478
 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
479
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
480
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
481
 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
482
 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
483
 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
484
Splinting a Femur Fracture
 Tie splints with
cravats
or
bandages
 Check
circulation
periodically
485
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
486
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
487
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
488
Dislocation of the Patella
 Usually dislocates to lateral side
 Produces significant deformity
 Splint in position found
 Support with pillows
489
 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
490
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
491
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
492
 Rigid splint applied the same as for knee injury
Three-sided cardboard splint can be used
493
Check circulation.
Gently slide four to
five strips of
bandages under
both legs
494
Pad between legs
495
Gently slide
uninjured leg next to
injured leg
496
Tie bandages.
Check circulation
497
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
498
Ankle Injuries
 Position
foot
in
middle of soft pillow
 Fold pillow around
ankle
 Tie pillow around foot
and lower leg
499
Foot Injuries
 Usually occur after a patient falls or jumps.
 Immobilize ankle joint and foot
 Leave toes exposed to assess neurovascular
function
4100
 Elevate foot
 Also consider possibility of spinal injury from a
fall
 A pillow splint can provide excellent stabilization
of the foot
4101
4102