► Splinting Principles and Procedures
Splinting is a medical task that has been around since the dawn of time. In its most simple explanation, we want to immobilize an extremity to allow it to heal. Most people can look at a fractured arm or leg that is bent in an awkward manner and immediately think, “Man, that just does NOT look right!” Intuitively, they want to grab it and straighten it out so it looks normal again. It’s common sense! If it doesn’t look right, we want to make it look right. The caveman probably noticed that if another caveman suffered a fracture that didn’t heal correctly, that person most likely ended up dead. If Caveman Bob can’t hunt…he’s gonna die! So he better find a way to heal up fast and get back into the hunt as soon as possible. It may not be such a dire consequence today, but splinting and casting allows us to heal properly and regain as much functionality as possible.
What Needs Splinting
Broken bones/Fractures are not the only things that require splinting. Here is a list of the most common injuries that need splinting:
1. Intra-articular (involving the joint)
2. Shaft of the bone
► Severe Soft Tissue injuries
► Joint Dislocations that have been reduced into normal position
► Inflammatory Conditions
3. Gout that is causing severe pain
► Deep Lacerations over a joint that can put added strain on the repair
► Lacerated Tendons
Benefits of Splinting
► Splints prevent movement of the injured site
Movement causes pain, period! If you take two bones and break them, you will see they have sharp edges. Now imagine moving those sharp edges back and forth; you can imagine the pain this would create within the bones and soft tissues. Eliminate the movement and the pain level decreases. I have had plenty of patients that have told me their pain level decreased dramatically once the splint was placed.
► Protection of the injured site from further injury
By completely immobilizing an injury, a splint can prevent a bad injury from turning into something way more severe, such as a lacerated nerve and subsequent paralysis of the limb. Most of our body’s arteries and nerves run very close to the bones. By running deep next to the bones, these structures are protected from becoming injured with minor trauma. However, when a major bone is fractured, we always worry about the possibility of lacerating an artery or nerve that we know runs right next to those large bones.
► Allow soft tissue injuries to heal
For example, an ankle injury: If we can prevent the ankle from moving, this will allow the stretched ligaments and tendons to heal properly. If not, the stretched ligament is very weak. It could easily rupture if re-injured before it has had time to fully heal. The surrounding tissue inflammation will also subside if the area is immobilized.
► Splints are not circumferential
In other words, they don’t wrap completely around the injury site. This allows for the inevitable tissue swelling that accompanies almost all injuries to occur without cutting off the circulation. This is why when you go to an Emergency Room with a fracture, they will normally put you in a splint and tell you to follow up with Orthopedics in a few days. The splint allows the fracture to swell in the first couple of days and then reduce a little before you see ortho and have a cast put on.
► Splints can be easily removed or re-adjusted
Most splints are held in place with a compression bandage, such as an ACE wrap. If the swelling becomes severe and slightly painful, I can simply loosen the ACE wrap a bit to accommodate for the increased swelling.
Complications of Splinting
► Compartment Syndrome
This is a condition where the pressures within the extremity have increased to a point that it is compromising blood flow. If you cannot get blood flow to the extremity, it can cause irreversible damage. The splint will need to be loosened slightly and the patient taken to an Emergency Room immediately. Luckily, this is not something that occurs within a few hours. This is more likely an overnight sort of thing.
► Pressure sores
These can develop if the splint is not padded properly, and pressure is placed directly over a body prominence. Sites commonly affected with pressure sores are ankles, wrists, and elbows. These bony prominences don’t have much tissue over them and it doesn’t take a whole lot of pressure over time to cause tissue breakdown at those sites.
This can be an issue if the splinted area suffered an open fracture, abrasion, or laceration. You will need to make sure you are checking these wounds frequently and cleaning them.
► Joint stiffness
This inevitably occurs because we have not allowed the joint to move. The tendons, ligaments, and muscles have all atrophied and constricted. Some gentle stretching and gradual return to movement will fix this right up.
Principles of Splinting
So now you have come to the conclusion the patient would benefit from a splint. Next comes the obvious question of, “How do I put a splint on?” Follow these principles and it should keep you out of trouble and enable you to put on a splint correctly. We also have a variety of videos showing you how to correctly put on a variety of splints.
► Examine the injured area
The patient is most likely going to be able to tell you, “It hurts really badly right here:” They will then point with one finger at the site of maximal pain. 99.99% of the time, the fracture is right underneath where they are pointing. (This ain’t rocket science folks)
► Check for pulses in the distal part of the extremity
We want to make sure I have a good strong pulse. If my forearm is badly bent and obviously fractured, one of my main concerns (besides crying like a baby from extreme pain) is that the fracture may have compromised my circulation. No circulation distally from the injury is the same thing as a tourniquet. I really need to make sure those pulses are there.
► Pad the splint
We do this to prevent pressure sores over bony prominences. Some splints come with a foam covering that will be sufficient for a couple of hours or so. Others types of splints are simple wooden planks, such as the Bass wood splint. Use your judgment and when in doubt, wrap some gauze or a shirt…anything around the splint to pad it and provide comfort to the patient. A few extra seconds to pad properly can make a big difference to the patient.
► Splint a fracture in the position you find it
We really, really don’t want to move a fracture too much. I already explained that manipulation of the extremity can cause a possible laceration of a nerve or artery. The absolute only exceptions to this rule are if you have 1) No pulse, or 2) The fracture is so badly disfigured you cannot transport in the current position. If you don’t have a pulse, you very gently apply traction to the extremity while moving it towards correct anatomic position. The minute you feel a pulse, you stop where you are and splint it in that position. Now, be prepared to hear a lot of yelling, screaming, and cursing when you do this. It hurts. It hurts a whole lot! Prepare the patient beforehand by telling him/her, “Listen, I don’t have a pulse which means you may lose your arm if I don’t move it and get a pulse back in there. Get ready for a whole lot of pain!” I would only move the extremity if the patient was going to be more than a couple of hours away from the hospital. If this is at home and the hospital is 30 minutes away….I’m not moving it!
► Immobilize the joint above and below the fracture site
For example: If I have a fracture of the forearm I must immobilize both the wrist and the elbow. If I have a fracture of the middle Tibia (shin bone), I must immobilize the ankle and the knee. I cannot simply put a short leg splint on immobilizing the ankle. If the knee can still move, the Tibia is not immobilized and the bones will continue moving inside the splint.
► Check for pulses again
If you had a good pulse prior to applying the splint, and now you don’t have one, you better fix that pretty quickly! Check to see if the splint is too tight, or if the limb needs to be moved a bit to regain the pulse.
Types of Splints
In my clinic, I have a bunch of different types of prefabricated splints. You name it, I have a splint for every joint, in either universal size, right or left, small, medium, and large sizes.
Outside of the clinic, my options are rather limited. There are portable splints that I carry and they take just a little training and manipulation to form them into whatever splint I am fabricating. (See the article and video on SAM Splints)
Traction splints are meant primarily for a femur fracture. For the non-medical types, that is the “thigh bone connects to the knee bone” part of the song. These splints are meant to overpower the strong muscles of the thigh and stretch the broken bones apart so they are not contracted and overlaying one another. Femur fractures are one of the most painful fractures you will ever encounter
Pelvic splints for pelvis fractures. This is an extremely difficult fracture to splint and there are so many blood vessels and nerves running through the pelvis, it is also a very dangerous fracture.
Anatomic splinting is an option in some cases. Buddy taping one finger to another can help immobilize it. Tying one leg to another can splint the injured leg. These are not the greatest of splints, but will do for a short time period.
When to seek medical attention
If the patient can move the extremity around fairly well, only has localized swelling, can walk on the lower extremity, or grasp forcefully and resist movement in all directions with the upper extremity; you most likely don’t need to seek medical attention. Treat with the PRICE methodology (see article on PRICE) and consider splinting the affected extremity. When in doubt, go to the ER.
You will need to seek medical attention if the patient cannot move the affected extremity or has profound weakness with attempted movement of the extremity. If the patient is walking with a pretty severe limp or will not attempt to put weight on the leg, this is a pretty good indicator a fracture may be present.
Deformity of the limb is also a pretty good sign a fracture is present. (I have to mention this or somebody is going to send me an email telling me I forgot the obvious) Remember what we discussed about moving a displaced fracture.
If you have pain that just seems to be out of proportion to the injury, this could be the beginning of compartment syndrome. A simple fracture that has been splinted should not be causing a pain level that is 8/10. I expect a splinted fracture to be like a 4 or 5/10 on the pain scale.
Lastly, but most importantly…..if you have to think for more than five seconds about whether or not you should go to the ER; then go to the ER. It’s always better to play it safe and get the opinion of experts in the field.