7 reminders for prehospital splinting of long bone and joint injuries
Despite a lack of evidence applying a splint effectively has been and will likely continue to be a mainstay of EMS practice
Splinting extremity fractures is a traditional field care procedure. From basic first aid to advanced level care providers, much time is spent training on and practicing the myriad of techniques and equipment used to splint broken bones and joints of the arms and legs.
So it might come as a bit of surprise to note that there is very little research supporting the practice of splinting. While there have been a few studies that have compared the different types of splints available on the market, to date there is no evidence that splinting makes a difference in terms of the patient's outcome.
Nevertheless, because of the purported effects of reducing pain and minimizing further damage, placing a well-sized splint effectively will likely continue to be a mainstay EMS practice.
There is an art to splinting. Rarely do manufactured splints exactly fit the presenting injury. The splint must often be adapted to provide maximum support to the injured extremity. In turn, this might reduce the pain that results from the soft tissue injury surrounding the fracture.
Here are seven important points to remember when splinting an extremity fracture:
1. Establish the injury’s baseline.
Prior to applying a splint, determine if there is adequate circulation, sensation and motor response past the injury site. Circulation can be checked by finding distal pulses or checking for capillary refill on the affected extremity and compare it to the unaffected side. Check for sensation by squeezing a finger or toe and asking if the patient can sense the pressure. Asking the patient to wiggle his fingers or toes can help confirm that motor-neuro pathways are intact.
2. Attempt realignment or repositioning.
In an angulated fracture, where the extremity is misshapen, there may be a loss of CSM due to compression or other soft tissue damage at the fracture site. If possible, apply mild traction to the distal extremity and straighten it prior to applying the splint. Doing so may help improve CSM and reduce the chance of further injury. In addition, it will be easier to shape the splint to the injury. A joint such as an elbow or knee may be more difficult to straighten; try to do so carefully if no resistance is felt. Otherwise, you may need to splint the joint in the position it was found.
3. Remember to add padding.
Pad the splint so that the voids are filled between the extremity and the splint itself. This makes the splint more secure, improves comfort and may decrease the pain associated with the injury.
4. Make a complete splint.
Immobilize the joints above and below the fracture site. This helps to immobilize the break itself and may help the patient reduce accidental movement of the injury.
5. Recheck CSM once the splint is in place.
If the patient complains of worsening pain, or there is a loss of CSM, readjust the splint carefully to see if it might have been applied too tightly. Continue to evaluate CSM every few minutes during transport.
6. Extremity fracture may be very painful.
Splinting may help reduce the discomfort. Analgesics such as morphine sulfate or fentanyl should be administered by qualified providers and according to protocol.
Document your findings and interventions carefully, including the status of CSM before and after applying the splint. Make sure to explain why a splint was indicated for the patient.
What other important findings would you add to this list? We are especially interested in tips and best practices you have for students and new EMS professionals.