Orthopedic Injuries, Splints, and Slings
Physical Examination and Functional Considerations
1. Begin palpation of the long bones distally, and proceed across all joints.
2. Palpable crepitus at the joint level mandates application of a splint.
3. If the patient is able to cooperate, have him or her move every joint through an active range of motion (ROM). This exercise quickly focuses the examination on the injury’s location.
4. When this is not possible, undertake passive ROM of each joint, after palpating the joint for crepitus and swelling.
5. If crepitus, swelling, deformity, or resistance to motion is noted, apply a splint.
6. If a joint is dislocated, attempt reduction after completing the neurovascular examination.
7. Reduction of the joint generally relieves much of the discomfort.
8. After reduction, assess stability of the joint by careful, controlled ROM evaluation.
9. Remember to perform serial neurovascular examinations (i.e., recheck status).
10. A joint with an associated fracture or interposed soft tissue is frequently unstable after reduction. In such circumstances, take great care while applying the splint to prevent recurrent dislocation.
11. Report to the definitive care physician the details of the reduction maneuver, including orientation of the pull, amount of force involved, sedation, residual instability of the joint, and prereduction and postreduction neurovascular status.
Circulatory Function
1. Injury to the major vessels supplying a limb can occur with penetrating or blunt trauma.
2. A fracture can produce injury to vessels by direct laceration (rarely) or by stretching, which produces intimal flaps. These flaps can immediately occlude the distal blood flow or lead to delayed occlusion. For this reason, repeated examination of circulatory function is mandatory before and during transport.
3. Assess color and warmth of the skin in the extremity distal to the injury. Distal pallor and asymmetric regional hypothermia may identify a vascular injury.
4. In the upper extremity, the brachial, radial, and ulnar pulses should be palpated. In the lower extremity, the femoral, popliteal, posterior tibial, and deep peroneal pulses should be palpated. If blood loss and hypothermia make pulses difficult to assess, temperature and color of the distal extremity become keys to diagnosis.
5. Any suspected major arterial injury mandates immediate evacuation after splinting.
Nerve Function
1. Nerve function may be impossible to assess in an unconscious or uncooperative patient.
2. Whenever possible, it is important to establish the status of nerve function to the distal extremity after the patient’s condition is stabilized.
3. Periodically compare the initial findings with additional examinations during transport of the patient. Deteriorating neurologic findings guide the speed of evacuation and any ameliorating maneuvers, such as further fracture reduction or splint modification. These decisions may greatly affect the final outcome of the patient.
4. Carefully document the sensory examination of the peripheral nerves with regard to light touch and pinprick.
5. Assess muscle function by observing active function and grading the strength of each muscle group against resistance.
Evacuation Decisions See Box 18-1.
1. Musculoskeletal injuries that warrant immediate evacuation to a definitive care center include any suspected cervical, thoracic, lumbar spine, pelvic, or femur injury.
2. A patient who has a suspected pelvic injury with instability, significant suspected blood loss, or injury to the sacral plexus should receive immediate emergency evacuation on a backboard (if possible) or modified immobilization (see Figs. 57-17 to 57-20).
3. All open fractures require definitive debridement and care within 18 hours to prevent the development of infection. Emergency evacuation is imperative. If evacuation time exceeds 8 hours, in addition to antibiotic administration and splinting, irrigation and debridement in the field should be attempted. Antibiotic options are listed in Box 18-2.
4. A patient with a suspected compartment syndrome must be evacuated on an emergent basis.
5. A joint dislocation involving the hip or knee warrants immediate evacuation, even if relocated, because of the associated risk for vascular injury or post-traumatic osteonecrosis of the femoral head (in the case of the hip).
6. A laceration involving a tendon or nerve warrants prompt evacuation to a center where an experienced surgeon is available.
7. In all but the most remote wilderness expeditions, arrangements should be made to promptly evacuate the patient when treatment or significance of the injury is uncertain.
Special Considerations with Open Fracture
1. An injury that includes disruption of the skin and a broken bone is an open fracture and is at risk for bacterial contamination. Assume that any deep wound over a known fracture represents an open fracture. If soil or foreign body contamination is severe, the patient is at risk for osteomyelitis and sepsis.
2. If medical care is realistically less than 8 hours away and the bone (limb) is not severely angulated or malpositioned, treat the injury with a compression dressing, splint, transport, and administer a broad-spectrum antibiotic.
3. If the delay will be more than 8 hours before definitive medical care, irrigation of the open wound is beneficial and may help prevent serious soft tissue and bone infection.
a. The water used for irrigation does not have to be sterile. Clean tap water or water disinfected for drinking can greatly diminish the bacterial burden.
b. Use a syringe from the medical kit as an irrigating tool (see Fig. 20-1).
c. Attach an 18-gauge needle (or irrigation tip) to the syringe.
d. Irrigate the wound copiously with the pressurized stream of water. For a large wound, more than a liter of water may be necessary.
4. Once the wound has been cleaned and irrigated, cover it with a sterile compression dressing.
5. A dilute solution of 10% povidone-iodine solution can be applied as a brief rinse over the visible bone ends. Realign any angulated or malpositioned fractures, and apply the required traction. It is less likely that major contamination will occur when the bone fragments slip back into the soft tissue envelope during reduction.
6. Administer a broad-spectrum antibiotic (see Box 18-2), and splint the extremity. If evacuation time exceeds 8 hours, the incidence of osteomyelitis is high.
Special Considerations with Amputation
1. In the wilderness environment, the amputation patient requires immediate evacuation.
2. Control hemorrhage by direct pressure. A tourniquet is usually not indicated. If a tourniquet is applied as a lifesaving measure, document the time and date of application and be prepared to sacrifice the limb. Check at reasonable intervals (e.g., once an hour) to see if pressure alone will control bleeding.
3. Without cooling, an amputated part remains potentially viable for only 4 to 6 hours; with cooling, viability may be extended to 18 hours.
4. Cleanse the amputated part with water, wrap it in a moistened sterile gauze or towel, place it in a plastic bag, and transport it on ice or snow, if available. Do not transport it in direct contact with ice or ice water.
5. Make sure the amputated part accompanies the patient throughout the evacuation process.
Special Considerations with Compartment Syndrome
Signs and Symptoms
1. Complaints by the conscious patient of severe pain that seem out of proportion to the injury
2. Extremely tight feel to the muscle compartment, with applied pressure increasing the pain
3. In the cooperative patient, decreased sensation to light touch and pinprick in the areas supplied by the nerve or nerves traversing the compartment, usually noted on the dorsum of the foot in the first web space, caused by pressure affecting the deep peroneal nerve in the anterior compartment of the leg
4. Most reliable signs: pain, tightness to palpation, and pain on passive stretch
5. Never wait for hypoesthesia, absence of a pulse, presence of pallor, or slow capillary refill to make the diagnosis. Even late in the course, there is usually a pulse and normal capillary refill (unless there is an underlying arterial injury).
Treatment
1. Expedite emergency evacuation. The patient must be definitively treated in the first 6 to 8 hours after onset of this condition to optimize return of function to the involved limb. Be sure that there are no tight bandages, dressings, or splints that can exacerbate the condition. Do not elevate the limb; try to keep it at the level of the heart. Elevation reduces mean arterial pressure in the limb, which can reduce blood flow.
2. Perform emergency fasciotomy to relieve the pressure, which, if untreated, can produce nerve and muscle cell death within 12 hours. An experienced physician or surgeon can perform limited fasciotomies in the field if evacuation will take more than 8 hours. Antibiotics should be started (see Box 18-2) if a fasciotomy is performed in the field.
Splinting
Improvisation: General Guidelines
1. When working with a complex improvised system, test your creation on an uninjured person (i.e., “work out the kinks”) before you use it on the patient.
2. Remember to include improvisation construction materials, including a knife, tape, parachute cord or line, safety pins, wire, and plastic cable ties, in your survival kit.
3. Maintain a creative approach to obtaining improvisational materials. Much of the patient’s gear can be harvested to provide necessary items. A backpack can usually be dismantled to obtain foam pads, straps, etc.
4. Practice constructing certain items before you must do this in an actual rescue setting.
5. Be sure to use adequate padding and check underneath both prefabricated and improvised splints frequently for skin irritation.
6. Cover open wounds with sterile or the cleanest possible dressings.
Extremity Splints
1. Splint the fracture before the patient is moved unless the patient’s life is in immediate danger. In general, make sure the splint incorporates the joints above and below the fracture. If possible, fashion the splint on the uninjured extremity and then transfer it to the injured one.
2. Skis, poles, canoe and kayak paddles, ice axes, and snow anchors can be used as improvised splints. Airbags used as flotation for kayaks and canoes can be converted into pneumatic splints for arm and ankle injuries. The Minicell or Ethafoam pillars found in most kayaks can be removed and carved into pieces to provide upper and lower extremity splints. A life jacket can be molded into a cylinder splint for knee immobilization or into a pillow splint for the ankle. The flexible aluminum stays found in internal-frame backpacks can be molded into an upper extremity splint. Other improvised splinting materials include sticks or tree limbs; rolled-up magazines, books, or newspapers; tent poles; and dirt-filled garbage bags or fanny packs.
3. Ideally a splint should immobilize the fractured bone in a functional position. In general, functional position means that the leg should be straight or slightly bent at the knee, the ankle and elbow bent at 90 degrees, the wrist straight, and the fingers flexed in a curve as if one were attempting to hold a can of soda or a baseball. The “soda can” position is appropriate for initial management and transport; however, for long-term splinting, apply a hand splint with the metacarpophalangeal (MCP) joints flexed at 90 degrees and the interphalangeal joints extended (the “intrinsic positive” position). This position places the collateral ligaments at maximum length and helps prevent joint contractures.
4. Secure the splint in place with strips of clothing, belts, duct tape, pieces of rope or webbing, pack straps, elasticized roller wraps, or gauze bandages.
Ensolite (Closed-Cell Foam) Pads
SAM Splint
Introduced in 1985, the versatile SAM splint (Fig. 18-1) has largely filled the niche formerly occupied by military-style ladder splints and wire mesh splints. It is constructed of a thin sheet of malleable aluminum sandwiched between two thin layers of closed-cell foam, weighs approximately 128 g (
oz), and can be easily rolled into a tight cylinder. Initially the splint has no rigidity, but after structural U-shaped bends are placed along the axis of the splint, it becomes quite rigid.
Triangular Bandage
1. Typically used to construct a sling and swath bandage for shoulder and arm immobilization, a good substitute for this bulky item can be made with two or three safety pins. Pinning the shirtsleeve of the injured arm to the chest portion of the shirt effectively immobilizes the extremity against the body (Fig. 18-2, A).
2. If the patient is wearing a short-sleeved shirt, fold the bottom of the shirt up and over the arm to create a pouch. This can be pinned to the sleeve and chest section of the shirt to secure the arm (Fig. 18-2, B).
3. Triangular bandages are useful for securing splints and constructing pressure wraps. Common items such as socks, shirts, belts, pack straps, webbing, shoelaces, fanny packs, and underwear can easily be used as substitutes.
Disorders
Cervical, Thoracic, Lumbar, and Sacral Spine
Spinal cord injuries are rare but may result in long-term disability. Complete spinal immobilization in the wilderness setting may not always be practical but should always be considered if there is concern for possible spinal injury. Spinal stabilization is first accomplished by manual techniques, and then with mechanical devices (see Figs. 57-17 to 57-20).
Signs and Symptoms
Treatment
1. Consider spinal immobilization for severe pain or tenderness, traumatic mechanism of injury, altered mental status, distracting injury, unreliable examination, neurologic complaints, head injury, or extremes of age.
2. Use commercial cervical collars if available for cervical spine immobilization.
3. Cervical spine immobilization can be improvised using towel rolls, backpack material, clothing, sandbags, fanny packs, SAM splints, water bottles, and shovels (see Figs. 57-18 and 57-21).
4. A full-length backboard is best for accomplishing immobilization of the thoracolumbar spine.
5. Thoracolumbar immobilization can be improvised using commercial or improvised rescue litters and carriers (see Chapter 57).
6. Maintain spinal alignment during patient movement with “logrolling” and manual cervical spine immobilization.
Upper Extremity Fractures
Signs and Symptoms
1. Complaints of shoulder pain, which may be poorly localized and exacerbated by arm or shoulder motion
2. Crepitus at the clavicle confirms the diagnosis
3. Although rare, associated pneumothorax, because the cupola of the lung is punctured
4. Shortness of breath and deep pain on inspiration
5. Associated injury to the brachial plexus, axillary artery, or subclavian vessels
Treatment
1. Localize the pain by gentle palpation to identify the area of maximum tenderness.
2. Auscultate the chest for equal breath sounds if a stethoscope is available.
3. Perform a thorough neurovascular examination of the adjacent extremity.
4. Examine the skin carefully for disruption because of the subcutaneous location of the bone.
5. If there is a significant open wound, suspected pneumothorax, or an injury to a nerve or vascular structure, arrange for evacuation.
6. Most midclavicle fractures are improved by applying a sling or figure-8 type of support, easily improvised with a shirt jacket or cravat. A figure-8 support works by pulling the shoulder girdle back, applying longitudinal traction to the clavicle so that the bony fragments are somewhat realigned. Figure-8 straps are poorly tolerated by some patients and, if applied too tightly, can cause nerve injury. Figure-8 supports may also worsen distal clavicle fractures and should not be used if a distal fracture is suspected. Usually a simple sling with swath is adequate.
7. Judicious use of ice or snow packs, if available, and analgesics should be used. Elevation may provide added relief during rest. Elevate the patient’s upper body and head by 10 to 30 degrees when supine. This is a general rule for any shoulder injury. Supine positioning is generally poorly tolerated by patients after shoulder injuries.
Humerus
Signs and Symptoms
1. Fracture of the proximal humerus, often caused by a high-velocity fall onto an abducted, externally rotated arm or by a direct blow to the anterior shoulder
a. Difficult to differentiate from a shoulder dislocation in the acute phase. If there is crepitus or if the upper arm is rotated while palpating the proximal humerus and they do not move as a unit, the humerus is fractured
b. Severe pain around the shoulder and with any arm motion
c. Anterior fullness in the area of the proximal humerus, suggesting associated anterior humeral head dislocation
2. Fracture of the distal humerus
a. More frequently extra-articular in children and intra-articular in adults, with the child generally sustaining a supracondylar fracture with an extension moment across the elbow in a fall from a height
b. Peak age of incidence 4 to 8 years, although this can also occur in an adult
3. Radial nerve damage (rare unless the fracture occurs in the mid to distal one-third of the humerus)
a. The radial nerve courses around the posterior aspect of the humerus and is occasionally traumatized when the humeral shaft is injured
b. Numbness over the dorsum of the hand and inability to extend the wrist or fingers
c. Usually caused by contusion or traction injury to the nerve and not to complete disruption
Treatment
1. When a fracture of the humeral shaft is suspected, firmly apply an appropriate splint of fiberglass, wood, or other improvised material with an elastic bandage on the medial and lateral sides of the humerus. Construct the splint so that it reaches proximal to the level of the fracture (Fig. 18-3).
2. Have the patient use a sling and swath for comfort.
a. With suspected proximal humeral injury, use the uninjured side as a reference and palpate the anterior aspect of the injured shoulder firmly while rotating the arm. Palpable crepitus with arm motion confirms the diagnosis. It is unlikely that a combined fracture and dislocation can be reduced in the field. Treat this as a fracture, with splinting of the extremity to the torso with a sling or a sling and swath.
b. Arrange for urgent evacuation for any associated significant distal nerve or vascular injury.
3. For an adult with pain, crepitus, deformity, and swelling after a fall, apply a splint and immobilize the arm to the torso. Be sure to apply the splint with the elbow at 45 to 90 degrees of flexion, depending on the patient’s comfort. A splint on the inner and outer surface of the arm that is molded to curve around the elbow provides satisfactory stabilization. Arrange for prompt evacuation if there is an open fracture or neurovascular deficit.
4. With radial nerve injury, there is a high incidence of spontaneous recovery of function. However, if the patient complains of arm pain associated with deformity and crepitus, carefully check the sensory and motor function of the radial nerve as part of the overall neurovascular examination.
Radius
Signs and Symptoms
1. Radial shaft fracture: usually a history of a fall with angular or axial loading of the forearm
a. Pain, deformity, and crepitus over the radial shaft after a fall or direct blow, with any arm motion exacerbating the pain
b. Possibly associated with dislocation of the distal radioulnar joint (Galeazzi’s fracture); tenderness, swelling, and deformity in the wrist
c. If associated with fracture of the ulna, possibly marked forearm instability or tenderness, crepitus, and deformity in the elbow and wrist
2. Radial head fracture: generally occurs in a young to middle-aged adult who falls onto an outstretched hand
a. Pain around the elbow with loss of full extension
b. Tenderness at the radial head on the lateral side of the elbow, and pain with passive rotation of the forearm
c. With a more severe, comminuted radial head fracture: pain and crepitus with attempts at motion; ROM severely limited
d. Frequently, hemarthrosis of the elbow
e. Swelling is noted as fullness posterior to the radial head and anterior to the tip of the olecranon.
3. Fracture of the distal metaphyseal radius: generally associated with a fall onto the outstretched hand from a significant height
Treatment
1. Carefully examine the wrist and elbow, looking for tenderness, swelling, deformity, and crepitus.
2. Once a shaft fracture of the radius or radius and ulna is suspected, splint the wrist, forearm, and elbow in the position of function.
3. For a radial head fracture, move the elbow through gentle ROM and then place it in a posterior splint at 90 degrees of flexion with neutral pronation and supination.
a. On a prolonged expedition when definitive care cannot be reached, remove the splint at 5 days and perform intermittent active ROM exercises; then reapply the splint for comfort.
b. With a nondisplaced or minimally displaced radial head fracture, early ROM prevents permanent loss of elbow motion.
c. If hemarthrosis has occurred, proper equipment is available, and you are confident about the diagnosis, aspirate the hemarthrosis and instill 5 to 10 mL of lidocaine to facilitate pain relief. This must be done under sterile conditions by a skilled individual.
4. For a distal radius fracture with significant deformity at the wrist (Colles’ fracture), apply longitudinal traction after appropriate sedation (Fig. 18-4). In certain circumstances with a Colles’ fracture, simple longitudinal traction will not work because the fracture is locked dorsally. To reduce, reproduce the injury deforming force to unlock the fracture (Fig. 18-5). That is, increase the volar angulation (hyperextend the wrist) at the fracture site, then pull distal traction, reducing the distal fragment volarly with your thumb.
FIGURE 18-4 Colles’ fracture (“dinner fork deformity”).
a. Next, apply a splint that immobilizes the wrist and elbow. A U-shaped (“sugar-tong”) splint, used in conjunction with a sling to limit rotation, is adequate for transport (see Fig. 18-1).
b. With an open fracture, significant neurologic deficits, or abnormal circulatory examination, apply the splints promptly and initiate evacuation. Keep the limb elevated above the heart during transport to minimize swelling.
Ulna
Signs and Symptoms
1. Ulna shaft fracture: when patient attempts to brace a fall with the forearm
a. Most often associated with fracture of the radial shaft at the same level
b. When isolated, most often occurs as a result of a direct blow, the so-called nightstick fracture
c. Can be associated with dislocation of the radial head (Monteggia’s fracture), affecting elbow function
2. Fracture of the proximal ulna (olecranon): result of a fall onto the posterior elbow or from an avulsion after violent asymmetric contraction of the triceps
a. Inability to extend the elbow actively against gravity if the triceps is dissociated from the forearm with a complete fracture of the olecranon
b. On initial examination: pain, significant swelling, and ecchymosis; palpable gap in the olecranon, with possible open fracture
c. With severe trauma, associated with intra-articular fracture of the distal humerus
Treatment
1. For ulna shaft fracture, apply a long-arm splint in the position of function. If the fracture is open, arrange for prompt evacuation.
2. For fracture of the proximal ulna, after the distal neurovascular examination and shoulder and wrist assessment, apply a splint in the position of function. A posterior splint at 90 degrees usually works well. If there is an open fracture, absent pulse, severe swelling, or neurologic deficit, arrange for immediate evacuation.
Wrist and Hand
Signs and Symptoms
1. Wrist fracture: history of significant rotational or high axial loading forces, such as those occurring with a fall onto the hand
a. Pain at first, then swelling of the wrist
b. Significant pain with any use of the hand or with rotation of the forearm
2. Carpal bone fracture: precise diagnosis impossible without radiographs
Treatment
1. Swelling can become severe. Remove all jewelry as soon as possible to prevent constriction as tissue swells.
2. Make a temporary hand splint with the hand in the position of function, with the wrist straight and the fingers flexed in a curve as if holding a beverage can.
3. Apply a long-term hand splint with the MCP joints flexed 90 degrees and the interphalangeal joints extended, creating the “intrinsic positive position.”
4. This position places the collateral ligaments at maximum length and prevents later joint contracture. For an open fracture or one accompanied by median nerve dysfunction, arrange for prompt evacuation.
5. For carpal bone fracture/wrist dislocation, reduce the fracture by grasping the hand in a handshake fashion and pulling with axial traction. Apply a short-arm splint.
6. For suspected scaphoid fracture, if appropriate splinting materials are available, apply a thumb spica splint, immobilizing both the radius and the first metacarpal bone (thumb).
a. Encourage the patient to follow up with an orthopedist as soon as practical.
b. Lack of appropriate immobilization can result in nonunion and/or avascular necrosis, which can develop into severe osteoarthritis and chronic pain.
7. For fracture of the hook of the hamate bone, use a short-arm splint, which also suffices for other suspected carpal injuries, until definitive treatment can be obtained.
8. Wrist fractures with significant swelling or fractures that have not been anatomically reduced can induce traumatic carpal tunnel syndrome. If there is evidence of median nerve paresthesias, urgent carpal tunnel release may be essential.
Metacarpal
Signs and Symptoms
1. Fracture of the metacarpal base or shaft: result of a crush injury or an axial load when a rock or other immovable object is struck; produces tenderness, crepitus, and deformity
2. Fracture of the metacarpal neck: result of the same mechanism as for the metacarpal base or shaft
