Splinting an Injury, by ShaneTheNurse

There you were just climb­ing that tree to fetch the squir­rel you just shot when the branch breaks and you fall and break your arms. Ouch! Thank­ful­ly you have a bud­dy that is trained to apply a splint and he is going to help you out.

No mat­ter if it is closed or open frac­ture the final result will be the same, a nice sta­ble splint that will keep the injured arm immo­bile and facil­i­tate opti­mal heal­ing or at the very least some degree of pain relief and immo­bil­i­ty until you can get to a doc­tor.

Splint­ing is not rock­et sci­ence, though there is a bit more to it than strap­ping two sticks to your bud­dy and call­ing it good. There are a lot of things that must be addressed before, dur­ing, and after the splint is applied.  For this dis­cus­sion we will make it so there are no asso­ci­at­ed spinal cord or oth­er neu­ro­log­i­cal injuries.

What does it look like? Does the limb look nor­mal or is there a new 90 degree with bones stick­ing out? Well in this case we have one of each.

• Cir­cu­la­tion – does the affect­ed limb still have good blood flow? Is it still pink, warm to touch? If you press on a fin­ger or toe does the skin return to nor­mal col­or rapid­ly or is it slow?
• Sen­sa­tion – can they feel you touch­ing the fin­gers or toes? Does it hurt?
• Motion – can they move the affect­ed limb? Can they move it with­out pain? Can they wig­gle fin­gers and toes?
• It is impor­tant to know these things now because you will have to check them again once the splint is applied.

For our bor­ing non dis­placed injury to the left fore­arm we will apply a sim­ple SAM splint. SAM splints come in a roll and are formable to a person’s limb. They are also reusable which makes them great for the sur­vival first aid kit. I like to do a wrap of some type of cush­ion­ing mate­r­i­al before I apply the splint but it is not absolute­ly need­ed in this case. Once you have the limb in a posi­tion of com­fort go ahead and form the SAM splint and then wrap with an elas­tic ban­dage, ACE wrap. Be care­ful not to wrap too tight. If you do not have the elas­tic ban­dage try to use some­thing like coflex or vet wrap. Once the limb is sta­bi­lized and your bud­dy feels good fash­ion a sling to keep the limb in a posi­tion of com­fort with the hand ele­vat­ed high­er than the heart to pre­vent excess swelling.

The oth­er arm is not so pret­ty, there is new elbow between the fac­to­ry orig­i­nal and the wrist. Here you real­ly need to eval­u­ate your skill lev­el and dis­tance to med­ical treat­ment. I can­not lie to you, there is just some­thing dis­turb­ing about see­ing bones stick­ing out of some­body. After all my years in the ER it still gives me a lit­tle chill.

If you have min­i­mal skills break out that SAM splint and immo­bi­lize that arm just as you did the oth­er one. Place the wrap at the elbow and wrist. Do not wrap over the exposed bones. Sling it and get to a hos­pi­tal.

For those with a lot more train­ing and expe­ri­ence, or if it will be days or weeks before you can get to a hos­pi­tal you will need to do a lot more work.

The break will have to be reduced, that is the bones will have to be put back in place. This is sim­ple enough but it needs to be done cor­rect­ly or there will be big prob­lems lat­er. First wash the exposed area with water using the most ster­ile water pos­si­ble. Once the area is washed you will need to wash your own hands to ensure min­i­mal trans­fer of bac­te­ria. This next part will not be pleas­ant for any­body. You will need to pull gen­tly on the arm with a steady force until the bones line up again. You may need to use one hand to manip­u­late the bones at the break to ensure they are as per­fect­ly inline as pos­si­ble. This sounds quite sim­ple but I can assure you this will be work, as the mus­cles around the break have already con­tract­ed and tis­sues are swelling. Once the bones are lined up your friend should report a decrease in pain. Assum­ing that went well and there are no oth­er prob­lems a dress­ing to the wound will be need­ed. One can hope to have a good med­ical kit with all the gauze and antibi­ot­ic oint­ment need­ed. The clean­est pos­si­ble cloth can be used with a lay­er of antibi­ot­ic oint­ment applied to the cloth if that is what you have. Apply the splint and sling as ear­li­er described, ensur­ing to not wrap the arm too tight­ly.

After the splint is applied you must check for Cir­cu­la­tion, Sen­sa­tion and Motion, CSM, and again every 20 min­utes for the first 4 hours then check hourly. I know that sounds extreme, but it is bet­ter to be extreme in this than for­get it or blow it off and your friend has a com­part­ment syn­drome and los­es his arm or the use of the arm. The risk for com­part­ment syn­drome is one of the rea­sons we do not gen­er­al­ly apply a cast in the ER any­more. Too many of them were applied incor­rect­ly result­ing in per­ma­nent dam­age and occa­sion­al­ly ampu­ta­tion.

A few types of splint­ing mate­r­i­al avail­able:

• Pre­cut fiber­glass which is avail­able in assort­ed widths and lengths. These are eas­i­ly formed around the limb and can be applied dry to allow air cur­ing which will take quite a while, or applied moist which will set up with­in a few min­utes.
• Pre­formed met­al are also avail­able which come in assort­ed sizes. For most peo­ple these would be imprac­ti­cal as there are so many and the left can­not be used on the right.
• SAM splints are quite inex­pen­sive and take up lit­tle space in your med­ical kit. They are also avail­able in var­i­ous sizes, are eas­i­ly applied and fit left or right.
• The old stand­by, twigs, branch­es, boards. All read­i­ly avail­able and eas­i­ly cut to size
• There are even card­board and plas­tic box splints avail­able.
• You could use pipe, met­al bar, essen­tial­ly any­thing that is straight or could be bent to accom­mo­date the bend of the elbow, wrist, or knee

Here are a few of the splints in my col­lec­tion. The splint­ing man­u­al is an excel­lent resource.

Just the oth­er day I read an arti­cle in the Jour­nal of the Amer­i­can Med­ical Asso­ci­a­tion, JAMA, about a lady in Haiti whose leg was shat­tered dur­ing the quake. Unfor­tu­nate­ly she had no splint­ing and the leg began to heal in the shape of an arc bow­ing out. By the time she was able to get to a doc­tor the dam­age was irrepara­ble giv­en the lim­it­ed resources of the area post-quake. A sim­ple splint, though not ide­al, would have helped her leg to heal in a straight line which would have pre­vent­ed this life­long defor­mi­ty and dis­abil­i­ty.

If you can­not get prop­er med­ical treat­ment, for what­ev­er rea­son, your best hope is the splint that is applied as soon as pos­si­ble after the injury.

A good wilder­ness first aid course will teach prop­er splint­ing tech­niques for a bad sit­u­a­tion.