Splinting and Immobilization

The goal of splinting is to prevent motion at the injury site, which reduces pain, prevents the fracture ends from damaging nerves and blood vessels (neurovascular compromise), and prevents a closed fracture from becoming open (skin breaking). Proper immobilization also prevents fat embolism (fat from marrow entering the bloodstream), reduces swelling, and allows faster healing. The principle is simple: stabilize in the position found, do not try to straighten a limb unless there is neurovascular compromise distal to the fracture. Always assess distal pulse, color, temperature, and sensation before and after splinting to ensure you did not cut off circulation.

Method 1 (Padded Board Splint): Take a SAM Splint or cardboard splint 8–10 inches long, pad it with foam or a towel, position the forearm palm-down or palm-up on the splint (whatever position the patient prefers), secure the splint with elastic wrap around the wrist and forearm without cutting off circulation, then apply a sling around the neck to support the arm at heart level. Recheck distal pulse and cap refill. Method 2 (Pillow Splint): wrap a pillow around the wrist and forearm, secure with elastic wrap, and apply a sling. For a hand fracture, tape the injured finger to the next uninjured finger (buddy taping) after ensuring no circulation is cut off. Always tell the patient to elevate the hand above the heart to reduce swelling.

Suspect spine injury in any mechanism that could cause it: car crash, fall from height, diving into water, blunt head injury, or if the patient has neck pain or neurological signs (weakness, numbness, tingling in limbs). Apply a cervical collar if spine injury is suspected: choose the correct size (measure from the chin to the shoulder), place the collar around the neck, secure the Velcro, and keep the head in neutral alignment (do not flex or extend). Maintain spine precautions: log-roll the patient (six people, one person at the head guiding, roll patient and spine as a unit) onto a backboard, secure with straps at the chest, hips, and legs, and tape the forehead to the board. Remove the collar only after imaging (X-ray, CT) clears the spine, never before transport.

Femur fractures cause severe pain, swelling, and internal bleeding (can lose 1–2 liters of blood into the thigh). Traction splint immobilizes the fracture and pulls the thigh muscle to reduce bleeding. Steps: (1) Assess distal pulse and sensation. (2) Position the Hare or Sager traction splint along the uninjured leg to measure length (from the ASIS—anterior superior iliac spine—to 6 inches beyond the heel). (3) Slide the splint under the injured leg and secure the hip belt. (4) Apply a groin strap carefully (does not cause further injury or pain). (5) Gently apply traction at the ankle until pain decreases and the limb reaches the same length as the uninjured leg. (6) Wrap the ankle and foot with elastic wrap to secure. (7) Recheck distal pulse. Transport promptly; prolonged traction can cause pressure ulcers.

A pelvic binder is a wide belt or wrap that stabilizes the pelvis in a fracture, reducing internal bleeding and pain. The pelvis has large blood vessels (iliac vessels) and the marrow (which can cause fat embolism); instability worsens bleeding. Use a pelvic binder if there is pain with compression of the ASIS (anterior superior iliac spine points), pain with compression of the symphysis pubis, or if the mechanism suggests pelvic injury (crush injury, high-speed collision). Position the binder so it crosses the hip joints at the level of the ASIS, secure snugly (firm but not cutting off circulation), and ensure the patient can still breathe. Do not wrap around the abdomen (restricts breathing). Recheck distal pulses. Remove only after imaging (pelvic X-ray or CT) clears the fracture.

Signs of neurovascular compromise: absent distal pulse, pale or cyanotic (blue) skin, cold limb, pain out of proportion to the injury, numbness or tingling (paresthesias), or weakness. If you find these signs after splinting, remove the splint immediately and try to straighten the limb gently (passive extension) to restore circulation. Recheck the pulse; if it returns, the issue was too-tight splinting or positioning. If the pulse does not return after straightening, notify a provider or paramedic immediately—the patient may need urgent vascular surgery. Do not ignore these signs; neurovascular compromise can lead to tissue death (necrosis) and loss of the limb if not corrected within hours.

Shoulder dislocation (usually anterior): place the arm in a sling against the body, do not try to reduce (push back into joint) in the field—that causes more damage. Apply ice if available, keep the arm still, and transport to the ED. The provider will reduce it under sedation. Knee dislocation: immediately assess distal pulse and cap refill. If no pulse, gently straighten the knee to restore circulation, then splint. If pulse is present, splint the knee in the position found (usually flexed) with pillows or a padded splint; do not force straightening. Immobilize both the hip and ankle to prevent any motion. This is a limb-threatening injury; rapid transport is critical.