Musculoskeletal Trauma and Splinting

Musculoskeletal Trauma and Splinting

Musculoskeletal injuries — fractures, dislocations, and soft-tissue damage — are among the most common traumatic emergencies you will encounter. Your primary goals are to prevent further injury, reduce pain, protect neurovascular structures, and prepare the patient for transport. Splinting is the chief tool for meeting those goals.

Classifying Musculoskeletal Injuries

Fractures are classified as closed (skin intact over the break) or open (bone or fracture hematoma communicates with the outside environment through a wound). Open fractures carry a high risk of infection and hemorrhage and require special handling. Fractures are also described by their mechanism and pattern (transverse, oblique, comminuted, and so on), though definitive classification belongs to the receiving facility.

Dislocations occur when joint surfaces lose normal contact. Common sites include the shoulder, elbow, hip, knee, and ankle. Never attempt to reduce a dislocation in the field unless your medical director has specifically authorized and trained you to do so. Immobilize the joint in the position found.

Recognizing the Injury

Signs and symptoms of a fracture or dislocation include:

• Deformity — angulation, rotation, or shortening of a limb
• Pain and tenderness — especially with palpation at the site
• Swelling and ecchymosis — from bleeding into surrounding tissue
• Crepitus — a grating sensation felt or heard with movement; do not purposely elicit it
• Loss of normal motion — or abnormal motion at a normally rigid site
• Neurovascular compromise — diminished pulse, capillary refill, sensation, or motor function distal to the injury

Always perform a neurovascular check — pulse, motor function, and sensation (PMS) distal to the injury — before and after every splinting intervention. Document both sets of findings on the PCR. A change in neurovascular status after splinting requires immediate reassessment and possible repositioning.

The Six Rights of Splinting

Regardless of splint type, every application follows the same core principles:

1. Above and below the fracture — the splint must immobilize the joint above and the joint below the suspected fracture site.

2. Neurovascular check before — assess PMS distally before touching the injury further.

3. Padding — pad bony prominences and voids to prevent pressure injury and maintain comfort.

4. Position of function — splint the extremity in the anatomical position of function where possible (slight wrist extension, fingers slightly curled). For dislocations, splint in the position found.

5. Immobilization — secure the splint firmly enough to prevent movement but not so tightly as to impair circulation; check that bandages allow one finger to slide underneath.

6. Neurovascular check after — reassess PMS distally immediately after application and again during transport.

Types of Splints

Rigid splints (SAM splints, cardboard, wood) are shaped and applied to the outside of the limb. They work well for forearm, wrist, lower-leg, and ankle injuries. Mold the splint before applying it, add padding, and secure with roller bandages.

Traction splints (Hare, Sager, and similar devices) are indicated for isolated mid-shaft femur fractures in patients without hip, knee, or ankle injury on the affected side. Traction counteracts powerful thigh muscle spasm, reduces pain, and limits internal hemorrhage. Contraindications include fractures at or near the knee or hip, avulsion or amputation of the foot or ankle, and pelvis fractures. Apply mechanical traction according to the device manufacturer's instructions and your local protocol, and verify distal PMS before and after.

Soft/pillow splints are well suited for ankle and foot injuries. Wrap the foot and ankle in a pillow or blanket and bandage in place. They conform to the injury and provide gentle, even padding.

Improvised splints — padded boards, magazines, or other rigid objects — are acceptable when commercial splints are unavailable. The same six-rights principles apply.

Open Fracture Management

For open fractures, control bleeding with direct pressure, then cover the wound with a moist (wet) sterile dressing before splinting to prevent desiccation of exposed tissue. Do not attempt to push bone ends back into the wound. Splint as you would a closed fracture, noting wound status on the PCR.

Shoulder Dislocation

Immobilize the shoulder in the position found using a sling and swathe or padding. Apply padding in the void between the arm and the chest wall to support the limb without forcing movement. Do not attempt reduction.

Prioritizing Multiple Injuries

When a patient has more than one musculoskeletal injury, address life threats first (airway, breathing, circulation). Then prioritize splinting by severity: a suspected femur fracture (significant hemorrhage risk) takes precedence over a forearm fracture. Open wounds requiring dressing should be managed before or during splinting of the affected extremity. Document all findings and interventions in chronological order on the PCR.

Safety Points

• Never apply a traction splint when contraindications are present; doing so can worsen a hip or knee injury.
• Check bandage tightness frequently; swelling can convert a comfortable wrap into a tourniquet.
• Any deterioration in distal PMS after splinting is a critical finding — loosen and reassess immediately.
• Reassess all splinted extremities every five minutes in the unstable patient and every fifteen minutes in the stable patient during transport.