It’s been 34 years since I got an EMT certificate. Since EMTs made minimum wage, I never used it. So I’ve forgotten pretty much everything over the years.
Let’s say you’re on a hike and come upon someone with a broken arm or leg. It needs to be immobilised. You happen to have a wire splint in your first aid kit (you’re a well-prepared hiker and always carry a well-supplied first aid kit), or else there is something else that can be used as a splint. Do you straighten the broken limb and splint it that way? Or do you splint it in its existing position?
Ferreals? I could flip McBurgers or drive an ambulance for the same paycheck?
When my brother wrecked his motorcycle he landed with his left heal at his left ear thanks to open fractures at the femur and tib/fib. His leg was basically a noodle (he got better). To transport him the EMTs unceremoniously straightened it out and got him on the board, and into the meat wagon. He didn’t seem to enjoy the process but it was clear there was no non-hurty alternative, and causing further injury did not appear to be much of a concern. Based on that it would make sense to apply the same logic in a wilderness injury situation: do what needs to be done to immobilize the injury and bug out ASAP.
I’ve never heard of a wire splint, but if you’re out in the woods, my Boy Scout training would tell me to find a relatively straight tree branch and use something (rope, torn t-shirt etc) to tie it above and below the knee. Even a tent pole would work, depending on the type and how the person is being transported.
In my Wilderness First Aid courses we’ve been told to immobilize in place unless you need to relocate the limb. Now, in the backcountry there can be many reasons to relocate an fractured limb. In particular a femur fracture may require traction, but once traction is put in place you must keep traction until handed off to definitive care.
For an arm, just splint in place unless there are blood flow or serious pain issues that require you to align. The same is probably true of a tib/fib fracture, since the patient isn’t getting out on their own anyway.
In the backcountry you assume you’re going to be providing care for at least an hour without help. Making the patient comfortable will make that process easier, so if re-aligning a fractured limb makes the patient more comfortable you do so. If you risk causing more tearing damage from the jagged bone end, you don’t.
I’d always thought that you were supposed to straighten the limb and splint it. But my dim memory of my training is what Telemark said: immobilise in place. Hence my confusion.
Fortunately there’s a fire station two or three miles from where I walk, so I’m unlikely to need the knowledge. But you never know…
If you are close to definitive medical attention, that is, a place with a doctor and X-rays, you should probably just splint it and get help. It gets trickier if the limb is discoloured or there is exposed bone.
A doctor would feel for pulses and do other tests to check blood flow. You can make sure the nerves are intact by checking individual nerve sensation on dermatomes on the limb and hands/feet, and motor sensation by reflexes and specific movements.
If there is an obvious deformity a quick pull on the distal limb may make sense. This might be painful.
It wasn’t much better when I got mine about five years ago (and let it lapse, same story.)
That looks more useful than a SAM splint, lighter too.
From my NOLS Wilderness Medicine Handbook (2016 edition), “if necessary (compromised CSM (circulation, sensation or motion) or angulated), use gentle traction in line (TIL) to establish normal anatomical position. Slow or discontinue if pain increases significantly or you meet resistance.” (Caveat: there are additional checks and qualifications in the book; this is just one small part quoted for this discussion.)
That said, I don’t see myself being in a position where I would apply traction, and I am very much not recommending it here. My EMT training taught us to splint in position. I think that the difference is that in a wilderness setting, the evacuation may be longer and more involved and the patient may have fewer complications and more comfort after reduction. In a non-wilderness setting (or close to the trailhead) it may be better to just rush the patient to an orthopedic surgeon.
Honestly, it seems that very few people get more than a few hours from a trauma center these days. If I was on a day hike and ran into someone with a broken limb, my priority would be on calling it in.
I worked in an ER for nine years that was pretty close to several ski hills. I saw most of the possible fractures. We were expected to fix most fractures in our small ER. The orthopaedic surgeons in Canada often don’t want to see anything (urgently) that doesn’t need to go to the OR. The books by McRae are the best for explaining treatment of complex fractures.
A given bone will fracture in different common ways, which might be treated very differently. It isn’t hard to apply in line traction. You need to do it if the nerves or blood supply is compromised and not close to medical attention, but since not everyone knows how to check this, I don’t want to offer specific advice — splinting in position is safer if there is no neurovascular compromise. You need to hold the proximal (closer to the trunk) limb still while you yank on the limb distal to the break. In the wilderness, pull hard and very quickly. Some breaks are not stable and will not stay reduced if you pull on them. Dislocated fingers are easy to reduce and pain is relieved quickly. Dislocated hips and ankles are much harder and less stable.
The idea behind splinting is first to reduce the pain of broken bones moving. For that reason, splinting alone is almost always sufficient and the right thing to do. Upper extremities almost always benefit from a sling. Ankles and knees are less painful with a wrap.
The exception is when circulation or nerves are compromised. The way to check, as mentioned by cornflakes, is to examine the extremity distal to the injury. You are looking for intact CMS or color (sometimes circulation), motion and sensitivity. If someone has injured his forearm, look at his hand. Is it pink, does he have some movement, can he feel you touching it?
Fortunately, most injuries do not result in compromised circulation. Applying traction correctly and without causing additional injury is a not easy in the field unless you have experience. If at all possible, just splint and get to help.
When I first started taking WFA training nearly 30 years ago we were taught how to apply traction for a broken femur, which is often a life threatening injury due to possible torn femoral artery. But they’ve dropped that from the instruction because:
[ol]
[li]It’s difficult for people with minimal training to do right[/li][li]Broken femurs are pretty rare in the backcountry (except in a few situations like rock climbing and skiing)[/li][li]Once leg traction is applied you must maintain it until hand off to definitive care[/li][li]It’s just as easy to do damage as is to help[/li][/ol]
We are still taught about fingers and arms, checking for circulation or other indicators that would require something more than splinting in place.
Obviously, neck and back is a whole different story.
The older way of splinting, using branches or rods to immobilize the damaged limb, is now discouraged owing to the discomfort and fact that using rigid splinting material can often cause secondary contusions and ulceration. The recommended practice (learned from a NOLS Wilderness First Responder course I took a couple of years ago and consisting with Red Cross and other first aid standards) is to use soft material to pad the damaged limb and then envelope that with a more rigid material such as a SAM splint or sleeping pad that will produce even pressure and prevent the limb from moving in any direction. A plastic framesheet from a backpack actually works quite well, and several examples showed the entire backpack being used around a leg fracture, with the leg going through the top opening and then through the sleeping bag compartment and the bag being stuffed with clothing and then cinched tight. Spints and other slings or bandages should always be made and tied such that they are adjustable for comfort and inspection of the damage.
Reduction of fractures in the field is generally not recommended unless the patient cannot be evacuated for days or weeks where the bone could start to set. As noted, a broken femur has to remain in traction because the natural contraction of the quadracepts will pull any set out of alignment. Reduction of dislocations is recommended for comfort and because such an injury can often be made useable and reduce the potential for further injury.
Blunt force injuries to the head, neck, and back or a hard fall require a focused spinal assessment before moving, and if the patient is not “alert and reliable” (e.g. sober and has a Level of Reponsiveness > A+Ox2) should be immobilized and evacuated using a vacuum spine board or a padded backboard and cervical collar.
I know the question is about splints, but the first priority is to make sure that the victim is breathing and not about to bleed to death. I was taught that binding the legs together is a good method of restraining a fracture. This works very well for fingers too.
Technically the first step of the assessment is to size up the scene for hazards to the first responders, try to identify a mechanism of injury (MOI), and apply body substance isolation (BSI, gloves, eye protection, and other protection available and necessary), and then check airway, breathing, and circulation (ABC) and apply critical care as necessary to treat these problems. Once those are verified, then the responder makes a decision about what appears to be the most critical injury and expose the wound site(s). After that you take vitals, perform a heat to toe exam, and take medical history in whatever order makes the most sense to the responder. Then the responder starts non-critical patient care, e.g. splinting a break.
I would not recommend splinting legs together unless both are broken or there is a pelvic fracture because of the difficulty in going to the bathroom without futher manipulating the injured limb. This is obviously not such an issue for fingers (or toes) but you should be careful about binding limbs together and potentially creating infection sides due to ulceration or blisters.
As long as there’s still PMS (pulse-movement-sensation), you splint in the position you found it in. If PMS is missing, that’ll depend on your local protocols. In the last county where I volunteered, you were supposed to make one attempt at realignment, but if you couldn’t get the pulse back the first time, then you stopped trying and splinted in the position it was in. In the county I currently volunteer in, if you don’t have PMS then you call med control.
(Now they’re referring to it as CSM instead of PMS, as **cornflakes **mentioned upthread, but you tell me which mnemonic device is easier to remember.)
