As with many of the emergency medical topics covered in this column, hands-on experience is the key to successfully managing an on-board problem. Handling orthopaedic trauma is an especially "tactile" situation and hopefully some images of splinting techniques will fill in the "thousand words" the pictures are reportedly worth.
A figure-8 splint CAN be used for a clavicular fracture, but I do not believe it is required. The clavicle, especially in younger patients, may fracture in a manner known as a "Greenstick". The bone will only partially "break"-much like the splintering of a young tree branch-hence the term "Greenstick". Immobilization of this fracture is difficult at best and, in most instances, unnecessary. The Figure-8 splint helps to limit the mobility of the AC (acromioclavicular) joint at the shoulder. This can also be accomplished with a simple sling. A swath can be added to further restrict movement.
Humerus (upper arm):Humeral fractures are frequently caused by an impact to the upper arm. As you recall, it is essential to immobilize the joint above AND below the injury, in this case, the shoulder and elbow. A sling and swath work well for this situation, but can also be augmented using a "Ladder splint". This splint is made of a malleable metal in a "ladder" construction. It can be molded to the required dimensions and then padded before being applied. This splint affords some rigidity, while still conforming to the angle of the elbow. After the splint is applied, the sling and swath offer additional immobilization. Another malleable quasi-rigid device is the SAM splint. This is more flexible than the ladder splint and therefore offers somewhat less rigidity but has the advantage of being easily molded to the desired configuration. Lastly, a full-arm air splint may be utilized, but this does nothing to limit shoulder movement and may prove to be impractical in the marine setting.
Radius/Ulna (forearm):A ladder splint or SAM splint can be readily adapted for immobilizing a forearm fracture as well. Also, because it is less problematic to secure both the wrist and elbow joints, other splints are equally useful. With the arm pronated (turned with the palm facing the ground) a board splint can be applied with a sling/swath utilized to limit movement. An air splint is also a bit more practical for this injury as it will not compromise the ability to use the sling/swath. It is because of the rotational component of the forearm that it is essential to maintain immobilization of both the wrist and elbow.
The wrist and hand can be immobilized in a similar fashion to the forearm with one distinct addition. The hand MUST be splinted in the position-of-function.The anatomy and structural interdependence of the bones, muscles, tendons, nerves and vascular bed of the hand is one of the most intricate arrangements of the human body. We take for granted all of these complex movements on a daily basis but try to imagine the loss of hand function, particularly that of a dominant hand. Try to go one hour in your daily life without the use of your dominant hand! Loss of hand function is extremely debilitating and all efforts to preserve this function should be undertaken. The hand should be placed as if it were holding a baseball with the fingers flexed around the object and the thumb and index fingers nearly touching. This is the same position the hand will adopt while at rest. "Fluffy" padding (a large roll of gauze as shown or a rolled-up washcloth will do) is placed in the palm before splint application. The splint is applied with particular attention to the neurovascular status of the fingers. As with ALL splint applications, the blood supply and sensory capabilities must be assessed distal to the injury both BEFORE and AFTER splinting (see Orthopaedic Injuries Part II for more details).
Phalanges (fingers/digits):The "position-of-function" idea carries on to the fingers. Clearly, a straight, rigid splint will not allow for the "natural" position of the fingers. I have frequently seen a tongue depressor and tape used to splint a digit but this is an unacceptable solution for orthopaedic recovery. The best device is a pre-padded, malleable aluminum splint that can be cut to length and secured in the position of function. This will offer both support and protection for the finger. Unfortunately, this is not a standard material in medical kits, and the simple alternative is a simple "buddy" splint. This consists of taping the injured finger to an adjacent uninjured finger. This technique will maintain a modicum of natural positioning and will allow for some early movement (as pain allows) which is an important component for complete recovery.
A few specific injuries warrant special comment.
Scapular Fracture (Shoulder Blade):
Fracture of a shoulder blade will present with the usual signs of any fractured bone: pain, swelling, ecchymosis (bruising) and occasionally some deformity. Scapular fractures are rare and their importance is not the fracture itself, but rather the high potential for associated injuries. Considering the location of the scapulae, the intrinsic strength of a large, flat bone and the considerable protection offered by the overlying muscles and tissue, it is clear that a significant force must be imparted to fracture this structure. Given this sizeable mechanism of injury, there is increased likelihood that other, more serious, injuries are present. Adjacent structures such as cervical and thoracic vertebrae, spinal cord, posterior ribs and lung are all at risk for sustaining critical injuries. At the risk of boring you with repetition, return to the ABCs! A broken neck or collapsed lung will certainly take precedence of a fractured shoulder blade. Treatment of a scapular fracture can be adequately accomplished with a sling and swath, but given the preceding discussion, complete spinal immobilization would be appropriate. (Back injuries will be covered in a future article).
Fractures of the Distal Humerus:
Another special upper extremity injury is a fracture of the distal humerus also known as a "supracondylar fracture" (this is the portion of the arm just above the elbow). These fractures occur most commonly in children under 11 years of age. The mechanism is that of falling on to an outstretched hand with the arm fully extended. Because some bones have not reached full maturity (ossification) in the pre-pubescent years, they are somewhat more prone to fracture when subjected to these stresses. Because of the location of this fracture and the subsequent misalignment of the bone ends, there is an increased likelihood that there will be compression of both arterial and nervous structures. Specifically, pressure on the brachial artery may compromise blood flow to the forearm/hand and compression of the radial nerve may result in "wrist drop" (the inability to dorsiflex the hand). Additionally, prolonged compromise to the vascular bed can lead to Volkmann's Contracture. This consists of degeneration, contracture, fibrosis and atrophy of muscle secondary to vascular damage.
Assessment is the same as for any other orthopaedic injury. The elbow will be very swollen and painful with some deformity noted. The neurovascular assessment is VERY important and, if compromised, immediate medical attention should be sought. As with any suspected fracture to a joint, the extremity should be splinted in the position found. However, if there is clear evidence of neurovascular damage, cautious realignment should be attempted. If any resistance is met or there is a marked increase in pain, the attempt should be aborted and the splint applied. A Ladder or SAM splint would work well in this setting as they can be molded to the desired position. A sling and swath will further aid in immobilization.
Be sure to look for the next section of Splint Hints for the lower extremities and keep checking in to SailNet.com!
The author would like to thank students from the Williamsport Hospital Paramedic Training Institute for their help with the photos shown on this page.