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[EMERGENCIES]

Field Splinting of Suspected Fractures: Preparation, Assessment, and Application

Randall M. Meredith, MD; Janus D. Butcher, MD

Emergencies Series Editor: Warren B. Howe, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 10 - OCTOBER 97


In Brief: Serious sports-related extremity injuries require a careful initial evaluation and subsequent protection of the extremity. After ruling out life-threatening injury and assessing neurovascular status, the examiner must decide whether a splint is required. The on-site physician needs to know which of a wide variety of preformed splints and splinting materials are best for the most common upper- and lower-extremity injuries. Appropriate padding, fit, and materials ensure optimal protection.

Initial on-site management of serious musculoskeletal injuries can pose a number of diagnostic and treatment challenges for the team physician. The main concerns in evaluating acute extremity injuries are to (1) determine the type and severity of injury (severe sprains, which may be difficult to differentiate from fractures, receive similar initial treatment), (2) assess the distal neurologic and vascular status, (3) determine the need for radiographic imaging and specialty treatment, and (4) select appropriate splinting for immediate protection.

The decision to order diagnostic imaging can be particularly problematic. Except for newer professional and a few college stadiums, radiographic equipment will not be available on site. The team physician must either send the athlete to a local facility for x-rays or splint the injury and allow the athlete to see his or her regular provider or hospital for further evaluation. If splinting is necessary, the physician must decide which prefabricated or custom-constructed splint to use.

Supplies and Preparation

[FIGURE 1]

It would be nearly impossible to maintain preformed splints for all potential injuries on the sideline, but a few simple supplies taken to the field will suffice for most musculoskeletal injuries (figure 1). The supplies should be chosen to fit the activity and risks involved. Many of the available preformed splints and splinting supplies are pictured in figures 2 and 3.

[FIGURE 2]

The event physician should also keep in mind that the supporting emergency medical services (EMS) vehicle will have splinting resources to augment the physician's supplies for more severe injuries (figure 4). The event physician should discuss the available equipment with the EMS personnel prior to the start of play. In addition, more comprehensive splinting supplies can be kept in the training room or coach's office, including casting materials and a broader range of preformed splints.

[FIGURE 3]

On-Field Assessment

Whenever an athlete is injured, the physician must first assess for associated injuries to the cervical spine and head. This is particularly true in high-speed sports such as cycling and equestrian events. After such serious injuries are ruled out, the injured extremity should be quickly evaluated on the field and protected during transport to the sidelines or medical station for complete evaluation. In serious injuries, the limb should be protected with an appropriate splint while the athlete is being removed from the field on a stretcher or cart.

[FIGURE 4]

Evaluation of the injured extremity is usually complicated by protective equipment, such as clothing, padding, or tape, which must be removed to allow complete visualization of the injury. In addition, the athlete will often minimize the injury in an attempt to return to play.

The team physician must consider the mechanism of injury and hazards of the sport to determine the extent of evaluation needed. If there is limb deformity, crepitation, ecchymosis, or swelling, the need for radiographs may be obvious. Other clues include pain with weight bearing, pain with joint manipulation distal and proximal to the injury, pain or abnormal bone motion with applied stress, and bruising distal to the injury site. In addition, any defect in the overlying skin may signal an open fracture, which may require urgent orthopedic referral (1).

The neurologic and vascular status distal to the site of the injury must always be assessed. Assessment of neurologic status should include both motor and sensory components. Motor function is evaluated by observing the range of motion in joints or digits distal to the injury. Sensory examination should include light touch and two-point discrimination when appropriate.

Vascular status of the injured limb is assessed by palpating pulses distal to the injury. In patients who have substantial swelling, this may require a Doppler device. Capillary refill time can also indicate vascular status. This is measured by elevating the limb above the level of the heart (when possible) and compressing the nail bed to empty the capillaries. Capillary refill time greater than 2 seconds may indicate vascular injury.

Vascular injury occurs most commonly with displaced fractures of the long bones. On-field reduction should be attempted only if vascular compromise is suspected. Reduction is usually accomplished by applying gentle in-line traction to the distal fracture segment while stabilizing the proximal segment.

Splinting Principles

Several principles apply in splinting. Splints should be well padded to avoid damage to skin and superficial tissues. This is often accomplished by wrapping elastic bandages around the splint material or by using a soft material such as a cotton prewrap to cover the injured limb.

When possible, the joints above and below the injury should be immobilized with the splint. Elastic bandages are generally used to apply the splint. Care must be taken to avoid applying these dressings too tightly and thus impairing distal perfusion. The treating provider must reassess the neurovascular status after applying the splint and periodically while awaiting definitive care.

Keep in mind that improvisation is often necessary. For example, if no appropriate splinting material is readily available, a lower-leg injury can often be protected by "buddy taping" the leg to the uninjured leg. Similarly, an injured finger can be secured to the adjacent finger for temporary protection. Splints can be fashioned from a wide variety of materials, including the athlete's equipment, coach's supplies, or forest debris (in cross-country events).

An ice bag can be incorporated into the splint by wrapping it in the elastic bandage. Care must be taken to remove the ice periodically to avoid cold injury to soft tissue. In general, the ice should be applied for no more than 10 minutes at a time. The injured extremity should also be elevated to minimize swelling.

Injury-Specific Splints

The following splints for commonly seen fractures are intended to protect a suspected fracture during transport for radiographs and while awaiting definitive treatment. They may also be used for short-term immobilization of serious soft-tissue injuries before bracing and rehabilitation.

Femoral shaft. These injuries are rare in team sports but are seen in high-velocity activities such as skiing, cycling, and equestrian sports (2,3). Because of the potential for severe vascular injury and the loss of substantial amounts of blood, femoral shaft fractures can represent a true emergency. EMS personnel usually have a traction splint in their vehicle that can be applied. Otherwise, a long back board or long rigid splint will serve to stabilize the injury for transport. Athletes who have a suspected femur fracture should be transported as soon as possible for further evaluation and treatment.

Tibial and fibular shaft. Fractures of the lower leg usually follow a direct blow. Typically these injuries involve ecchymosis, swelling, and tenderness over the fracture site and pain with weight-bearing activities. Suspected lower-leg fractures should be immobilized using a plaster, metal, or wire posterior splint or foam leg splint. Radiographs should be obtained in all suspected fractures of the lower leg.

Ankle. In serious ankle injuries, the mechanism of injury provides substantial clues to the presence and location of a fracture. Inversion (adduction) injuries commonly result in damage to the lateral ligaments, or they can lead to an avulsion fracture of the distal fibula. With eversion (lateral rotation and abduction) injuries, the talus acts as a wedge between the tibia and fibula, resulting in injury to the deltoid ligament, syndesmosis, and, frequently, the proximal fibula (Maisonneuve fracture). The medial malleolus may also be fractured with an eversion injury. The more severe trimalleolar fracture usually occurs with axial loading, as in jumping from a height.

Evaluation of the acutely injured ankle should include palpation of the proximal fibula, particularly with eversion injuries. While debate continues regarding radiographic evaluation of the acutely injured ankle, all but the most mild ankle sprains probably warrant x-rays.

Severe acute ankle injuries should be protected initially with a posterior splint (figure 5a). In a grade 1 or 2 sprain, this splint should be replaced with a functional brace to allow early rehabilitation. If a serious fracture is suspected, an "L and U" (sugar tong) splint (figure 5b) can be applied for transport to the hospital.

[FIGURE 5]

Foot and toe. Fractures of the hindfoot and midfoot include calcaneal, talar, and metatarsal fractures. These injuries are usually splinted using a posterior "L" splint, and the athlete does not bear weight until the evaluation is complete. Nondisplaced fractures of the phalanges can be splinted with "buddy taping" and placing the athlete in a rigid shoe for comfort.

Elbow. Fractures of the elbow commonly result from a fall on an outstretched hand with the elbow in extension. These fractures range from the relatively minor radial head fracture to the supracondylar fracture-dislocation, which requires urgent orthopedic referral.

In general, suspected fractures of the elbow can be splinted in a posterior elbow splint in 20° to 30° of flexion (4). Alternatively, radial and ulnar straight splints can be applied with elastic bandages. The injured arm is then placed in a sling for comfort until radiographs are obtained.

Forearm and wrist. Shaft fractures of the long bones of the forearm are prone to severe displacement. Thus, all suspected forearm and wrist fractures must be radiographed. The forearm and wrist can be immobilized using a preformed rigid wrist splint, or by constructing an ulnar or radial gutter splint from available casting material (figure 6a).

[FIGURE 6]

Scaphoid fractures account for about 70% of all carpal fractures (5). These injuries are common in many sports, with a reported incidence of 1 injury per 100 college football players per year (6). The typical mechanism for this fracture involves falling on an outstretched hand, and a common complaint is pain and tenderness in the anatomic "snuff box." These injuries can be particularly problematic because initial radiographs are frequently negative, and failure to immobilize early in the course can result in nonunion or avascular necrosis.

When a scaphoid fracture is suspected, the wrist should be immobilized in a thumb spica splint (figure 6b). If initial radiographs are negative but the index of suspicion is high, immobilization should continue (preferably in a short arm cast) and a second radiograph obtained in 10 to 14 days.

Hand and finger. Metacarpal fractures commonly occur in contact sports. A number of manufactured splints can help immobilize these injuries (figures 2b and 6). Alternatively, an ulnar gutter splint (figure 6a) can be constructed using plaster or fiberglass.

Phalangeal fractures occur frequently in ball and contact sports. Care must be taken in the evaluation of these injuries because of the high incidence of associated tendon and ligament injuries (7). Splinting options for these fractures include preformed plastic orthoses, aluminum and foam moldable splints, and rigid metal immobilizers (figure 2b). Alternatively, the finger can be immobilized by "buddy taping" it to the adjacent finger until the evaluation is complete.

Honing Splinting Skills

After the usual initial assessment of a serious musculoskeletal injury, sports medicine physicians can use splints to protect the injured part while transporting the athlete off the field or for short-term immobilization of serious soft-tissue injuries. Because these situations are so common in sports, it behooves physicians to know proper splint principles, application, and preparation.

References

  1. Bach BR: Acute knee injuries: when to refer. Phys Sportsmed 1997;25(5):39-50
  2. Nelson DE, Rivara FP, Condie C, et al: Injuries in equestrian sports. Phys Sportsmed 1994;22(10):53-60
  3. Frost A, Bauer M: Skier's hip: a new clinical entity? proximal femur fractures sustained in cross-country skiing. J Orthop Trauma 1991;5(1):47-50
  4. Townsend DJ, Bassett GS: Common elbow fractures in children. Am Fam Physician 1996;53(6):2031-2041
  5. Rettig AC, Patel DV: Epidemiology of elbow, forearm, and wrist injuries in the athlete. Clin Sports Med 1995;14(2):289-297
  6. Riester JN, Baker BE, Mosher JF, et al: A review of scaphoid fracture healing in competitive athletes. Am J Sports Med 1985;13(3):159-161
  7. Bowman SH, Simon RR: Metacarpal and phalangeal fractures. Emerg Med Clin North Am 1993;11(3):671-702

Dr Meredith is a flight surgeon at McDonald Army Community Hospital at Ft Eustis, Virginia. Dr Butcher is the director of primary care sports medicine in the Department of Family Medicine at D. D. Eisenhower Army Medical Center in Augusta, Georgia. Dr Howe is a team physician at Western Washington University in Bellingham, Washington, and an editorial board member of The Physician and Sportsmedicine. Address correspondence to Janus D. Butcher, MD, Dept of Family Practice, D. D. Eisenhower Army Medical Center, Ft Gordon, GA 30905.


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