A Few Immobilization Footnotes

 

 
 
 

Jason Friesen, BA, NREMT-P | | Monday, July 27, 2009


It's 2 p.m. on a sunny Saturday afternoon when you're called to a reported auto-versus-motorcycle collision on a road known for its scenic, winding terrain. When you arrive on scene, you find one patient lying supine on the ground, 50 yards from his mangled motorcycle. He's responsive to voice but not answering appropriately, and as you work to take off his helmet, you notice significant damage to the helmet_s left and back surfaces, including multiple long, deep scratches and a single three-inch-wide puncture. The patient is unable to give you a chief complaint, but is breathing heavily and guarding, favoring his left arm, which has severe pain on palpation. His leather jacket is scuffed and torn across the entire left side, and the fire crew points out his left leg, which fits the description of a "grossly angulated fracture" better than any you have ever seen before.

This case demonstrates why splinting -- a skill that_s not performed very often -- can make or break your treatment of life-threatening injuries, and it emphasizes the need for frequent refresher training. There have been many in-depth articles inJEMSregarding the proper method and manner for splinting (see the end of this article for links), but here are a few helpful tips and insights to keep in mind if your splinting skills have slipped.

The Body Splint

Valuable time is often lost trying to properly fit a splint to a fractured/dislocated extremity when your patient is in need of more definitive therapy. Therefore, when you find it necessary to expedite transport, or you can't get the right fit, remember that the patient's body may already provide the most optimal splint. In the case of tib/fib fractures, it may be prudent to secure the affected extremity to an unaffected one. The same can go for upper extremity injuries: Instead of unnecessarily manipulating an injured limb or joint, secure the affected area to the torso in a position of comfort. As long as PMS is intact, the remaining goals of splinting are twofold: prevent further injury and provide comfort. If we can ensure those three things, the method by which we do them doesn't need to be debatedwhen more pressing issues are at hand. Remember, just as guarding is an instinctual method for self-preservation, so should we see securing an upper extremity injury to the torso as a natural means of preventing further injury, as well as providing additional psychological comfort.

Drop the Pelvic Rock:Pelvic fractures can be fatal. For that reason, there's no excuse for underestimating or overlooking them. However, the traditional technique we've been taught to check for pelvic instability -- the "Pelvic Rock" -- actually puts the patient at greater risk for increased morbidity and mortality. According to Prehospital Trauma Life Support, "Multiple small arteries and veins lie adjacent to the pelvis and may be torn by bone ends or as the sacroiliac joints fracture or open up. Overaggressive palpation or manipulation of the pelvis (pelvic rock) can significantly increase blood loss when an unstable pelvic fracture is present."[1] Therefore, it's suggested that you assess for pelvic instability by applying gentle pressure "anterior to posterior and from the sides." Although the effectiveness and utility of applying a PASG, or "pelvic binders," to stabilize pelvic fractures remains disputed, the use of a tightly wrapped towel or sheet around the injured area is a common and effective method of stabilization.

PHTLS further dictates that "the lower extremities should also be adducted and internally rotated and secured in that position." Likewise, when moving these patients, it's important to be mindful of the aforementioned potential for causing greater injury. Thus the optimal method for moving them is with a scoop, which allows them to be secured as they are found, without any excessive jostling; backboards force the patient to be log-rolled, risking unnecessary manipulation of the pelvis, while "sheeting," if possible, doesn't provide the needed stability.

Neighborhood of the Joints:Traction splints were devised to do just that: provide traction for long bone fractures. The clinical theory behind applying traction is multifaceted: realign and immobilize fractured femurs; control/reduce blood loss; and provide pain relief (by increasing pressure in the thigh and subsequently reducing swelling, controlling muscle spasm and immobilizing any sharp bone ends). However, it's important to recognize when a traction splint is indicated, and when applying one has the potential to cause more harm. It's essential, then, that we also pay special mind to the contraindications for applying a traction splint: suspected pelvic and hip fractures; avulsion/amputation of the ankle or foot; and fractures involving the knee.

In these instances, applying traction has the potential to cause significant secondary injuries. Unfortunately, it is not so cut and dry as a few simple contraindications. Often, it may be difficult to determine whether it's the femur or knee that's injured, depending on the extent of the injury. Likewise, some patients may not be able to describe where the pain is exactly, whether it's because they can't differentiate between the hip (or knee) and the femur, or because they aren't in a sound mental state to do so. For this reason, Manitoba Health (Canada) makes a distinction by including the following provision in their Emergency Treatment Guidelines: "For injuries within [0.5Ï2 inches] of a joint, forced application of traction device can cause increased pain and damage; if such an injury is present, do not use a traction device -- support in position of most comfort and best neurovascular care."[2] Although this exact measurement may not be supported by formal clinical evidence, its intention is right on point.

Infection Disconnection:Although open fractures aren't listed as a contraindication for applying a traction splint, there's ample reason why you would not want to apply one if the patient has sustained this type of injury. To begin with, in any open fracture, there's great risk for osteomyelitis, which is a serious complication consisting of infection of the bone or bone marrow. Treatment for this injury is protective (i.e., covering the exposed area with sterile dressing after carefully removing any "gross contamination").[3] Never try to reinsert a bone end back inside the extremity, not only because of the risk of infection, but also because of the danger of causing secondary injuries to arteries and/or veins from unstable, sharp bone ends. As recommended by PHTLS, "The prehospital care provider needs to consider any open wound near a possible fracture to be an open fracture and treat it as such."[1] In some cases, natural muscle spasm originating in the thigh may cause the bone to reinsert itself naturally. If this occurs, it's important to maintain stabilization of the affected extremity and report your findings to the hospital.

Please Don't Touch:Use of the traction splint is by no means incontestable; ample discussion regarding its effective use in the prehospital setting exists both for and against it. To begin with, traction splints come in different shapes and sizes, and each one has its own specific manufacturer's recommendations for safe and effective use. For example, the Sager splint has a recommendation of traction at 10% of the patient's body weight, up to a maximum of 15 lbs. One study from 2002, however, showed that, of 182 prehospital providers observed using traction splints, an average of two and a half times the recommended force was recorded, with a range of 3.5Ï111 lbs.[4] Additionally, we're also taught that it's necessary to straighten angulated fractures, especially when PMS is compromised, and that attempts to do so should be made until resistance is met, or until the patient complains of excessive pain. However, due to the potential for secondary injuries resulting from manipulation of the affected extremity, repositioning may not always be recommended.

Although the full extent of injuries sustained via the primary mechanism is nearly impossible to diagnose without radiological imaging, it may be possible that arterial circulation is only partially occluded, whereas manipulation of the extremity may induce a full severance of the artery. This is always a factor when dealing with lower extremity injuries with their proximity to the popliteal artery. A loss of distal circulation is undoubtedly a grave finding. However, it may not be immediately threatening to either life or limb. In fact, a 2001 article discussing the use of traction splints cites evidence that "the lower extremity can tolerate up to four to eight hours of diminished perfusion without detriment to outcome of injury."[5] For this reason, several factors should be taken into consideration when deciding whether or not attempts to reposition angulated fractures should be made, including mechanism of injury, onset and time of injury, patient and injury presentation, patient extrication issues, length of transport and available hospital resources.

References

  1. Salomone JP, Pons PT: PHTLS: Prehospital Trauma Life Support, 6th Edition. Mosby EMS. St. Louis, Mo., 2007.
  2. www.gov.mb.ca/health/ems/guidelines/etg.html
  3. Lee C, Porter KM: "Prehospital management of lower limb fractures." Emergency Medicine Journal. 22(9):600Ï663, 2005.
  4. Borschneck AG, Spotts C: "Traction force challenge." Emergency Medical Services Magazine. 31(5):72Ï74, 2002.
  5. Abarbanell NR: "Prehospital midthigh trauma and traction splint use: Recommendations for treatment protocols." American Journal of Emergency Medicine. 19(2):137Ï140, 2001.

Additional Resource

For more on immobilization, read"The Lost Art of Splinting"here.

Jason Friesen,BA, NREMT-P, spends his free time working to help develop EMS projects in underserved countries through his nonprofit Trek Medics International.He can be contacted viawww.trekmedics.org.




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