This article is a best practice guide on the safe and effective general use of splints in the prehospital environment. It is meant to be an informative guide for decision-making while allowing for critical thinking. As such, the guide should not be used as a rule book.
There are many different kinds and brands of splints; however, only commonly encountered splints will be discussed in this article. Methods of application and use of the different splints, as well as the decision-making required to choose the correct splint, will be discussed.
This will assist practitioners in providing patients with the best possible management when immobilising injuries. Please note that exceptional and unique cases will not be discussed in this article; this includes traction splints and pelvic splints.
What are splints?
A splint is a device that is used to support an injury that has caused a body part (normally an extremity) and the associated joints not to function in a normal manner; it achieves this by restraining, immobilising and/or supporting the injured body part (Farlex, 2012). The most relevant injuries requiring the use of splints are dislocations, fractures, severe sprains or strains and torn tendons or ligaments (Cuske, 2008).
Why do we use them?
A splint performs its function by acting as an artificial skeleton or bone structure that assists in supporting the weight of the injured limb, reducing the stress it is under. According to the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) (2016), it achieves a number of purposes which are vital for patient wellbeing. Splints can reduce pain, prevent further injury and help to maintain the condition of the limb. Correctly applied splints can also help to control haemorrhage (Caroline, 2014). When the limb is immobilised, the splint helps to minimise stressors on the injured part, which normally reduces pain and unintentional movement (Lee and Porter, 2005). Inadequate splinting or failure to apply a splint can have adverse consequences such as increased pain; further trauma (e.g. a closed fracture becoming an open fracture); haemorrhage; and potentially long-term damage affecting rehabilitation and recovery (Caroline, 2014).
Factors to consider
Determining whether a splint is required or not depends on several factors which can be obtained following a thorough assessment of the injured area. Information required includes:
Further examination to ascertain for additional fractures or injuries is also essential. If a person has suffered significant injury to a body part, which inhibits normal function or causes distress, a splint should be considered.
Splinting of a limb can impact the area quite significantly. According to International Trauma Life Support (Campbell, 2014), the positioning of the limb can either assist or hinder the patient's comfort and also the circulatory perfusion distal to the splint. When the injury is immobilised, it also becomes easier to move the patient (Lee and Porter, 2005).
Splints work to minimise movement and restrict abnormal movement, i.e. immobilisation, as the normal structures that should be in place to do this are either damaged or unable to perform this function (JRCALC, 2016). With most long bone fractures, this works by immobilising the joint distal and the joint proximal to the injury to allow these non-injured areas to serve as the support base for the injury (Campbell, 2014). The splint itself acts as the framework, permitting these other joints to extend their supportive function.
Some forms of splints
These classifications are generic as many new types of splints are becoming more versatile.
Board splints
Board (box) splints are among the most common types of splints found. They come in a variety of shapes and sizes to try to accommodate most generic limb injuries (Campbell, 2014) (Figure 1). They are formed from pre-cut material with specific fold/bend points to allow for splinting of arms, wrists, legs or ankles (SAM Medical, 2017). Depending on the type used, they may or may not come with additional padding; if there is none, it would be crucial to pad it yourself prior to application to prevent extra discomfort or pressure sores from developing (JRCALC, 2016).
Vacuum splints
Air/vacuum splints can be used for most applications (Figure 2). They have the advantage that they can conform to the shape of most injuries. This is beneficial if the limb is significantly out of normal positioning, although they are normally quite bulky and may be impractical (Campbell, 2014). A pump or suction unit is required to remove air from the splint once it is in place. These splints are susceptible to pressure changes—a noticeable concern if the patient were to go through altitude changes during transport (usually during helicopter-based evacuations).
Considerations for application
In all cases, a good safe approach is essential as fractures/dislocations generally require significant force to occur (Perdue, 2018). This may suggest a dangerous environment.
Assessment
It must first be ensured that the patient's airway, breathing and circulation are initially assessed and stable. Once you have identified a limb that potentially requires splinting due to injury, it is of utmost importance to expose the limb and assess it in full to evaluate the full extent of the injury (Lee and Porter, 2005; Cuske, 2008). This includes temperature; noticeable colour changes; swelling; abnormalities (compare to other side); and neurovascular status distal to the injury.
This normally falls under the 5 Ps assessment, which involves checking for the following (CNF Medical, 2015; Queensland Government, 2016):
Checking the Ps will allow the clinician to detect if there is any compromise in the perfusion and/or sensory/motor response in that area, which may be caused by compartment syndrome, potentially further complicating management (Gerakopoulos and Oleksak, 2012).
Management
In the case of a simple fracture, a distal pulse should be present. For these cases, try and splint the fracture in its current position. If a limb is in an abnormal position and a distal pulse is absent, manipulation of the limb may be required. This would entail moving the limb to its normal position with the aid of analgesia and sedation if possible (Campbell, 2014; JRCALC, 2016). Perfusion of the limb is of great importance because if there is no pulse, the extremity becomes a threatened limb, meaning the tissues will not have adequate perfusion and may lead to massive tissue death if perfusion cannot be restored (Gerakopoulos and Oleksak, 2012; Campbell, 2014).
At the point when it becomes evident that the limb needs to be manipulated, it is important to realise that all of these procedures are excruciatingly painful; hence analgesia and sedation are recommended (National Institute for Health and Care Excellence (NICE), 2016).
There is minimal evidence to support or refute these procedures prehospitally but a recommendation by Prehospital Trauma Life Support is to limit the attempts to a maximum of two (National Association of EMTs (NAEMT), 2003; Campbell, 2014). The practitioner's scope of practice and the severity of patient-reported pain score will determine which medications and doses are used. Some (not all) of the common prehospital medications that can be used for sedation and analgesia (individually or in conjunction with each other) are entonox, morphine sulphate, midazolam and ketamine (JRCALC, 2016). It is always wise and recommended to consult senior medical support if unsure.
It is important to note that in the case of open fractures, replacement of exposed bone ends should not be attempted. Depending on the splint used, it may need extra preparation; for instance, box splints need to be padded first and all equipment needs to be prepared prior to application (JRCALC, 2016). Splinting is ideally undertaken with at least two people to ensure that the limb is supported accordingly throughout, but certain instances may require more personnel depending on the extent, severity and location of the injury. An example of this would be if a radius/ulna fracture were to occur, the splint would need to extend from the wrist joint to, and including, the elbow. To protect the injured area while applying the splint, shared support and minimising of unintentional movement would be required.
Step-by-step application
This section assumes that patient contact has already been made, consent obtained, the injury identified and exposed, and any life-threatening injuries have either been treated or negated. If at any time, your life is at risk, the normal safety considerations would take place.
If for some reason the environment was hazardous and you were already with the patient, this could constitute a special circumstance. In such a scenario, you may need to remove the patient from the dangerous environment prior to splinting and/or analgesia—life over limb.
Summary
The splinting procedure is just as important as the preparation and post-care management. This ensures the best care for the patient and that the correct decisions are made before interacting with the patient. This also allows the procedure to run more smoothly and decrease the chances of negative side effects in the long term.