Definitions: What are fractures, sprains, strains and dislocations?
A fracture is described as a break in the continuity of a bone; this can be the result of excessive force, repetitive load bearing activity (stress fracture) or abnormal bone structure (pathological fracture such as osteoporosis).1 A sprain is defined as a stretching or tearing of a ligament, a ligament is a fibrous attachment that joins bone to bone and stabilises a joint.2 A strain is a term used to describe the stretching and tearing of a muscle or tendon, a tendon being a fibrous continuation of the muscle that attaches muscle to bone and is essential for the leverage mechanisms of human movement.2
In a dislocation the bone is entirely displaced from the joint causing the articulating surfaces to no longer be intact. If the joint is only partially dislocated this is known as subluxation, this causes the articulating surfaces to only be in partial contact. In the event that the ligaments supporting a joint are disrupted causing an increased gap between the articulating surfaces, this is referred to as diastasis.3 It is important to note that these conditions may not be present in isolation, the forces required to cause one type of injury may well cause a further injury.
General principles of musculoskeletal injury management
In the prehospital setting there are five key elements that underpin the management of musculoskeletal injury:
- Reduce pain
- Prevent further injury
- Ensure neurological and vascular supply distal to the injury
- Reduce the risk of fat embolism
- Promote recovery.
Pain control
Pain control in the acute management of musculoskeletal injury may take many forms ranging from simple reassurance, immobilisation of the limb (discussed later), pharmacological management (see Chapter 15, Pain Assessment and management) and the use of cold compresses. The use of reassurance as a method of pain relief is not based upon evidence; however reassuring patients is undoubtedly a major facet in the role of any prehospital and acute care practitioner.
The use of cold treatment for musculoskeletal injury has long been documented as a method of reducing pain and swelling at the site of an injury. There is little high level evidence to support this notion; however the application of a cold compress to an area will reduce the blood flow by vasoconstriction thus reducing inflammatory mediators and inflammation. The reduction in local body temperature will also slow nerve conduction, thus inhibiting pain sensation experienced. Care should be taken if using a cold compress as this may cause thermal burns to the site of application.
Immobilisation of the limb
The immobilisation of an injured limb is based upon the principles of general musculoskeletal injury management stated previously in this chapter. Through the application of splinting there are a number of benefits to the patient that are based upon sound pathophysiological reasoning. Splinting is applied as a method of reducing the movement of broken bone ends and to support the fracture site. Through the movement of broken bone ends pain is commonly experienced alongside an increased risk of damage to nerves, blood vessels, muscles and overlying skin. This can potentiate the injury increasing both mortality and morbidity; therefore the reduction in movement of the injured limb can reduce this risk. Immobilisation may reduce the occurrence of bleeding through allowing the formation of clots in damaged blood vessels and reduce the likelihood of potentially fatal fat emboli.
The placing of a limb in a splint of any form should reduce the pain for the patient and increase their comfort, thus subsequently reducing anxiety and the circulation of catecholamines which may cause peripheral vasoconstriction and reduced peripheral tissue oxygenation.2,4
Principles of splinting
The principles of splinting are a core element for any prehospital care provider ranging from the first aider to the advanced trauma specialist. The failure to effectively splint a musculoskeletal injury may result in increased pain and further injury, alongside the potential for increased damage to the injured area due to improper handling. The following principles of splinting should be considered whenever splinting is required (see Procedure below).
| Procedure | Rationale |
| 1. The injured area should be carefully visualised prior to splinting the limb. | It is imperative that the practitioner is aware of what potential injuries are present. Foreign bodies within the wound or severe bleeding from an open fracture should be considered prior to splint application as they are difficult to manage after a splint is applied. |
| 2. Ensure that splinting is required. | Splinting as with all procedures is not without risk, the time taken to apply splinting may be detrimental in the multisystem trauma patient who requires rapid evacuation to an appropriate facility. The use of splints also limits the ability to visualise the patient, therefore the risks and benefits of splinting must be considered. |
| 3. Prior to splinting assess the neurovascular status distal to the site of the injury and repeat after splinting. | A pre- and post-treatment assessment should always be considered to ensure that no harm is caused by your actions. |
| 4. Manage wounds on the immobilized part prior to splinting. | Once the splint is applied it may be difficult to gain access to the wound to manage bleeding effectively. |
| 5. The splint should immobilise the joint above and below the suspected injury site. | This will reduce the movement of the limb or injured part. |
| 6. Pad the splint well. | This will reduce movement of the injured limb, increase comfort and reduce the likelihood of pressure injury. |
| 7. Support the injured part proximally and distal to the injury whilst applying the splint. | This will provide manual stabilisation of the injured part whilst the splint is applied, this will reduce the pain experienced during the procedure. |
| 8. If the injured limb is grossly deformed consider applying traction and straightening the limb. | This should only be considered if there is suspicion that the limb is being threatened by the injury. Signs include the loss of distal neurovascular supply and taut skin over the site of the suspected fracture (and suspicion that the bone fragment may pierce the skin).5 |
| 9. If it is not possible to straighten the limb to a near anatomical position, it should be splinted in the position of deformity. | Resistance or severe pain when attempting to re-align the limb should indicate that re-location is unlikely to be successful at that time therefore attempts should be ceased. |
| 10. Splint firmly but not too tight. | Excessive tension may inhibit distal blood flow thus potentiating injury. |
| 11. Try to avoid covering the finger or the toes of the patient when splinting (unless not feasible). | The fingers and toes are useful areas to check for distal neurovascular status following the application of a splint. |
Types of splinting
Any device that is utilised to immobilise an injury can be considered a splint. There are a variety of widely used splinting devices within emergency care settings; this chapter will discuss the most commonly used; providing guidance on the benefits and limitations of each.
Slings and support bandages
A sling is commonly used for the splinting of a shoulder or arm injury, they may be used in isolation or as an adjunct to support additional devices such as a rigid splint (discussed later). A sling formed from a triangular bandage holds the injured limb to the body and takes some of the weight from the injured limb, potentially reducing pain caused by limb movement. Slings should be avoided in patients with a neck injury due to additional pressure being placed upon the neck. There are commonly two applications of a sling to the upper extremity, a broad arm sling and a high arm sling (or elevated sling). These differ in application however provide similar benefits to the patient. A broad arm sling is most commonly used for injuries at the elbow or below, whereas a high arm sling is used for injuries above the elbow; however there is little evidence to support either technique over the other therefore a sling should be applied to the comfort of the patient. A step-by-step guide to the application of a broad arm sling technique and high arm sling technique can be seen below. With the application of a sling the support to the limb can be enhanced by the use of an additional support bandage around the torso. This will serve to further immobilise the limb and is particularly useful in shoulder dislocations and clavicle injuries.
The application of a broad arm sling
| Procedure | Rationale |
| 1. Gain informed consent and explain the procedure to the patient. Provide any required analgesia for the procedure to be undertaken. | A pain free and less anxious patient is easier to treat. Informed consent is essential in providing care for patients who are able to consent. |
| 2. Ensure that the triangular bandage is clean and in good condition prior to use. | To reduce the risk of cross infection and ensure that the sling will not fail resulting in pain. |
| 3. Lay the long side of the triangular bandage vertically down the uninjured side of the patient with the injured arm flexed at the elbow to 90° (if possible), the bandage should pass behind the injured arm (Figure 16.1). | A broad arm sling requires the injured arm to be flexed to approximately 90° for it to be effective, this will allow the arm to rest upon the sling. reducing pressure on the injury site. |
| 4. Bring the bottom edge up and over the arm. | This will cradle the injured arm within the sling. |
| 5. Tie the two ends together behind the patient’s neck using a simple reef knot. Consider applying a pad beneath the knot (Figure 16.2). Pin or tie the point at the elbow to form a cradle. | A reef knot allows the knot to be easily undone, padding beneath the knot may reduce pain from friction or pressure from the knot upon the neck. |
| 6. Re-check the distal neurovascular status of the limb. | This should be checked after any intervention to ensure that no harm is done. |
Figure 16.1 Broad arm sling step 1.
Figure 16.2 Broad arm sling step 2.
The application of a high arm sling
| Procedure | Rationale |
| 1. Gain informed consent and explain the procedure to the patient. Provide any required analgesia for the procedure to be undertaken. Ensure the triangular bandage is clean and undamaged. | A pain free and less anxious patient is easier to treat. Informed consent is essential in providing care for patients who are able to consent. All equipment should be checked to ensure it does not fail. |
| 2. Place the sling over the injured arm with the arm elevated towards the opposing shoulder. The longest side of the triangular bandage should run from the shoulder of the uninjured arm towards the elbow of the injured arm. | The sling must be carefully applied to ensure it works as an effective cradle for the injured limb. |
| 3. Pass the point of the longest side of the triangular bandage under the injured arm and behind the back of the patient. The end is then tied with the opposite end of the longest side behind the patient’s neck using a reef knot (Figure 16.3). Consider padding beneath the knot. | A reef knot allows the knot to be easily undone, padding beneath the knot may reduce pain from friction or pressure from the knot upon the neck. |
| 4. Ensure that the arm is comfortable and securely supported. Re-check the distal neurovascular status of the injured limb. | Always check that any interventions are effective, if not then re-consider your actions or remedy and problems. |
Box splints
Box splints are a commonly carried by emergency care personnel, yet are often overlooked due to the simplicity of their use and due to the favourability of other devices. A box splint is most commonly used for lower leg injuries; however they may be used for knee and arm injuries also. These splints consist of three long padded sides and a foot piece (Figure 16.4) which is designed to place the foot at a 90° angle (anatomical position).
The splint forms a ‘box’ around the injured limb with one side exposed to allow for ease of application and review of the limb once it has been splinted. Box splints are effective in immobilising a straight limb, especially when combined with additional padding. However box splints are of limited use in a deformed limb due to their rigid structure which will not conform to the shape of the limb. A step by step guide to using a box splint is shown below.
Figure 16.3 High arm sling step 2.
Figure 16.4 A box splint.
Application of a box splint
| Procedure | Rationale |
| 1. Gain informed consent and explain the procedure to the patient. Provide any required analgesia for the procedure to be undertaken. Ensure the equipment is clean and undamaged. | A pain free and less anxious patient is easier to treat. Informed consent is essential in providing care for patients who are able to consent. All equipment should be checked to ensure it does not fail or provide an infection risk. |
| 2. The injured limb (leg) should be exposed and footwear removed if possible. | This is desirable for both examination and post immobilisation checks. |
| 3. The leg should be supported manually and carefully raised, the splint should be passed under the leg. | Support is required to ensure that the injury is not worsened by the movement and also to reduce pain. |
| 4. The two sides of the splint should be folded up against the leg to form a box around the limb, the foot piece should be placed against the sole of the foot at 90° or in a position that is comfortable. | This will box in the leg and provide stability, it may be necessary to add additional padding at this point to support the limb. |
| 5. The Velcro straps should be carefully placed over the leg avoiding the area of injury, the foot strap should be passed over the top of the foot (Figure 16.5) | This provides firm support for the limb, passing the straps tightly over the injured area may worsen the pain or injury and should be avoided. |
| 6. Re-check the distal neurovascular status of the limb. | This should be checked after any intervention to ensure that no harm is done. |
Figure 16.5 Application of a box splint.
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