Assessing Musculoskeletal Injuries
Musculoskeletal injuries are extremely common in EMS, resulting from falls, sports injuries, motor vehicle collisions, and industrial accidents. While isolated musculoskeletal injuries are rarely life-threatening (with the exception of femur fractures and pelvic fractures, which can cause significant hemorrhage), they cause substantial pain and disability. Proper assessment and splinting reduce pain, prevent further injury, and facilitate safe transport.
Assessment of musculoskeletal injuries uses the "6 Ps": Pain (is there pain at the injury site?), Pallor (is the skin distal to the injury pale?), Paresthesia (does the patient report numbness or tingling?), Paralysis (can the patient move the extremity?), Pressure (is there swelling or a feeling of tightness?), and Pulses (are distal pulses present?). Always assess and document circulation, sensation, and motor function (CSM) distal to the injury before and after splinting.
Splinting Principles
Effective splinting follows several key principles:
- Splint in the position found: Unless there is a neurovascular compromise (absent distal pulses or severe pallor), splint the extremity in the position in which you find it. Attempting to straighten angulated fractures can cause additional injury to blood vessels and nerves.
- Immobilize the joint above and below: For long bone fractures, the splint must extend beyond the joints above and below the fracture site. For joint injuries, immobilize the bones above and below the joint.
- Pad the splint: Place padding between the splint and the extremity to prevent pressure injuries, especially at bony prominences like the ankle, elbow, and wrist.
- Check CSM before and after: Always document distal circulation, sensation, and motor function before applying the splint and reassess after application. If CSM deteriorates after splinting, loosen or adjust the splint.
Splint Types and Applications
Several splinting devices are available in EMS:
- Rigid splints: Board splints and SAM splints (moldable aluminum foam splints) that can be shaped to fit various extremity positions. Best for forearm, wrist, lower leg, and ankle injuries.
- Traction splints: Specifically designed for isolated mid-shaft femur fractures. Apply mechanical traction to realign the bone and reduce pain and internal bleeding. Contraindicated in hip or knee injuries, pelvic fractures, and partial amputations.
- Vacuum splints: Conform to the extremity shape and become rigid when air is removed. Excellent for angular fractures where repositioning is not appropriate.
- Sling and swathe: Used for shoulder and clavicle injuries. The sling supports the arm while the swathe secures the arm against the body.
Special Considerations
Open fractures (where bone protrudes through the skin or a wound communicates with the fracture site) require sterile dressing over the wound before splinting. Do not push exposed bone back under the skin. Cover the wound with a moist sterile dressing, apply the splint, and transport. These patients are at high risk for infection and require antibiotics and surgical washout at the hospital. For any fracture with compromised distal perfusion (absent pulses, cold or blue extremity), gentle realignment with steady, in-line traction may be attempted to restore circulation, but never force the movement.