Module 19: Fractures

This module discusses the management of fractures in the Tactical Field Care (TFC) setting, highlighting your role as a Combat Medic.

Fractures

This module discusses the management of fractures in the Tactical Field Care (TFC) setting, highlighting your role as a Combat Medic.

All Service Member and Combat Lifesaver training educates non-medical personnel about basic splinting techniques, but as a Combat Medic you will often learn additional techniques that allow you to apply different splints or provide oversight to Combat Lifesavers as they apply splints.

There are one cognitive and two performance enabling learning objectives in this module to support the TCCC Guideline section on splinting that states “splint fractures and recheck pulses.”

You will learn how to identify the signs of a suspected fracture and distinguish between fracture types. Additionally, you will demonstrate the basic care for fractures, including the application of malleable and improvised rigid splints.

Depending on the unit mission, you may also receive additional fracture management training and be asked to demonstrate additional splinting techniques.

Splinting fractures is the “S” in the MARCH PAWS sequence.

Fractures of the extremities or the rib cage are often more likely to be identified and are more easily diagnosed than fractures involving the pelvis or spine.

As discussed in the module on circulation, a pelvic compression device is indicated in any casualty who suffers severe blunt force or blast injury and has pelvic pain, a lower limb amputation or near amputation, physical findings suggestive of a pelvic fracture (for example, laceration or bruising at bony prominences of the pelvic ring, crepitus, a deformed or unstable pelvis or unequal leg lengths), unconsciousness, or shock.

Fractures of the extremities are a more common injury and share some of those same presenting signs. In the setting of trauma, localized pain and swelling should be treated as a suspected fracture, even if no other signs are present; although if the pain is significant enough to alter the casualty’s use of the extremity it may be fractured even when swelling is absent. Additionally, the presence of a hematoma or crepitus in the area of the injury, or a physical deformity of the bone (either under the skin or through an open wound), is sometimes present. Occasionally the casualty or another responder will tell you that they actually heard a snap or crack when the bone fractured.

Spinal fractures often present with localized spinal pain, or pain radiating down the extremities from nerve irritation, and may include a deformity at the point of injury, a hematoma, or crepitus. In some cases, motor function can be affected leading to partial or complete paralysis, and sensation can be diminished or absent. Splints are not applied to spinal fractures, although the casualty may be immobilized, depending on the tactical situation; so, we won’t address them further in this module.

Keep in mind that many casualties may have a high pain tolerance and the adrenaline from a traumatic event may mask some of the signs for a period of time. So, maintain a low threshold for treating a painful or deformed bone as a potential fracture.

The essential difference between a closed and open fracture is the integrity of the skin overlying the fracture. If the skin is broken, then it is considered an open fracture.

Internal hemorrhage from fracture sites should also be considered. Rough handling of an injured extremity not only may convert a closed fracture to an open one but also may significantly increase internal bleeding from bone ends, adjacent muscle tissue, or damaged vessels.

Internal blood loss in ml per fracture:

• Femur: 1,000ml - 2,000ml
• Pelvis: 1,000ml - Massive

The potential compromise to the tissues surrounding the fracture can be as significant in a closed fracture as it is in an open fracture, so closed fractures should not be treated with any less concern. However, the potential for contamination is greater in open fractures and warrants additional preventive measures. This is necessary to help prevent a bone infection, or osteomyelitis, which interferes with the fracture healing process.

Any open wound near a possible fracture needs to be considered an open fracture and treated as such. Generally, a protruding bone or bone end should not be intentionally replaced; however, the bones occasionally return to a near-normal position when realigned for splinting or immobilization.

Open fractures may not always be easy to identify in a trauma patient. Although bone protruding from a wound is obvious, soft-tissue injuries in proximity to a fracture/deformity may have resulted from a bone end that broke through the surface of the skin only to recede back into the tissue.

Always ensure that any open injuries are bandaged and bleeding has been controlled!

The primary objectives of fracture management and splinting are to prevent further injury to local tissues or organs, to protect the nerves and vessels that run parallel to bones, and to make the casualty more comfortable by relieving their pain.

Prior to splinting, an injured extremity should be identified at the location of the fracture and place the extremity in a neutral position or position of function.

Remember, one of the primary objectives of splinting is to prevent movement of the injured body part; so be sure to splint your casualty prior to moving them whenever you can, as that is the most common time for a fracture to be compromised.

Hemorrhage control in open fractures should have already been addressed as part of your tactical trauma assessment and treatments prior to this point but should be re-assessed prior to any further management of the fracture.

Pulses, skin color, and sensorimotor function distal to the site of the fracture should be assessed, looking for any changes compared to the unaffected side. Even a seemingly minor fracture has the potential for compromising the vascular or nerve structures that run alongside the bones, and compromise to the neurovascular status of the extremity impacts the urgency of the evacuation request in order to save the limb. Also, splinting has the potential for compromising the casualty’s distal neurovascular status, and a baseline assessment needs to be performed to compare with a post-application assessment.

It is common for an injured extremity to swell distal to the fracture, so any watches, rings, bracelets, or potential constricting materials should be removed and secured.

When dealing with an open fracture, the wound should be dressed prior to splint application. If sterile or clean water is available and if the tactical situation permits, the wound can be irrigated to remove foreign bodies that may be a source of infection. But oftentimes, that is not an option in the TFC phase and the wound can be dressed as is, once the bleeding is controlled.

In some cases, injuries unrelated to the fracture may be hidden once a splint is applied; so, ensure that all wounds and injuries that might be covered by the splinting process are treated and documented prior to splint application.

Always immobilize the joint proximal and the joint distal to the site of the fracture in your splint. There are rare times when this cannot be done, but every effort should be made to immobilize both joints, as movement at either joint will result in movement at the fracture site, resulting in both increased pain and possible further injury.

Once you have applied a splint, be sure to reassess the pulses motor and sensory (PMS) function distal to the fracture and compare that to the baseline PMS assessment you performed prior to splint application. If there is a decline in function, then the splint needs to be removed and reapplied, ensuring that it did not place the limb in a non-anatomic position or that the securing bandages were not applied too tightly.

Although splinting can result in decreased pain, it is still appropriate to administer pain management based on the TCCC Guidelines. And antibiotic administration is indicated for any open fractures.

Consider elevating the extremity to reduce edema and decrease pain, if tactically feasible. This is not always possible, particularly during casualty transport. Also, take care to avoid having the litter straps apply direct pressure on a fracture site whenever possible, as this will both create additional pain and potentially cause further injury.

Document all findings and treatments on a DD Form 1380 TCCC Casualty Card and attach it to the casualty.

Begin by collecting all of the potential splinting materials you will need prior to starting. Once you begin the process of applying a splint it is difficult to leave and gather additional materials without having to start over again. The actual splinting materials can be malleable (formable to the contours of the site of the fracture) or rigid, but the principles of splinting are the same for both malleable and rigid materials. Padding and materials to secure the splint once applied are also necessary.

Whenever available, asked a Combat Lifesaver to help you. They can support the injured extremity during splint application if the casualty is unable to do that themselves and can assist in holding the splint in place while it is secured.

Before applying it to the injury, measure and/or shape the splinting materials on the opposite (hopefully uninjured) extremity, whenever you can. This reduces the amount of manipulation at the site of the injury. When designing the splint, be sure to leave access to allow for a PMS assessment after the splint is applied.

As mentioned previously, ideally you want to design the splint so that the injury maintains its normal anatomic position. And the splint should encompass the joints above and below the site of the fracture.

Padding is essential, both for casualty comfort and sometimes for proper alignment. Ensure that any voids are filled to prevent the splint from applying pressure directly on the extremity, in particular over areas that are already tender.

Padding is essential, both for casualty comfort and sometimes for proper alignment. Ensure that any voids are filled to prevent the splint from applying pressure directly on the extremity, in particular over areas that are already tender.

Secure the splint with cravats, pressure bandages, cloth strips, or any available tape. Enough pressure should be applied to maintain the splint in position, but avoid exerting excessive pressure when securing. Also, tuck any loose ends of materials so that they do not create problems during casualty transport.

Depending on the situation, you may also consider slings and/or swathes to help keep the extremity close to the body and avoid unnecessary movements.

This could even include using the casualty’s shirt and safety pins as a makeshift sling.

And as mentioned before, be sure to recheck the casualty’s PMS distal to any splint you apply and adjust the splint accordingly if there is a change from baseline.

The two most common types of malleable splints are foam-padded aluminum/metal splints like the SAM® splint and wire ladder splints. These splints gain rigidity by folding or creasing the metal framework, so have to be molded and bent to stabilize the bone. Simply wrapping them around the area of injury or joints will not provide the support needed. Some evacuation assets also use vacuum splints that are molded around the fracture and become rigid when the air is removed.

One advantage that malleable splints have, when compared to rigid splints, is that they can be contoured to the area of injury and be molded around joints at angles. This not only provides the rigidity they need to support the fracture, but minimizes the need for excess packing and often provides more comfort for the casualty. That said, malleable splints still need to be properly padded with other materials, despite foam padding on their surface.

There are a myriad of shapes and uses for malleable splints, and it is important to practice the most common splints prior to deployment, using the same materials you will potentially have access to when downrange.

In general, malleable splints are good for shorter bones and angled splint positions, as the additional creases and bends lead to increased rigidity when compared to a straight, long splint. That said, multiple malleable splints can be combined and secured in ways that support longer bone fractures, as well.

This video will go over the proper techniques for malleable splinting in a tactical field care setting.

MALLEABLE SPLINTING

Several different types of materials can serve for rigid splints. Some of these are materials dedicated to splinting, but often the tactical situation lends itself to improvisation.

It is less common to see rigid splints in current aid bags or on transport vehicles. These padded boards take up more room and are less versatile than malleable splints. Depending on the unit mission and operating procedures, you may encounter traction splints. They are a type of rigid splint that applies traction to the extremity while stabilizing the long bones and are commonly used on femur fractures where the large muscles can make restoring the normal anatomic position of the fracture problematic.

More commonly, you will find yourself using something from the environment as a rigid splint. This could be a sturdy tree limb, a piece of wood, a metal or wooden pole, folded cardboard, or even the casualty’s weapon, ensuring that it is unloaded and safe. The length of the objects may be pre-determined and create application problems, depending on the site being splinted.

Another issue to remember with rigid splints is that the lack of anatomic contours means that more padding will usually be needed, so be sure to gather adequate padding materials prior to application.

Rigid splints are often good for long bones (like you see in leg fractures) because of the strength of the materials used. But it is very common for the ends of the splints to protrude beyond the extremity itself, creating a potential hazard during casualty transport, and care should be taken to minimize this, whenever possible.

This video will go over the proper techniques for rigid splinting in a tactical field care setting.

RIGID SPLINTING IN TACTICAL FIELD CARE

There are a handful of common errors made when applying splints, including:

• Manipulating the fracture site too much; resulting in pain, additional damage to tissues, blood vessels, and nerves
• Splinting near or over a wound that has not been properly treated
• Failing to immobilize joint above and below fracture when possible
• Securing too tightly, cutting off blood flow
• Making casualty uncomfortable during transport/evacuation

Taking care to follow the recommended steps for splint application will help avoid these errors.

1 PDF Malleable Splint Instruction Skills Card

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2 PDF Rigid Splint Instruction Skills Card

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This module reviewed the basic principles of splinting in the Tactical Field Care phase.

We discussed identifying fractures and classifying them as open or closed. We also reviewed the basic management of fractures, to include application of splints.

Afterward, you demonstrated splint application using both malleable and rigid splints in the skill stations.

Remember, the primary objectives of fracture management and splinting are to prevent further injury to local tissues or organs, to protect the nerves and vessels that run parallel to bones, and to make the casualty more comfortable by relieving their pain.

To close out this module, check your learning with the questions below (answers under the image).

Check on learning

Answers

What are the three objectives of fracture management and splinting?

The primary objectives of fracture management and splinting are to prevent further injury to local tissues or organs, to protect the nerves and vessels that run parallel to bones, and to make the casualty more comfortable by relieving some pain.

True or False: When applying a splint, ensure the joints above and below the fracture are immobilized in the splint whenever possible.

True. Always incorporate the joint proximal and the joint distal to the site of the fracture in your splint.

What should you assess before and after splinting?

Pulses, skin color, and sensorimotor function distal to the site of the fracture should be assessed. Once you have applied a splint, be sure to reassess the pulses motor and sensory (PMS) function distal to the fracture, and compare that to the baseline PMS assessment you performed prior to splint application.