Fracture Stabilization

1. Fracture instability, especially long bone, can compromise effective patient resuscitation due to ongoing hemorrhage, continued soft tissue damage and respiratory splinting from increased pain. This leads to increased cytokine release, inflammatory response, and shock.12-15 Early stabilization of femoral shaft fractures is associated with decreased pulmonary complications (including acute respiratory distress syndrome), ICU time, hospital days and mortality and others.16-19 Long bone stabilization is an important part of early damage control surgery by stabilizing both anatomy and physiology, and is required in the setting of a temporary shunting or definitive vascular repair. Splinting may be the only far-forward option for fracture stabilization and affords the receiving surgeon the greatest number of surgical options. Splinting also may be the most appropriate intervention for low energy fractures and those in the upper extremity and distal lower extremity such as wrist, hand, humerus, elbow, ankle, and foot fractures. An appropriate splint can be effective in temporizing any suspected or known fracture or soft tissue injury until more appropriate stabilization or imaging is available.
2. Open wounds should be addressed first and the status of the underlying wound as well as the date and time of the most recent debridement and irrigation should be documented on the splint itself. If the patient is to be transported, splints must be suitable for the mode of transportation and acceptable within limits of passenger space. Caution should be utilized so splints are not constrictive/circumferential or predispose to compartment syndrome, especially prior to long evacuations. Splints should immobilize the joint above and below the fracture and should have adequate padding at pressure points to prevent soft tissue injury. Splints are intended to limit further injury and are not meant to be definitive treatment. Anatomic reduction may not be possible or necessary for initial splinting of fractures, but a restoration of overall length and alignment of the limb should be sought. A neurovascular exam, including assessing for compartment syndrome, should be documented pre- and post-splinting with or without reduction attempts, to confirm that perfusion and function remain intact after fracture manipulation.
3. Finger and hand injuries may be immobilized with standard splinting methods. Forearm and elbow injuries are best splinted with a long arm posterior splint or a sugar-tong splint. Humerus and shoulder fractures are best immobilized using a sling and swathe or coaptation splint, ensuring there is enough padding at the axilla. Long leg splints for tibia fractures and below the knee splints for ankle and foot fractures provide adequate stability for transport. Ensure the splint padding allows access for limb compartment.