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Wilderness Medical Society - snowmass 2005 (Page 201)

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Wilderness Medical Society - snowmass 2005
31
10)
Is there adequate circulation distal to the suspected fracture site? And
11)
How willing is the patient to use the injured area? Is the patient able to
bear any weight or load on the affected limb?

The key elements of a splint are adequate padding for comfort and adequate
rigidity for safety without compromise of distal circulation. Splinting may be
accomplished with formal splints or improvised splints, e.g., clothing, adhesive or athletic
tape, foamlite sleeping pads, ice axes, ski poles, or natural material. The patient is the
best source of information on how well splints are working. Peripheral pulses or capillary
refill, as well as neurologic function distal to the injury must be monitored before and
after all splinting. Recheck pulses, capillary refill, distal limb color, and nerve function
(sensation and movement) periodically to ensure that the splint wrap is not too tight. It is
important to give the patient the responsibility of notifying someone of any changes in
sensation or level of pain.

A. Shoulder: Fractures of the shoulder girdle are quite often stable and require nothing
more than sling immobilization, cold compresses, if available, and allowance for gentle
motion of the forearm and hand. A fracture of the clavicle may be treated with a sling and
swathe. The hand and wrist must be accessible for feeling pulses.

B. Upper Arm: The humeral shaft is palpable on the medial side throughout its entire
length. Therefore, when a fracture is suspected, palpate the length of the humerus,
beginning either proximal or distal to the patient's area of complaint. In this way, very
small, non-displaced fractures may be identified. Ask the patient to extend her or his
wrist, digits and thumb to check the radial nerve function and document for future
reference. Immobilizing the arm against the body wall is nature's best splint. Humeral
fractures can be very adequately padded and immobilized in this manner with a sling and
swathe. For comfort leave the elbow free and dependent, allowing gravity to apply gentle
traction to the fracture site, which is splinted to the thorax with only the swathe. An
unstable or displaced humeral fracture may require a padded splint.

C. Lower Arm: Adequately splint fractures of the elbow, forearm, and wrist,
incorporating the joints above and below. If possible, splint the elbow at 80 to 90 degrees
of flexion to elevate the forearm and hand and reduce swelling.
The stability provided by a rigid splint is worth the effort, especially in a long and
difficult transport. Splint fractures of the distal ulna and radius with the hand placed in
the position of function with a rolled up sock, glove, or other soft material tucked into the
palm. Then immobilize the hand, wrist, and forearm in a splint. Active exercise of the
hand is quite helpful in promoting circulation.
Correct marked angulation. Applying a splint to a badly angulated forearm
fracture is difficult and usually unstable. Gentle traction with an assistant applying
counter-traction to the upper arm results in an overall improvement with a negligible risk
of creating further vascular or neurologic damage. Move slowly and stop if force is
required for further movement, or the patient complains of significantly increasing pain.

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