Advanced Trauma Life Support ATLS Student Course Manual 2018

PAIN CONTROL 163
Management
Immobilization must include the joint above and
below the fracture. After splinting, be sure to reassess
the neurologic and vascular status of the extremity.
Surgical consultation is required for further treatment.
Principles of Immobilization
Unless associated with life-threatening injuries,
splinting of extremity injuries can typically be
accomplished during the secondary survey. However,
all such injuries must be splinted before a patient is
transported. Assess the limb’s neurovascular status
before and after applying splints or realigning
a fracture.
Femoral Fractures
Femoral fractures are immobilized temporarily with
traction splints (see n FIGURE 8-3; also see Traction Splint
video on MyATLS mobile app). The traction splint’s force
is applied distally at the ankle. Proximally, the post is
pushed into the gluteal crease to apply pressure to the
buttocks, perineum, and groin. Excessive traction can
cause skin damage to the foot, ankle, and perineum.
Because neurovascular compromise can also result
from application of a traction splint, clinicians must
assess the neurovascular status of the limb before
and after applying the splint. Do not apply traction
in patients with an ipsilateral tibia shaft fracture. Hip
fractures can be similarly immobilized with a traction
splint but are more suitably immobilized with skin
traction or foam boot traction with the knee in slight
flexion. A simple method of splinting is to bind the
injured leg to the opposite leg.
Knee Injuries
Application of a commercially available knee immobilizer
or a posterior long-leg plaster splint is effective
in maintaining comfort and stability. Do not
immobilize the knee in complete extension, but with
approximately 10 degrees of flexion to reduce tension
on the neurovascular structures.
Tibial Fractures
Immobilize tibial fractures to minimize pain and
further soft-tissue injury and decrease the risk of
compartment syndrome. If readily available, plaster
splints immobilizing the lower thigh, knee, and ankle
are preferred.
Ankle Fractures
Ankle fractures may be immobilized with a well-padded
splint, thereby decreasing pain while avoiding pressure
over bony prominences (n FIGURE 8-10).
Pitfall
Application of traction to
an extremity with a tibia/
fibula fracture can result in
a neurovascular injury.
Upper Extremity and Hand Injuries
The hand may be temporarily splinted in an anatomic,
functional position with the wrist slightly
dorsiflexed and the fingers gently flexed 45 degrees
at the metacarpophalangeal joints. This position
typically is accomplished by gently immobilizing
the hand over a large roll of gauze and using a
short-arm splint.
The forearm and wrist are immobilized flat on padded
or pillow splints. The elbow is typically immobilized
in a flexed position, either by using padded splints
or by direct immobilization with respect to the body
using a sling-and-swath device. The upper arm
may be immobilized by splinting it to the body or
applying a sling or swath, which can be augmented
by a thoracobrachial bandage. Shoulder injuries are
managed by a sling-and-swath device or a hook- andloop
type of dressing.
PAIN CONTROL
prevention
• Avoid use of traction
in extremities with
combined femur and
tibia/fibula fractures.
• Use a long-leg posterior
splint with an additional
sugar-tong splint for the
lower leg.
The appropriate use of splints significantly decreases
a patient’s discomfort by controlling the amount
of motion that occurs at the injured site. If pain is
not relieved or recurs, the splint should be removed
and the limb further investigated. Analgesics are
indicated for patients with joint injuries and fractures.
Patients who do not appear to have significant pain
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