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Splinting, Bandaging and Immobilization Techniques and Devices.

A GUIDE FOR EDUCATION & COMPETENCY

Compiled by: Wendy Porteous

ACKNOWLEDGEMENTS Thank you to: Pat Standen and Di Woods for reviewing the document and providing their expert advice, and Ambulance Victoria for so generously allowing their clinical practice guidelines to be used as a guide.

For information regarding this Guide contact: Pat Standen Department of Human Services PO Box 712 Ballarat 3353 Email: pat.standen@dhs.vic.gov.au Phone: 03 5333 6026 http://www.dhs.vic.gov.au/regional/grampians/

Version 1.0

Date April 2009

Major Changes

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Front page image sourced from http://www.webweaver.nu/clipart/img/people/men/bandaged-man.gif

DISCLAIMER: Care has been taken to confirm the accuracy of the information presented in this guide, however, the authors, editors and publisher are not responsible for errors or omissions or for any consequences from application of the information in the guide and make no warranty, express or implied, with respect to the contents of the publication. Every effort has been made to ensure the clinical information provided is in accordance with current recommendations and practice. However, in view of ongoing research, changes in government regulations and the flow of other information, the information is provided on the basis that all persons undertake responsibility for assessing the relevance and accuracy of its content.

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The purpose of this guide is to assist educators in the Grampians Region to design their own Health Service specific package for Registered Nurses Division 1 & 2 required to manage patients in an emergency situation. The aim of this guide is to provide generic information based on principles of care. It is the responsibility of each individual practitioner and Health Service to ensure appropriate education for all equipment and that competency in the use of the equipment is maintained.

The following package will review the relevant anatomy and physiology that is required for an understanding of the practice of splinting and bandaging. It will then cover what is commonly in clinical practice and why; as well as looking at the machinery of splinting. Although splinting and bandaging can be used in a variety of clinical settings, this package will primarily focus on their use in acute musculoskeletal injuries related to the extremities.

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TABLE OF CONTENTS

INTRODUCTION..5 Overview Anatomy and Physiology...7 Stages of healing..10 Musculoskeletal tissue.11 Soft tissue injuries.12 Principles of management...13 Types of soft tissue injuries.14 Strains and sprains...16 Dislocations and subluxations.16 Fractures16 General principles of splinting.19 Indications, contraindications and cautions..19 Splints.20 Soft Non-rigid splinting.22 Other general use rigid and semi-rigid splints..30 Semi-rigid formable splints......32 Traction splints..41 Pelvic sling/splints.53 Clinical Practice Guidelines and competencies...64 References and suggested further reading..76

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Introduction
Splinting and bandaging plays an important role in the management of musculoskeletal injuries and for definitive therapy of soft tissue injuries, particularly those involving extremity fractures and joint dislocations. Splinting may be the definitive treatment or a temporising measure until the time of reevaluation and/or casting. Immobilisation facilitates the healing process by decreasing pain and protecting the extremity from further injury. Other benefits of splinting are specific to the particular injury or the problem that is being treated. For example, in the treatment of fractures, splinting helps maintain bony alignment. Splinting deep lacerations that cross joints reduces tension on the wound and helps prevent wound dehiscence. Immobilising tendon lacerations may facilitate the healing process by relieving stress on the repaired tendon. The discomfort of inflammatory disorders such as tenosynovitis is greatly reduced by immobilisation. Deep space infections of the hands or feet as well as cellulitis over any joint should similarly be immobilised for comfort. Limiting early motion also may reduce oedema and theoretically improve the immune systems ability to combat infection. Hence, puncture wounds and animal bites of the hands and feet may be immobilised until the risk of infection has passed. Splinting large abrasions that cross joint surfaces prevents movement of the injured extremity and reduces the pain that is produced when the injured skin is stretched. Patients with multiple trauma should have fractures and reduced dislocations adequately splinted while other diagnostic and therapeutic procedures are completed. Immobilisation decreases blood loss, minimizes the potential for further neurovascular injury, decreases the need for analgesia, and may decrease the risk of fat emboli from long bone fractures. The primary objective of splinting is to prevent motion of fractured bone fragments or dislocated joints and thereby to prevent the following complications.

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1. Laceration of the skin by broken bones, which will increase the risk of contamination and infection 2. Damage to local blood vessels causing excessive bleeding into surrounding tissue, ischaemia, and even tissue death 3. Restriction of blood flow to an area as a result of pressure of bone ends on blood vessels 4. Damage to nerves by inadvertent excessive traction, contusion, or laceration resulting in possible permanent loss of sensation and paralysis 5. Damage to muscles with subsequent necrosis, scarring, and permanent disability 6. Increased pain associated with movement of bone ends 7. Shock 8. Delayed union or non-union of fractured bones or dislocated joints

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Anatomy and Physiology


Extremity injuries, although common, rarely pose an immediate threat to life. Extremity trauma can be life threatening when it produces severe blood loss, either externally or from internal bleeding to the extremity. Extremity trauma can also be limb threatening, i.e. it can result in the loss of a limb or function of a limb.

The mature human body has approximately 206 bones. These bones provide the architectural framework for the body.

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Other structures such as tendons, cartilage, ligaments, soft tissue and muscle allow the bones to perform many functions such as support, serving as a reservoir for minerals and haemopoietic function (production of red blood cells), shielding internal organs, and activities such as protection, work, and play which are coordinated by involuntary and voluntary muscle movement.

Bone is dynamic and can adapt itself when forces are applied to it. Bones can be grouped based on shape, such as flat (innominate pelvis), cuboidal (vertebrae) or long (tibia). Furthermore, bones can be classified as cancellous (spongy or trabecular bone) or cortical (compact). Cortical bone is found where support matters most, in shafts of long bones and outer walls of other bones. Cancellous bone is honeycomb in appearance and makes up the internal network of all bones.

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Periosteum surrounds bone and contains a substantial network of blood vessels that supply the bone with blood and nutrients. Inside the long bones of the extremity is the medullary cavity containing yellow marrow (mostly fat) and red marrow (responsible for blood cell production). Therefore, when a long bone is fractured, blood loss occurs and fat can be released from the medullary cavity potentially causing fat embolism.

Injuries to the soft tissue, which includes muscle, skin and subcutaneous fat, can occur in combination with fractures. Sometimes soft tissue injuries are more significant and have more serious ramifications than the fracture itself.

Healing of an uncomplicated fracture may take from 6 weeks to 6 months. Vascular compromise, infection and other injuries may lengthen the healing process and in some cases, non-union may occur.

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The five stages of fracture healing do not occur independently, but overlap as progression of the healing process occurs.

Stages of fracture healing


Stage I: Haematoma Formation Description Immediately following fracture, bone ends rub together called crepitus causing pain. Amount of haematoma Depends on the damage to bone, soft tissue and vessels around the fracture Granulation tissue forms after fibroblasts, osteoclasts and and chondroblasts invade the haematoma as part of the inflammatory sequelae. Osteoclasts remove dead bone and osteoblasts produce bone Length 1-3 days

II: Granulation

3 days 2 weeks

III: Callus Formation

The fracture becomes sticky due to plasma and white blood cells entering the granulation tissue. This material assists in keeping bone fragments together. Parathyroid hormone increases and calcium is deposited. This is the most important stage; slowing or interruption at this stage means that the last two stages cannot progress, leading to delayed healing or non-union Osteoblasts and connective tissue are prolific, bringing the bone ends together. Bridging callus envelops the fracture fragment ends and moves towards the other fragments. Medullary callus bridges the fracture fragments internally thus creating a connection with the marrow cavity and cortices of the fracture fragment. Trabecular bone replaces callus along the stress lines. Unnecessary callus is absorbed. Bony union is thus achieved

2-6 weeks

IV: Ossification/ Consolidation

3 weeks 6 months

V: Remodelling

Re-establishment of the medullary canal. Fragments of bone are united. Surplus cells are absorbed, bone is remodelled and healing is complete

6 weeks 1 year

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Musculoskeletal tissue
There are two types of tissue in the musculoskeletal system, muscle and connective tissue. Connective tissue is specified as tendon, fascia, ligaments, and cartilage.

Skeletal Muscle Skeletal muscle tissue is a voluntary muscle and has a unique ability to contract, therefore providing the body with the ability to move. Skeletal muscle has high metabolic demands and is provided with a rich blood supply by arteries and veins that penetrate the epimysium (fascia), and are finally embedded in the innermost sheath, the endomysium.

Muscles are enclosed within fascial compartments, which protect the muscle from damaged tissue swelling. Pressure within the compartment can increase so much that muscle ischaemia occurs, resulting in compartment syndrome.

Nerve Supply One or two nerves supply muscle. Each nerve includes efferent (motor) and afferent (sensory) fibres. Nerves provide movement and sensation. Sensory nerves carry impulses to the central nervous system (CNS). Motor nerves carry impulses away from the CNS. Traction, compression, ischaemia, laceration, oedema or burning can damage nerves, resulting in nerve deficit distal to the site of injury.

Vascular Supply The nutrient artery provides bone marrow and some cortex in adult long bones with a rich blood supply. The large ends of long bones are supplied by circulus vasculosus. Because of the close proximity of nerves and vessels to bony structures, any musculoskeletal injury can potentially cause vascular and/or neurological compromise. This is a result of these systems being extremely sensitive to compression and impaired circulation. If vascular supply is impaired, tissue perfusion is reduced and ultimately will lead to ischaemia. Irreversible damage to nerves, vascular structures and muscles can occur within 6 to 8 hours if

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progression from ischaemia to muscle necrosis occurs. Poor arterial perfusion is evidenced by pallor, and cyanosis is suggestive of venous congestion. Improper handling of fractures can complicate further care of the patient and increase the degree of injury, as well as causing further bleeding, pain, increased incidence of fat embolism and further damage to soft tissues, nerves and vessels.

Soft Tissue Injuries


Typically, musculoskeletal trauma results in injury to both soft tissue and bone, activating the sequelae of wound healing and fracture repair. Evidence suggests that delay or prevention of fracture healing can be directly linked to extensive soft tissue injuries.

Soft tissue injuries incorporate many structures, namely blood vessels, nerves, muscle, skin, ligaments and tendons. Contusions, blistering, burns and crushed areas of skin are an indication of a transfer of a large amount of energy. Major contamination from grass, soil or other foreign material should be removed if accessible. Copious lavage with sterile saline should be used in grossly contaminated wounds before a sterile dressing is applied. Where applicable, the limb should be splinted in normal alignment.

Mechanism of soft tissue injury


Degloving: - a shearing force resulting in soft tissue being stripped away from the bone. It can affect a small area or entire limb.

Penetrating: penetrating objects such as bullets, knives, or fracture ends can completely divide blood vessels causing vascular damage.

Tension: tension forces result when the skin is struck by a blunt object. This causes the skin to be torn away from its subcutaneous base, which can produce avulsions or lacerations.

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Compression/crushing: tissues can be crushed between an object and underlying bone, which can produce significant devitalisation of tissue. Compression forces on blood vessels can cause intimal damage, rupture and sometimes sever the vessels completely. Spasm can result following intimal damage.

Stretching: skin can be stretched at the moment of impact and the damaged skin may perish. Fracture blisters can result from transient ischaemia of the skin. Fracture blisters develop within 48 hours of injury, which in turn complicates internal fixation, as they are a potential source of infection. Blood vessels can be stretched when a bone is fractured and this can cause intimal damage to the vessel, which is common near the knee or elbow.

Injection injury: although not common, this is a serious injury, generally to the hand/digit. Such injuries are caused by accidental high-pressure injection of grease, water, solvent or paint. Devitalisation of tissue is immediate and extensive tissue destruction can lead to necrosis within 48 hours if left untreated.

Human bites: although relatively rare, are serious injuries, particularly if they involve tendons, joints or ligaments in the hand. Fist fights can produce wounds around the knuckles if they come into contact with teeth. When the anaerobe from a tooth is sealed into a joint or around the capsule, serious infection develops which can lead to destruction of the joint and stiffness. The human mouth is a veritable reservoir of bacteria. If left untreated, these bites can become grossly infected with a myriad of organisms.

Principles of management
Elevation: elevating a limb in a non-dependent position (on pillow or frame, no higher than the level of the heart) will assist in improving venous return and reducing oedema. Over elevation can contribute to poor venous return and associated complications.

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Cooling: (cryotherapy) should be concurrent with elevation. Cooling is accepted as a fundamental part of acute soft tissue injury treatment. By reducing tissue temperature, cryotherapy can decrease pain and metabolic processes, thereby minimising inflammation. Assess the patient at regular intervals to monitor for signs of potential thermal injury resulting from cooling therapy. Generally, cooling therapy is applied for a duration of 10 to 30 minutes every 1 to 3 hours for the first 24 to 48 hours.

Protection: splinting of a joint can control pain and reduce further injury to soft tissue by decreasing movement.

Types of soft tissue injuries


Blood vessels: blood vessels can be damaged in four ways: crushing, penetrating, spasm, and stretching.

Nerves: can also be damaged by crushing, penetrating and stretching with most injuries to nerves occurring with a combination of all three. Nerves must always be tested subsequent to any significant trauma. Acute nerve injuries can be missed therefore it is important to ask the patient if they have weakness, numbness or tingling in the specified area. If a nerve injury is diagnosed, always look for associated vascular injury. Classification of nerve injuries: Neurapraxia is a transient loss of function caused by external pressure or simple contusion and has an early recovery. Axonotmesis is seen classically after dislocations and closed fractures and is due to severe compression resulting in loss of function. Recovery may take weeks to months. New axonal processes grow 1 to 2 mm per day. Neurotmesis is due to complete division of the nerve. It has no recovery unless surgically repaired, and function may be adequate post surgical repair, but is rarely normal.

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Muscles: are extremely vascular and their blood supply crucial. If the muscles blood supply is impeded by compartment syndrome, arterial damage or tight plasters/dressings, the muscle becomes ischaemic. Ischaemic muscle becomes fibrous tissue. This is a major issue in fracture management as fibrous tissue contracts and pulls the associated joint out of anatomical alignment. Coincidentally, muscle crushed by direct force can also become fibrous tissue, which shortens the muscle and hampers joint movement. Lacerated muscle is difficult to repair, as sutures will not hold well enough to stop contraction of the muscle, therefore pulling the edges apart.

Skin: can be damaged by a number of forces as well as direct trauma. If a force is great enough to fracture a bone, the skin at the fracture site is bound to be injured.

Ligaments: connect bone to bone. They provide stability and guidance for joints. Ligaments have enormous tensile strength that can withstand forces of up to 226 kg before rupturing. There are a large number of ligaments in the body. There are four ligaments in the knee alone: posterior cruciate, anterior cruciate, lateral collateral and medial collateral. The three grades of ligament injuries are: Sprain: where stability is maintained Partial rupture: where some fibres remain and there is some loss of stability. Complete rupture: where continuity of the ligament is ruptured and there is complete loss of stability. Some patients may say they heard a snap. Pain is severe and bleeding under the skin will cause swelling and haemarthrosis (only if bleeding occurs into the joint). Most ligament ruptures can be treated nonoperatively, but there are some exceptions where the ligament needs to be repaired surgically. Nursing management of these patients includes splinting the joint and cooling/ice packs.

Tendons: connect muscle to bone and permit conduction of force by muscle to bone which results in joint movement. Tendons and ligaments have much
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lower oxygen consumption than skeletal muscle. This low metabolic rate means that they are slow healing after injury.

Strains and sprains


A strain is any painful twisting or pulling (wrenching) of a joint. It does not tear ligaments and it may simply be an overstretching or tearing of a muscle. A strain is painful. Patients often call strains pulled muscles. A sprain is where the joint is temporarily twisted/bent into an abnormal position. Tearing of ligamentous fibres occurs, but the joint will remain stable. There is bruising, swelling, pain and loss of joint movement. These symptoms can vary depending on the severity of the sprain. Nursing management of sprains is rest, ice, compression (with firm strapping/bandaging) and elevation.

Dislocations and subluxations


A dislocation is when the articular (joint) surfaces are no longer in contact; and can be described as anterior/posterior or medial/lateral. A subluxation is partial displacement of the articular surfaces. Both injuries occur when the joint is forced beyond its anatomical range of motion. Symptoms of dislocations include loss of normal mobility, pain, change in contour of the joint and discrepancy with the length of the extremity.

Fractures
Bone has some degree of elasticity. A fracture results from stress/force placed on the bone which it cannot absorb. It may be caused by direct or indirect trauma, stress or weakness of the bone, or may be pathological in origin. The types of force used to cause fractures are direct violence, indirect (generally a twisting injury), pathological (generally a weak bone from tumour or osteoporotic bone) and fatigue (repeated stress on the bone, for example from military marches).

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Classification

Fractures are classified as stable or unstable. Stable fractures are unlikely to be displaced, whereas unstable fractures are likely to be displaced. Fractures are also classified as open, or closed. With closed fractures, there is no penetration of the skin by bone. Conversely in open fractures, the bone breaches the skin or one of the body cavities, or the force that caused the fracture penetrates the soft tissue.

Type
Transverse fractures cross the bone at a 90o angle and are generally stable post reduction. Oblique/spiral fractures are at a 45o angle to the axis, usually from a twisting force causing upward thrust. Most long bone fractures are due to violent twisting motions, such as a sharp twist to the leg, when the foot is stuck in a hole, producing a spiral fracture. Comminuted fractures are high-energy injuries where the bone is splintered in more than two fragments. These are generally associated with significant soft tissue injury. Impacted fractures occur when one fragment is forced into another. The fracture line may be difficult to visualise. Crush fractures occur when cancellous bone is compressed or crushed. Avulsion fractures occur when soft tissue and bone are torn away from the insertion site. Greenstick fractures occur when the compressed cortex bends/buckles. If the force persists, the cortex will fracture. These are usually seen in children as their bones are much more porous and soft. Epiphyseal or growth plate fractures (Salter-type) may affect future bone growth because of early closure of the epiphyseal plate and resultant limb shortening. Angulation may occur with partial growth plate fractures because bone growth continues in the noninjured area.
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General Principles of Splinting


Indications
To immobilize and stabilize fractures and dislocations as soon as possible to prevent further soft tissue or bony damage. To decrease pain from impaired neurological function or muscle spasm. To decrease swelling associated with injury by reducing blood and fluid loss into the soft tissues. To immobilize injured areas after burns, bites, and stings. To immobilize an area during the healing of infectious or inflammatory processes and after the surgical repair of muscles and tendons.

Contraindications
There are NO absolute contraindications to applying a splint

Cautions
1. Injured extremities should be handled gently, minimise movement of the affected area 2. Bony prominences should be padded to avoid undue pressure and skin breakdown 3. Joint above and below should be immobilised 4. In general longitudinal traction may be applied while a splint is being applied except when the injury involves a joint, dislocation, or open fracture 5. Align a severely deformed limb so a splint can be applied DO NOT force an extremity into a splint!! 6. Avoid zips, knots, or attachments over the injury site 7. Assess and document neurovascular status before and after splinting

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Splints
A splint is any device used to immobilise a fracture or dislocation. This may be an improvised device, such as a rolled newspaper, cane, ironing board, stick or virtually any object that can provide stability; it may be the patients own body; or it may be one of the many commercially available splints, such as wooden splints, inflatable splints, and traction splints. Splints are divided into four basic types. Soft splints soft, non-rigid, such as a pillow, and crepe bandages. Rigid - Hard splints firm surface; rigid, such as a board. Pneumatic splints inflatable splint; provides rigidity without being hard. Traction splints provides support, capable of maintaining longitudinal traction for lower extremity fractures.
SOFT SPLINT NON-RIGID SPLINTS

Include bandaging material blankets cloth cravats foam rubber pillow sling

HARD-RIGID AND SEMIRIGID SPLINTS

Include Aluminium or other pliable metal cervical collars backboards wood/fibre glass/ plastic cardboard fibre glass wire ladder splints leather moulded plastic Page20

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Include Include -

plaster vacuum finger splints knee immobilizer

PNEUMATIC INFLATABLE SPLINTS

air splints pneumatic antishock garments (PASG)

TRACTION SPLINTS

Donway Thomas Sager Hare

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SOFT NON-RIGID SPLINTING


A soft splint is one that has no inherent rigidity, such as a pillow or rolled blanket, crepe bandage or sling.

PILLOWS, BLANKETS and IMPROVISED SOFT SPLINTS


Pillow splints can be fashioned from any soft bulky material that is readily available.

Splinting using a towel, in which the towel is rolled up and wrapped around the limb, then tied in place.

Pillow splint, in which the pillow is wrapped around the limb and tied .

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Hand/wrist pillow splint

BANDAGING
Bandages are used to give support to an injured area or apply pressure to an area in order to limit swelling. Bandages fall into two main categories: 1. tubular bandages 2. roll bandages

TUBULAR BANDAGES
Tubular bandages usually are elasticised and come in varying sizes. They are designed to be applied in a double layer.

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ROLL BANDAGES
Roll bandages are manufactured in various forms and sizes. They may be either stretchable or non-stretchable. In addition they may be adherent or nonadherent. Adherent bandages are better for giving support as they do not slip once applied. Non-stretch bandage should not be applied around an injured limb as any subsequent swelling will cause vascular impairment. When applying a roll bandage around a limb always start distally and work proximally. Generally each turn of bandage should overlap the previous turn by 2/3rds.

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SLINGS
Slings are used to: support fractures of the clavicle, scapula, humerus, elbow, forearm, wrist or hand after reduction of dislocated shoulder, dislocated elbow, or dislocated digits infections of the arm support a plaster of Paris cast of the arm or any arm injury to reduce swelling of the forearm, wrist or hand to provide elevation of the arm for any purpose

BROAD ARM SLINGS Application: Place the long straight side of the sling parallel to the sternum and place the apex of the sling behind the injured arm. Extend the upper end of the sling over the opposite shoulder. Bring the lower end of the sling over the shoulder of the injured arm. Tie the two ends behind the neck. Secure the elbow in the sling using a safety pin for an adult or adhesive tape for a child.

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a) In this method of applying the sling, the forearm is supported from both shoulders by the sling. 1. Bend arm at elbow so that little finger is about a handbreadth above level of elbow 2. Place one end of triangle over shoulder on injured side and let sling hang down over chest with base toward hand and apex toward elbow 3. Slip sling between body and arm 4. Carry lower end up over shoulder on uninjured side 5. Tie the two ends at the neck. Knot should be on either side of neck, not in the middle where it could cause discomfort 6. Draw apex of bandage toward elbow until snug, bring it around to front, and fasten with safety pin or adhesive tape. b) If it is desirable to support the forearm without pressure on the collarbone or shoulder of the injured side, the following steps are taken. 1. Bend arm at elbow 2. Drape upper end of triangle over uninjured shoulder 3. Slip sling between body and arm 4. Carry lower end up over flexed forearm (ends of fingers should extend slightly beyond base of triangle) 5. Slide lower end of bandage under injured shoulder between arm and body and secure the two ends with a knot 6. Draw apex toward elbow until snug, and secure with safety pin or adhesive tape.

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http://upload.wikimedia.org/wikipedia/commons/7/71/Forearm_splint.jpg

HIGH ARM SLINGS This is predominantly used when the hand is injured or infected and needs dependent drainage. Application: Bend the patients arm so that the fingers touch the opposite clavicle. Apply the upper side of the sling along and parallel to the upper border of the patients forearm and hand so that the sling extends to a little beyond the elbow on the injured side. Tuck the base of the sling well under the injured forearm and hand. Take the lower end of the sling up across the patients back and tie it to the end on the injured side. Tuck in at the elbow.

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COLLAR AND CUFF


Used to support an injured shoulder, clavicle or upper extremity, Collar and Cuff slings are made of foam surrounded by slightly stretchable soft material. Collar and Cuff can be used to form a variety of slings and braces, such as a balanced arm sling, wrist support sling, clavicle brace or shoulder immobilizer. The soft foam in its sleeve provides strong but comfortable support when fastened into position. Used in place of traditional slings, collar and cuff provides comfort for the patient without additional padding. As a balanced arm sling, collar and cuff provides effective support at the elbow and wrist, without obscuring the affected limb and without applying any force to the injured side.

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OTHER GENERAL USE RIGID AND SEMI-RIGID SPLINTS


All splints, regardless of size, adjustability, or other unique qualities, are primarily classified by whether or not they are intrinsically formable. Fixed shape splints are defined as rigid, and those that can be adjusted to a variety of shapes as formable or semi-rigid. The most commonly use splints are: Rigid (non-formable): board splints (whether made of wood, plastic or metal) long boards (long spine boards)

Semi Rigid (formable): cardboard splints wire ladder splints SAM splints Vacuum splints

Padding is required with any splint whose surface in hard, irregular, or not exactly conforming to the external shape of the area to which it is applied. Generally it is easier and better to separate the task of padding the surface of the splint from that of adding such additional padding as is needed to fill voids between the splint and the limb. Some commercial splints come with foam padding already attached to their contact areas. If padding is not preapplied, layers of gauze, combine, towels etc. can be fixed to any surface that will contact the patient. The thickness of the material that is used to pad the splint should be sufficient to serve as a shock absorber and to provide firm localised pressure on any protrusion, without interfering with the support and immobilisation that the splint provides along its length.

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BOARD SPLINTS
Board splints are long rigid flat rectangles (usually with corners) which historically were made from thin wooden boards. Even though today they are available in a variety of plastics and lightweight metal alloys, they remain predominantly constructed from lightweight but strong thin plywood. Regardless of the materials from which it is made any flat, rigid non-formable rectangular splint is still called a board splint. Although there is no standard for the length of board splints, they are generally between 8 and 12 cm wide. Two approximate lengths which are commercially available are found to be of general usefulness when splinting. About 40 cm long, for splinting limited areas only, such as the upper arm, the forearm, wrist, and hand, or the lower leg. About 1 metre long, for splinting and entire extremity in a straight extended position. Tongue blades (spatulas) are useful when individual fingers need to be splinted in a straight extended position, and should be included in any consideration of board splints. The surface of a board splint which will contact with the patient must be padded prior to use. Some commercial splints include padding over the rigid surface. Board splints are generally best used when a firm flat rigid splint is needed, such as isolated wrist, forearm, and hand injuries.

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http://chestofbooks.com/health/body/massage/Margaret-D-Palmer/Lessons-on-Massage/images/fig-117-Fractured-LegBandaged-to-Back-Splint.png

http://www.cprflorida.net/images/reference/Splints.jpg

SEMI RIGID FORMABLE SPLINTS Aluminium Splints SAM Splints


The SAM splint is a durable aluminium splint wrapped in hypoallergenic foam. It contains no stays of any type, it is universal, and can be shaped to be straight or angled to meet any basic need. This malleable material has no intrinsic rigidity. The splint moulds easily, is x-ray translucent and contains padding between its core material and fluid impervious outer shell. The SAM splint is not sufficiently rigid to be used when relatively flat, and is dependent upon the upward bending of its outer edges (forming it into a semi-circle or U across its width) to make it rigid along its length. When forming and applying
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the splint it is essential that a sufficient portion of each side is bent upwards, or the splint may undesirably bend along its length.

http://www.nitro-pak.com/images/3001%20Sam%20Splint%20Arm-%20Leg-200x200.jpg

http://www.mtongil.com/goods/Sam%20Splint.jpg

http://www.snowdonia-adventures.co.uk/images/leg_with_fixed_with_splints.jpg
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http://www.abledata.com/product_images/images/01A1109.jpg

Wire Ladder Splints


Wire ladder splints are made from heavy gauge wire rods formed into a flat rectangular frame with evenly spaced wire rungs welded across its width. Their surface can be bent at any angle and any curve that is desired. The ability to form curved areas is an especially useful attribute, making them particularly applicable for fractures with marked deformity. They are sufficiently rigid that they can be used as straight flat splints, yet they will remain in any other shape to which they are bent. Once the wire splint has been formed to the size and shape desired padding must be secured to any of its surfaces that will lie against the patient.

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CARDBOARD SPLINTS
Cardboard splints are generally made of either fluid-impervious plastic impregnated corrugated cardboard or thin corrugated sheets of plastic. Even if made of plastic, such thin corrugated splints are defined as cardboard splints. Cardboard splints are purchased and stored as long as long flat rectangles with rounded corners. There is a score (a pressed indentation) which runs the full length of the splints, several inches from each long edge of the splint. Prior to use, the splint must be bent at these scores so that the area outside of each forms a perpendicular side, and the splint has a box like shape with open ends. Most commercial cardboard splints also come with high density foam padding pre-attached to the middle section (or base) of the splint so that it lies between its two sides.

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VACUUM SPLINTS
Vacuum splints are generally thin flat rectangular bags filled with thousands of small round or multi-faceted plastic beads. The splints outer covers are sealed and air-proof (also fluid impervious). Somewhere on the splints outer surface there is one or more valve stem(s) to allow the connection of a vacuum pump to evacuate air from within the splint. When the splint contains air as well as the beads, the plastic beads can move freely against each other and the splint can be formed into any needed shape. When the air is evacuated from the splint with the hand pump, the beads are tightly pressed against each other and the splint becomes rigid in the exact shape to which it has been formed around the extremity or body. Most vacuum splints are x-ray translucent and include Velcro tabs to assist in holding the splint against the limb until the air has been evacuated from the splint.

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PNEUMATIC SPLINTS - AIR SPLINTS


Air splints are dual walled air-proof plastic sleeves which contain a closable stem and valve to allow then to be inflated by mouth. Although they are flexible when empty to facilitate storage and installation, when inflated they only assume a completely straight (or straight with a perpendicular foot section) shape. When applied, an air splint must always be inflated enough to make it fully rigid. Although the amount or air needed to make it rigid varies and allows the splint to adjust to the varying girths of the extremity being splinted, the splints inflated shape can not be varied. An air splint can only be used on an area which is aligned and conforms to the inflated straight (or straight with its foot perpendicular) shape of the splints design. If any curvature or angle which is not designed into the splint is present, it will be straightened when the splint is inflated. Although non formable, the adjustable girth of most inflatable splints allows each to be used for several applications. Air splints are radiologically transparent (except for the zip). Because they provide external pneumatic pressure totally around the length of the limb, there is a risk that the circumferential pressure can inadvertently act as a tourniquet on the underlying and distal circulation. Exposure to extreme heat or direct sunlight for an extended period after the splint has been inflated can cause expansion of the air in the splint and cause it to tighten around the extremity. Air pressure within the splint is also subject to fluctuations in altitude, making their use in air transport limited.

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PASG PNEUMATIC ANTISHOCK GARMENT


The pneumatic antishock garment (PASG) has been used for many years in the prehospital and Emergency Department setting for the treatment of shock. The mechanism of action of the PASG is controversial. The increase in blood pressure after application of the PASG can be attributed to three affects:

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increase

peripheral

vascular

resistance,

enhanced

venous

return

(autotransfusion), and reduced volume loss from control of haemorrhage. Current indications for use of the PASG are limited. In Australia, its use is predominantly limited to the stabilization of pelvic and lower extremity fractures, i.e. as a pneumatic/air splint. By enclosing both the lower extremities and pelvis and by producing effects similar to a large air splint, the garment prevents movement.

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TRACTION SPLINTS
Traction splints are used to stabilize a fracture of the femur. Pulling on a broken limb draws the bones into line just as a string of beads straightens when it is pulled at each end. Muscular contraction will shorten any limb unless there is a bone to hold its ends apart and the traction must therefore be strong enough to overcome the muscle power, but not so strong that it holds the ends apart.

They consist of a buttress applied to the ischial tuberosity with metal arms extending distal to the foot. Between the metal bars, bandage or straps are applied to support the weight of the limb. Traction can be applied to the limb in a variety of ways.

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SKIN TRACTION
Skin traction is applied by means of adhesive strapping stuck directly onto the skin. Application (a) one person applies continuous manual traction to the leg (b) apply a foam traction kit or improvise with non-stretch 7.5cm strapping, I. With the foot flexed at a right-angle, position the spreader plate 7-10 cm from the sole of the foot and at right-angles to the leg. Ensure that this position is held and that the foam padding covers the malleoli.

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II. Measure the length of the strapping required and cut or fold each strip to this length. III. Beginning at the ankle, apply one or two turns to hold the foam padding securely in position. Next, using firm but even tension, apply the bandage in a figure of eight style from without inwards to retain the leg in a neutral position. It is important that no wrinkles should occur in the bandage at this stage, as pressure areas may develop. If too much tension is applied, then constriction of the blood floe to the foot and ankle may occur. The skin traction can be used in conjunction with the Thomas splint.

THOMAS SPLINT
The simplest form of fixed traction is a Thomas Splint. Originally devised by Hugh Owen Thomas in the 1800s.

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Uses: To provide support and/or splintage to a femoral fracture. To reduce internal blood loss and to relieve pain and muscle spasm. To provide fixed traction.

Procedure:

1. Select the size of the ring of the Thomas splint by measuring around the thigh of the injured leg at the level of the groin and adding 5 cm to allow for swelling. Select the length of the Thomas splint by measuring the inside of the leg from the groin to the heel and adding 25 cm in order to permit full plantar flexion of the foot. 2. Apply gentle traction to the leg by pulling on the strings of the skin traction while simultaneously supporting the heel. The pull of the cord must be along the line of the foam extension piece. Traction is maintained until the procedure is completed. 3. Pass the splint over the foot and position it comfortably at the groin. 4. The length of the splint is covered in a sling either of flannel or tubular gauze bandage, which supports the leg. 5. The skin traction strings are attached to the end of the Thomas splint and tied securely, maintaining gentle traction on the leg. 6. The leg is then stretched with a Spanish Windlass (nowadays usually made of two wooden tongue depressors) and the counter pressure taken by a padded leather ring at the upper end of the splint under the ischial tuberosity.

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7. Elevate the end of the Thomas splint.

DONWAY SPLINT
The Donway Traction Splint is designed to be fitted to a patient with no necessity to lift the limb prior to applying traction. The detachable ischial ring is slid under the patient without moving the limb. The main frame is then placed over the leg, with the two components locked together. The pneumatic system pushes the loose fitting ischial ring into correct alignment with the ischium and maintains traction by pushing apart the foot and the ring. But moderate tightening of the ischial strap, comfortable support is attained under the patients ischium for the duration of traction. The design of the ischial ring prevents force being exerted on the groin area, reducing the possibility of pressure areas. Traction is effected through the use of a pump which allows the force to be evenly applied on a progressive basis until the desired level is attained.

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The Donway has been designed to provide a direct linear relationship between the pneumatic pressure generated and the resulting traction force being exerted. When traction has been achieved, the collets are locked and the air is released from the system.

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Instructions for Use:

1. Feed the ischial ring under the knee, adjust around the thigh and fasten the buckle to achieve a loose fit.

2. Depress the air release valve to ensure that no excess pressure is retained in the system.

3. Unlock the collets, raise the footplate into the upright position and place the splint over the leg.

4. Adjust the side arms of the splint to the desired length, attach to the ischial ring pegs and lock by turning the side arms.

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5. Open the ankle strap and employing the necessary support, place the patients heel in the padded portion of the strap with the foot against the foot plate.

6. Maintaining the heel against the foot plate, adjust the lower Velcro attachment to ensure that the padded support member is positioned high on the ankle.

7. Criss-cross the top straps tightly over the instep starting with the longest strap.

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8. Tighten the straps around the foot-plate and secure with the Velcro attachment. The ankle strap and footplate are designed to ensure that, when traction is applied, the direction of pull is through the axis of the leg with the pressure being equally applied to the entire surface of the foot.

9. Apply pneumatic pressure with the pump, up to the desired level of traction and upon completion, moderately tighten the strap to secure the ring in the ischial load bearing position.

The operating range of the splint is 10-14 lbs traction. Safety pressure relief valves automatically operate if this range is exceeded, in this

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event, the collets should be locked, the air released, and the normal procedure for application of traction repeated. If the limb is badly displaced by the fracture, it is recommended that slow manual traction be used to align the leg, which should be adequately supported. Application of pneumatic traction will complete the re-alignment of the leg and ensure that traction is maintained along the osteal line. The application of equal pneumatic pressure in both arms of the splint ensures correct fitment of the ring to the ischium. Fine manual adjustment can be made where required. 10. Align the opened leg supports with the calf and thigh. Feed the leading tapered edge under the leg, over the top of the frame of the opposite side arm and back under the leg.

Adjust the tension to provide the required support and secure with the button fastener.

11. Feed the knee strap under the leg and secure above the knee with the buckle fastener.

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12. As the injured leg is under traction and adequately supported, the heel stand can be raised. Recheck the traction level and adjust where necessary.

13. Turn the collets until hand tight and apply a further quarter turn to lock the position of the side arms, and release the pneumatic pressure by depressing the air release valve until the gauge reads zero. The patient can now be moved.

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OTHER TRACTION SPLINTS


Hare Traction Splint

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Pelvic Slings/Splints
Patients with unstable pelvic fractures from high-energy mechanisms like pedestrian versus motor vehicle or a fall from a great height are at high risk of fatality from major blood loss. Understanding the anatomy of the pelvis and surrounding structures and the types of pelvic fractures that can occur can in the recognition and stabilization of a pelvic fracture. There are several methods to stabilize a fractured pelvis, but all share the goal of stabilization and reduction.

Anatomy and Function


The function of the pelvis is to bear weight. The weight of the upper body is borne by the pelvis and distributed to the legs when a person is standing or to the ischium when a person is sitting. The pelvis also protects major blood vessels and organs in the lower abdominal cavity, including parts of the digestive, urinary and reproductive systems. The pelvis is the attachment point for numerous muscles that connect the legs to the body. The actions of walking, running, standing and many other functions involve movement of an intact and stable pelvis. The pelvis is a ring of paired bones that is the attachment point between the upper and lower skeleton. The pelvic ring is formed by pairs of fused bones. The pelvis includes the sacral section of the spinal cord in the posterior. Attached to each side of the sacrum is an ilium, the top of which is known as the iliac crest. On the anterior portion of the pelvis are the pubis and the ischium. The two pubis bones are connected by the symphysis pubis. Many organs and blood vessels pass through or near the bones of the pelvis, including the bladder, urethra, end of the large intestine and internal reproductive organs. Large blood vessels located in the pelvic ring can be the source of severe bleeding, and large amounts of blood from uncontrolled haemorrhage can accumulate in the free space around the pelvis. The right and left iliac arteries descending from the aorta are located in the pelvis. Blood returns from the lower extremities via the right and left iliac veins. Major
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blood vessels also supply the tissue, bones and organs in the pelvic ring. Blood loss can also originate from bony fracture surfaces and surrounding soft tissue injuries. Uncontrolled bleeding is the leading cause of death for patients with a complex pelvic fracture.

Mechanisms of Injury Primary mechanisms of injury for pelvic fracture often involve large amounts of energy and/or mass. A motor-vehicle collision, motorcycle crash or even a downhill skiing accident are examples of high-force and high-speed collisions. Falls from height, such as a construction worker falling from a roof or a rock climber falling from a cliff, may result in pelvic fracture. Crushing injuries can also apply sufficient force to the body to cause a pelvic fracture. Pelvic ring fractures can be caused by different types of forces, such as lateral or anteroposterior compression and vertical shear forcing. Vertical shearing is likely from a fall; lateral compression is the most common type of force that can cause a pelvic fracture, since force is applied to the body from the side, as in a side-impact motor-vehicle collision.

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With anteroposterior compression, force is applied from front to back, which is typical in a head-on motor-vehicle collision. An iliac crest fracture, which is a fracture to the upper wing of the ilium, may present with localized pain, tenderness and bruising, but it is a relatively stable injury that is less likely to threaten adjacent organs or blood vessels. While this might be painful and show instability during a physical exam, the pelvic ring is intact. This type of pelvic fracture is isolated and stable, and the life threat is low. A pelvic ring fracture, which can occur in any of the locations where the separate bones fuse together, is a very serious injury that could involve significant blood loss and internal organ damage. For example, a separation could occur between the ilium and sacrum, or between the two pubis bones, or multiple separations could occur. The pelvic ring is more likely to separate in two or more places than in just one.

Any fracture of the pelvic ring is much more complex because of the amount of free space for internal bleeding and the damage that separated bone ends can cause to blood vessels and organs. A pelvic ring fracture is sometimes
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called an open book fracture, due to the now open appearance of the previously closed and stable pelvic ring.

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Stabilization
Stabilization of a suspected pelvic fracture is an important treatment. Continued movement of an unstable pelvic fracture can cause further injury, damage and blood loss. Early control of life-threatening bleeding is the primary goal of emergency treatment. The treatment goal is to reduce and stabilize a fractured pelvis. It is theorized that a circumferential pelvic sheet wrap or mechanical device: applies compression so there is less potential space for blood to accumulate in the pelvic cavity; puts pressure against, or tamponades, bleeding sources, such as fractured bony surfaces or ruptured vessels; reduces instability of the injured pelvis that could cause further damage to tissue, organs, bony surfaces and blood vessels; and reduces the patients pain by limiting movement of the pelvis. A variety of methods are available to stabilize an injured pelvis. One of the remaining accepted uses for MAST trousers or pneumatic antishock garments has been for pelvic fracture stabilization. Other methods that are becoming more popular include use of a standard hospital draw sheet to create a pelvic sheet wrap; the SAM Sling and the Traumatic Pelvic Orthotic Device, or TPOD. All of these methods apply circumferential compression to close the book.

Sheet Wrap
Following are the recommended steps for applying a pelvic sheet wrap. After identifying an unstable pelvis, fold the sheet smoothly (do not roll the sheet); place the sheet under the patients pelvis so it is centered over the greater trochanters, where the head of the femur attaches to the pelvis. On exam, you can palpate the bony prominence of the femur. In the supine position, the patients greater trochanter is often even with the space between his distal wrist and the base of the thumb. Wrap and twist the two running ends of the sheet around the patients pelvis. Once tightened, cross the running ends and

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tie or clamp them to maintain tension. Individuals must use their judgment regarding the correct amount of pressure.

Pelvic stabilization sheet wrap

The SAM Sling


The intention of the SAM Sling is to reduce and stabilize an unstable pelvic injury. It can be quickly applied at the accident scene or in the emergency department. Early application is recommended to reduce the risk of severe life-threatening bleeding. Its main design feature is a buckle that engages when a set amount of pressure is applied. The SAM Sling is padded for comfort and can stay on patients during x-ray. The SAM Sling is applied by placing the sling underneath the patient at the level of the buttocks and aligned with the greater trochanters and symphysis pubis. The sling is then closed and the buckle is tensioned to apply force in both directions.

The SAM Sling


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The T-POD
The T-POD is another device for emergency stabilization of a pelvic fracture. According to the manufacturer, it can help prevent blood loss during patient transport and aid in pain control. The T-POD is applied to a supine patient by first sliding the support binder under the small of the patients back and then under the pelvis. A pulley system attached to the binder is used to tension the system.

The Traumatic Pelvic Orthotic Device, or T-POD

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The SAM Sling.


The SAM Sling is the current device for pelvic immobilisation used by Ambulance Victoria. Instructions for use Step 1. Unfold the Sling with the white surface face up

Step 2. Place white side of Sling beneath patient at level of buttocks (greater trochanters/symphysis pubis).

Step 3. Firmly close Sling by placing black Velcro side of flap down on blue surface of Sling. Fold back material as needed. Try to place buckle close to midline.

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Step 4. Grab orange handle on outer surface of flap and release from flap by pulling upward

Step 5. With or without assistance pull both orange handles in opposite directions to tighten Sling.

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Step 6. Keep pulling until you hear the buckle click and feel free handle stop.

Step 7. As soon as the free handle stops, maintain tension and firmly press the orange handle against the blue surface of the Sling.

Step 8. To remove Sling, lift orange handle next to flap and release Velcro by pulling upward. Maintain tension and slowly allow Sling to loosen.

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Step 9. Do not cut to remove. Release orange pull handle in order to remove.

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Clinical Practice Guidelines and Competency Assessment Tools

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References and Suggested Further Reading


Bache, J., Armitt, C. & Gadd, C. Practical Procedures in the Emergency Department, London,1998, Mosby. Buttman, A., Martin, S., Vomacka, R, & McSwain, N. Comprehensive Guide to Prehospital Skills. St Louis, 1996, Mosby Yearbook. Curtis, K., Ramsden, C. & Friendship, J. (Eds) Emergency and Trauma Nursing, Sydney, 2007, Mosby Elsevier.

Frakes, M.A. & Evans, T. Major Pelvic Fractures. Critical Care Nurse Vol 24, No 2 April 2004. pp. 18-30. McSwain, N, Frame, S., & Salome, J. (Eds) PHTLS Basic and Advanced Prehospital Trauma Life Support. 5th Edition. St Louis, 2003, Mosby.

Meredith, R. & Butcher J. D. Field Splinting of Suspected Fractures: Preparation, Assessment, and Application. The Physician and Sportsmedicine. Vol 25. No. 10. Oct 1997.

Proehl, J.A. (Ed) Emergency Nursing Procedures, 3rd Edition. St Louis, 2004, Saunders. Roberts: Clinical Procedures in Emergency Medicine. 4th Edition. 2004, W.B. Saunders, Philadelphia. Semonin-Holleran, R. (Ed.) Air and Surface Patient Transport Principles and Practice. 3rd Edition. 2003, Mosby Inc, St Louis. Chapter 18. pp. 305-319.

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Simpson, T., Krieg, JC., Heuer, F., Bottlang, M. Stabilization of pelvic ring disruptions with a circumferential sheet. J Trauma-Inj Infect Crit Care 52(1):158161, 2002.

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