Chapter

Splints, Bandages, Slings and

Braces in the Casualty Environment

5
Trauma epidemic is spreading like a wildfire. When a
traumatized patient is brought to casualty, primary survey
and assessment of the patient is the priority to rule out
life, threatening problems. Airway, breathing and
circulation of the patients should be assessed and
maintained. Shock is a common problem especially in
polytrauma patients which must be managed as a priority.
Pneumatic antishock garments will also help in reducing
the shock. Along with maintenance of ABC and antishock
measures, the surgeon should examine the patients for
injuries. In conscious patients, all the sites of pain should
be evaluated. All limbs, pelvis and spine must be examined
for tenderness in all patients.
Damage to underlying structures like muscles, tendons,
ligaments and synovial joints as well as bones may occur
during injury. These injuries result in pain and take a long
time to heal. Splints maintain proper posture and provide
much needed rest to the injured part. For healing it is
important that the relevant tissues and associated joints are
supported and rested. Splints provide support to tissues.
However, if proper immobilization and support are not given
during the healing phase, significant delay in repair along
with pain due to joint movements occurs. Permanent
damage due to damage to internal structures can occur,
resulting in lifelong disfiguration.
Awareness regarding prevention can significantly reduce
the complications. The aim of providing splintage in fracture
patients is to alleviate pain which is due to movements of
the fracture fragments and damage to muscles and other

SC Goel, Amit Rastogi

soft tissues and to temporarily immobilize fractures,

dislocations, and soft tissue injuries. Evidence of
rudimentary splints is found as early as 500 BC.

INDICATIONS OF SPLINTAGE IN TRAUMA

Fractures
Sprains
z
Joint infections
z
Tenosynovitis
z
Acute arthritis/gout
z
Lacerations over joints
z
Puncture wounds and animal bites of the hands or feet.
It is very important to take a proper history and enquire
about mode:
z
Fall vs blunt trauma vs twist
z
How did you land?
z
Where is the worst pain (use one finger)?
z
Could you walk right afterwards?
z
Neck pain/back pain if severe fracture(s).
Examination should be directed to diagnose suspected
fractures:
z
Point tenderness/deformity
z
Open fracture
z
Joint swelling
z
Muscle spasms
z
Function/sensation below fracture
z
z

30

First Aid and Emergency Management in Orthopedic Injuries

ROM/walk
z
Neck/back if distracting injury.
Splintage for immobilization of the injured part must
include joint above and below the fracture. It should not be
too tight. Padding should always be used. It should not be
too loose also.
In case of open wounds, the wound is covered with sterile
dressing and compression bandages are applied to reduce
bleeding. Splinting of the open fractures is done in the same
way as closed fractures.
Before a patient is sent to Radiology Department for
X-rays, splintage must be done. This will avoid further
damage to parts and make the patient comfortable.
z

Advantages of Splinting

Further soft tissue injury (especially to nerves and vessels)

is avoided and closed fractures are saved from becoming
open
z
Pain is relieved due to immobilization
z
The incidence of fat embolism and shock is reduced
z
Patient transportation and radiographic studies are
facilitated.
The splints may be of three types: soft, rigid and traction.
z
Soft splints may be slings and cuff and collar support
for upper limb; pillow support to the injured part of
lower limb and also for upper limb or inflatable clear
plastic air splintonce inflated it conforms to the shape
of the limb and becomes stiff enough to immobilize the
injured part without causing excessive harmful pressure.
However, the pressure inside the splint must be frequently
monitored
z
Rigid splints are made of firm material and must be
padded. Materials used are wooden board, cardboard,
malleable metal frames, moulded plastic or metal, etc.
Plaster of Paris bandages may also be used for rigid
supports. Circumferential casts should never be used as
they may cause compartment syndrome and other
complications
z
Traction splints counteract strong muscular forces,
realign and maintain the alignments, and provide
effective immobilization of the fractures. Unconventional
splints can be made of folded newspapers, wood,
cardboard, umbrella, etc. in case of nonavailability of
proper splints
z

In developed countries, a fiberglass splinting material,

called Orthoglass, is commonly used for several reasons:
i. It is clean, unlike most plaster splinting materials.
ii. It comes in rolls and can be easily measured and cut
according to the patients dimensions.
iii. It comes prepadded, which saves time and energy
trying to roll out padding.
iv. It dries in about 20 minutes, and there are no risks
for burns involved.
Commonly Used Splints

Posterior elbow
z
Volar wrist splint
z
Finger splints
z
Thumb spica
z
Sugar tong
z
Ulnar gutter
z
Thomas knee splint
z
Long leg splint
z
Posterior lower leg
z
Posterior full leg
z
Ankle stirrup.
Ideal first aid splint should be efficient, light, inexpensive,
easily applied to a variety of anatomical locations, easily
stored or carried and radiolucent.
All wooded splints must be padded with cotton wool
and covered with gauze bandages. The splint can also be
made of plaster of Paris slab, which will be more comfortable
as it takes the shape of the body contours. Various
thermoplastic materials are also used for making splints.
They are convenient, comfortable and light in weight.
Knitted polyester/cotton substrate impregnated with a
polyurethane resin is being substituted for the plaster of
Paris bandages. It makes a strong, light weight, compact,
water resistant, durable and radiolucent cast. These are more
convenient, comfort and aesthetics to the patient, but are
more costly.
Crepe bandages: Crepe bandage can be applied in order to
increase external pressure and maintain homeostasis. It helps
in vasoconstriction. It can be helped to immobilize the joints
and help tissue repair when it allows rest to strained/injured
part, especially ankle, wrist, knee, etc. (photo). It can be
applied uniformly or in figure-of-eight pattern.
z

Splints, Bandages, Slings and Braces in the Casualty Environment

Traction may also be used to immobilize the limb. By

aligning the fracture, there is less risk of additional damage
to soft tissues. By mild traction, fascial compartments are
stretched and a tamponade effect can occur. Open book
type fracture of pelvis should be splinted with a pneumatic
shock garments.
Surface traction is applied over the leg and the weight is
suspended over the pulley(s) of Brauns or Bohler Brauns
splint or as Russell traction. Countertraction is affected by
the weight of the body mainly while the patient is lying on
a plane nonsagging bed and further by elevating the foot
end of the bed. In case of upper limb, surface traction is
applied over the forearm and countertraction is mainly by
body weight.

Fig. 5.2: Pneumatic ankle splint.

(For color version, see Plate 1)

Cramer Wire Splint

Cramer wire splint is a universally applicable malleable splint

made of wires resembling miniature ladders with malleable
metal uprights and wire rungs (Fig. 5.1). They can be bent
into appropriate shapes, padded and bandaged to the
extremities. They do not appreciably interfere with X-ray
examinations and are most useful. It is padded with cotton
wool and covered with bandage. It can be moulded to fit
any joint and body contours, shoulder, elbows, etc.
Pneumatic Splints

Inflatable splint can be used for immobilization of fractures

below the knee and injuries of the forearm. This type of
splint can interfere with blood flow in an injured limb should
be kept in mind. The splint is inflated by mouth or pump
(Fig. 5.2). They should not be applied over clothing, because
folds can cause high pressure points and blistering. The
pressure of 20 to 30 mm Hg obtained in this way produces
sufficient rigidity for fracture immobilization. More recent
developments in design have produced a fluted splint which
is claimed to give good fixation without any embarrassment
to the circulation.

Fig. 5.1: Cramer wire splint.

31

Splints can be made from wood, aluminum, plaster of

Paris or thermoplastic materials. Universal arm and leg splints
are aluminum and prefabricated to fit the leg or upper limb.

SPINE
Spine board: Spine board can be stretcher/canvas stretcher
as in military for transport of emergency patient. The patient
has to be logroll to a spine board which requires four
individuals. Leader immobilizes the head and neck in crossed
arm technique, while others are positioned at the shoulders,
hips and lower legs. Head is immobilized, while straps at
chest, pelvis and knee joints secure stability.
Pneumatic collar: It is used in condition of injuries around
neck and stabilizes the structures during emergency care
and transportation.
Hydraulic collar: Similar to above in function but water is
used in plastic sleeve instead of air to support the neck.
Rigid adjustable cervical collar: It is made out of rigid
polyethylene plastics. Edges are soft cushioned with vinyl
covered foam (Fig. 5.3). Height of the collar can be
accurately varied. It is recommended where better
immobilization of the cervical region is required, than
provided by soft collar. Philadelphia collar may also be used.
Sterno-occipital mandibular immobilizer: SOMI differs
from fore-post collar insofar as its two posterior uprights
arise from a sternal plate, extending upward and backward,
and attach to the occipital support. Its single anterior
upright, with attached mandibular support, can be quickly

32

First Aid and Emergency Management in Orthopedic Injuries

Fig. 5.3: Philadelphia cervical collar.

(For color version, see Plate 1)

Fig. 5.4: ASH brace (anterior hyperextension brace).

(For color version, see Plate 1)

and easily removed from the sternal plate. This allows the
patient to eat, wash or shave while remaining in a supine
semi-immobilized position. As it has no interscapular plate,
it can be applied with relatively little disturbance to the
supine patient. Although, control function of cervical
extension and lateral flexion is significantly less, SOMI
provides approximately the same control of cervical flexion
and rotation as is provided by other post appliances.

chest, with the provision that that in some associated chest

injuries it may be necessary to dispense with the body bandage.
Clavicle brace:
1. It braces the clavicle back thus maintaining length of
clavicles without telescopy.
2. Arm pouch sling with/without shoulder immobilizer.
Shoulder immobilizer supports and immobilizes the
dislocated shoulder and fractures of clavicle bone more
effectively. Pouch holds the arm and the arm restraint
band immobilizes the shoulder.
Cuff and collar sling: A comfortable sling can be made out of
Gauze bandages or a triangular sling out of cloth (Fig. 5.5).
Ready made slings made of polyurethane foam covered with
cotton stockinet to replace the conventional arm support
are available. It works as functional fracture sleeve to the
patients with fracture of the diaphysis of the humerus and
others.
Shoulder abduction frame: Generally prefabricated, these
orthoses consist of chest, axillary, and elbow supports
joined by overlapping bars that permit accommodation
to various limb lengths. Adjustable shoulder and elbow
joints may also be included for setting the angle of elbow
flexion and shoulder abduction. Mostly used in brachial
plexus/ axillary nerve injury, deltoid palsy of poliomyelitis,
late treatment of tuberculosis of shoulder and shoulder
joint injuries. Function is to support the upper arm and
shoulder, protecting the shoulder from adduction
contracture. It relieves tension on the superior aspect of
the shoulder. Upward support will tend the shoulder
external rotation, stretching the internal rotators and relieve
tension on the deltoid and rotator cuff as needed postsurgery.

Dorsolumbar Spine

1. ASH brace: It provides extension, prevent rotation and

stabilizes the spine in the sagittal plane for wedge
compression and thoracic vertebrae cases (Fig. 5.4). It is
based on the principles of three point force application
involving lumbar vertebra on one side and sternal and
symphysis pubis supporting on other side. Chest support
provides stimus to restrict active flexion. As it is waterproof and hence can be worn while bathing.
2. Rib corset: It compresses and binds the rib cage while
allowing sufficient flexibility for comfortable breathing
in rib/sternum fractures and dislocations. It is made of
superior quality elastic webbing. It reduces discomfort
of sudden rib cage expansion from deep breaths following
thoracic surgeries.

UPPER LIMB
For the upper limb a padded cramer wire splint with the
elbow at a right angle and the arm in a sling is an effective
form of temporary immobilization for any injury from the
lower third of humerus downwards. For injuries to the
shoulder and upper part of the humerus, by far the best
form of splintage is a sling with the arm bandaged to the

Splints, Bandages, Slings and Braces in the Casualty Environment

33

Fig. 5.5: Cuff and collar sling.

Fig. 5.6: Cock-up splint.

(For color version, see Plate 2)

Lateral Elbow Splint

This right angle splint is useful to immobilize distal arm,

elbow and forearm. It consists of the wooden bars joined at
right angle. This joint coincides with patients elbow joint.
Cock-up splint (Fig. 5.6)
Forearm splint (Fig. 5.7)
Finger Splints

These are very useful devices for emergency as well as

definitive stabilization of finger injuries both skeletal as well

Fig. 5.7: Forearm splint.

(For color version, see Plate 2)

as soft tissue. Most finger splints are made of aluminum

and are padded at pressure points. All of them are mouldable
(Figs 5.8A to F). The finger cot splint is basically used for
splinting fractures and soft tissue injuries around the PID
joint. The Frog splint is specially designed for definitive
treatment of mallet finger and swan neck deformities in the
rheumatoid hand. Mallet fingers can also be treated in the
mallet finger splint as it recipes only the DIP in Hyperextension. The Finger Extension splint is used to immobilize
MP Joint in 90o flexion and the finger in full extension
(Intrinsic Plus Position).

34

First Aid and Emergency Management in Orthopedic Injuries

Figs 5.8A to F: (A) Finger rings, (B) Open finger cot splint, (C) Stack splint, (D) Swan-neck splint,
(E) Finger extension splint, (F) Finger cot splint. (For color version, see Plate 2)

traditionally strapping was done as it prevents varus/valgus

stresses.

LOWER LIMBS

Fig. 5.9: Thumb spica splint.

(For color version, see Plate 3)

A thumb spica splint is useful in the acute care of injured

thumb especially for fracture of the base of the proximal
phalanx but should not the used for Bennetts fracture as it
does not retain reduction (Fig. 5.9). The swan splint is used
in acute or chronic rupture of the middle slip of the extension
apparatus of the finger. Silicon finger rings can be used to
treat soft tissue injuries or dislocation in the finger for which

Lower limb injuries can be immobilized in a similar way,

using cramer wire or wood box splints for injuries from the
foot to the upper tibia and a Thomas splint with clove hitch
or skin traction for fractures from the knee upwards. For
transport from the site of the accident it may be more
convenient to immobilize femoral injuries in a long Liston
splint; this is a padded wooden bar extending from the axilla
to the foot and fixed to the body and leg by slings. This
method has fallen into disrepute, mainly because of the
inadequate way in which it has been applied, but it still has
a place in first aid treatment of the injured. If traction is
used, it must be remembered that it can only be used
temporarily and must be heavily padded to prevent skin
sores; skin traction is preferable and can be applied almost
as quickly provided that prepared rolls of traction adhesive
plaster are readily available. Care must be taken to protect
the ankle and malleoli with wool roll to prevent the adhesive
plaster pulling on the skin over this part.

Splints, Bandages, Slings and Braces in the Casualty Environment

Thomas Knee Splint

The Thomas knee splint is widely used to provide

immobilization and traction in injuries of shaft of femur,
neck of femur and knee injuries. Thomas splint was
described originally by High Owen Thomas as a knee
appliance which he used in the ambulant management of
chronic or subacute inflammation of the knee joint. The
present splint consists of a padded oval metal ring covered
with soft leather, to which are attached inner and outer side
bars (Fig. 5.10). These side bars which bisect the oval ring
are of unequal length so that the padded ring is set at an
angle of 120 degrees to the inner side bar. At the distal end
the two side bars are joined together in the form of a W.
The outer side bar is often angled out 5.0 cm below the
padded ring, to clear a prominent greater trochanter. To
determine the size of Thomass splint the distance from the
crotch to the heel is measured and 15 to 23 cm is added to
it. This distance equals the length of the inner side bar.
Slings of lint or suitable cloth are tied between the side
bars, on which the limb can rest. Two ends of the sling are
fastened with two large safety pins. In this way the tension
of the sling can be adjusted easily after the splint has been
fitted to the limb, to ensure uniform support of the limb
and to avoid excess pressure in the region of the neck of the
fibula and the tendo calcaneus. The distal sling must end
about 6 cm above the heel to avoid pressure sores developing
over the tendo calcaneus.
The slings tend to slip distally on the side bars of the
Thomass splint. This can be prevented by pinning each
sling to the one above or by binding the side bars with zinc
oxide strapping before applying the slings.
A Pearson knee flexion attachment can be attached to
Thomas splint to provide for Knee flexion. The hinge of
this attachment must coincide with the axis of movement
of the knee joint. The movement of flexion and extension
at a normal knee joint is not one of simple hinge movement,
but is complex, following a polycentric pathway (the instant

Fig. 5.10: Thomas splint.

35

centers determined for each increment of flexion moving

posteriorly in a spiral pattern).
After the splint has been fitted, the limb is bandaged
into the splint.
Thomas splint with the addition of plaster of Paris,
known as Tobruk splint was used by the British Army in
World War II for transportation of injured soldiers. Thomas
splint can be used to apply fixed traction. The limb is
supported on the Thomas splint, and the pulling string is
tied under desired tension to the notch at the end of the
splint and countertraction is obtained by hitching against
some fixed bony points, e.g. ring of the Thomas hitching
against the ischial tuberosity. The pulling string is checked
daily for maintaining tension and tightened as needed.

BOHLER BRAUN SPLINT

This consists of a metallic frame with 4 pulleys. This is useful
in distal femoral fractures and leg injuries. Traction is applied
to the limb which is kept off the frame (Fig. 5.11).
Long Leg Splint

Long Liston splint is a rigid splint which is used to

immobilize fractures of pelvis, hip and thigh (Fig. 5.12). It
is about 3" in width and extends from axilla to about 4"
beyond heel. The distal end of the splint is zigzag-shaped to
allow secure fixation to the limb. It is used as fracture aids.
It can be wooden or foam lightweight splint. It supports
and immobilizes the leg during transport, pre/post operation
care, following TKR/surgery/ injury. It maintains knee joint
in functional position. It is reusable and convenient.

Fig. 5.11: Bohler Braun splint.

36

First Aid and Emergency Management in Orthopedic Injuries

Fig. 5.12: Long leg splint.

Fig. 5.13: Posterior leg splint.

Posterior Leg Splint

The splint is right angle splint used for fractures of leg bones
(Fig. 5.13). The foot rests on horizontal limb of the splint.
It extends proximally to above the knee.
Skin or skeletal traction with pulleys: Skin traction is used
as adhesive liner or foam liner. Skeletal traction is given
through a Denham pin passed through proximal tibia or
calcaneum. The main purpose it to immobilize, reduce
muscle spasm, pain and help in tissue repair. Traction is
useful as first aid in femoral fractures.
Knee braceLong and Short: It is a device to immobilize,
support and protect the injured knee. Made out of high
quality, three layered Polyurethane foam fused fabric, which
provides comfort. Spring steel reeves on the lateral sides and

contoured aluminum splints on the dorsal side ensure perfect

support, fitting and immobilization. Elastic Velcro flaps help
to get a better grip and fitting of the brace around the knee.
It is indicated for fractures, muscular, ligament injury and
dislocation of knee.
The universal knee brace, as the name suggests is used
to immortalize the knee in most types of synovitis and
ligament injuries. It neutralizes varus/valgus forces and can
be set to provide only the required degree of flexion and is
hence useful for acute as well as postoperative treatment of
ligament injuries around knee (Figs 5.14 and 5.15).
The open patella knee hinge is used in the acute setting
of knee injuries during sports associated with knee effusions/
hemarthroses (Fig. 5.16).
Gaiter polypropylene splint: Such splints are largely used as
back support in knee joints in order to support weaker group
muscles. In spastic muscles it works as stimulus, as posterior
part impinges around.
MAST/PASG: Also called as military antishock trousers/
pneumatic antishock garments. It was extensively used earlier
in the war injuries to delay death by shock by compressing
extremities and rerouting available blood to the central
organs. PASG is a full body suit and can lead to morbidity
and even mortality if used injudiciouslyhence no longer
a favoured device. MAST is a bilayer trouser made with
impervious to air fabric which can be inflated to above
systolic pressure so as to act like a tourniquet for both lower
limbs.

Splints, Bandages, Slings and Braces in the Casualty Environment

Fig. 5.14: Rigid knee brace.

(For color version, see Plate 3)

37

Fig. 5.16: Open patella knee brace.

Complications

Fig. 5.15: Universal knee brace.

1. Burns
Thermal injury as plaster dries
Hot water. Increased number of layers, extra fastdrying, poor paddingall increase risk.
If significant painremove splint to cool.
2. Ischemia
Reduced risk compared to casting but still a possibility
Instruct to ice and elevate extremity
Close follow-up if high-risk for swelling, ischemia
When in doubt, cut it off and look
Rememberpulses lost late.
3. Pressure sores
Smooth cotton and proper plaster.
4. Infection
Clean, debride and dress all wounds before splint
application
Recheck if significant wound or increasing pain.
In case of any complaints of worsening pain, the splint
should be taken off immediately and patient examined for
compartment syndrome.