Splinting and Immobilization Techniques and Devices Final PDF

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 Date Major Changes Page No

1.0 April 2009
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.
Splinting,BandagingandImmobilizationTechniquesandDevices Page2
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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 re-
evaluation 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 Description Length
I: Haematoma Immediately following fracture, bone ends rub together - 1-3 days
Formation called crepitus causing pain. Amount of haematoma
Depends on the damage to bone, soft tissue and vessels
around the fracture
II: Granulation Granulation tissue forms after fibroblasts, osteoclasts and 3 days -
and chondroblasts invade the haematoma as part of the 2 weeks
inflammatory sequelae. Osteoclasts remove dead bone and
osteoblasts produce bone
III: Callus The fracture becomes sticky due to plasma and white
Formation blood cells entering the granulation tissue. This 2-6 weeks
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
IV: Ossification/ Osteoblasts and connective tissue are prolific, bringing

Consolidation the bone ends together. Bridging callus envelops the
fracture fragment ends and moves towards the other 3 weeks -
fragments. Medullary callus bridges the fracture 6 months
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
V: Remodelling Re-establishment of the medullary canal. Fragments

of bone are united. Surplus cells are absorbed, bone 6 weeks -
is remodelled and healing is complete 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
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- plaster
- vacuum
- finger splints
- knee immobilizer
PNEUMATIC INFLATABLE SPLINTS
Include
- air splints
- pneumatic antishock garments (PASG)
TRACTION SPLINTS
Include
- 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 non-
adherent. 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 hand-
breadth 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 pre-
applied, 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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Bandaged-to-Back-Splint.png
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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.
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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 T-
POD. 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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Splinting, Bandaging and

Immobilization Techniques and

A GUIDE FOR EDUCATION &

Compiled by: Wendy Porteous

Thank you to:

For information regarding this Guide contact:

Version Date Major Changes Page No

Front page image sourced from -

It is the responsibility of each individual practitioner and Health Service to

Overview Anatomy and Physiology...7

Soft tissue injuries.12

Types of soft tissue injuries.14

Strains and sprains...16

Dislocations and subluxations.16

General principles of splinting.19

Indications, contraindications and cautions..19

Soft Non-rigid splinting.22

Other general use rigid and semi-rigid splints..30

Semi-rigid formable splints......32

Clinical Practice Guidelines and competencies...64

References and suggested further reading..76

Splinting and bandaging plays an important role in the management of

Immobilisation facilitates the healing process by decreasing pain and

The primary objective of splinting is to prevent motion of fractured bone

Healing of an uncomplicated fracture may take from 6 weeks to 6 months.

Stages of fracture healing

Stage Description Length

IV: Ossification/ Osteoblasts and connective tissue are prolific, bringing

V: Remodelling Re-establishment of the medullary canal. Fragments

Soft Tissue Injuries

Soft tissue injuries incorporate many structures, namely blood vessels,

Mechanism of soft tissue injury

Penetrating: penetrating objects such as bullets, knives, or fracture ends can

Types of soft tissue injuries

Blood vessels: blood vessels can be damaged in four ways: crushing,

Nerves: can also be damaged by crushing, penetrating and stretching with

Skin: can be damaged by a number of forces as well as direct trauma. If a

Tendons: connect muscle to bone and permit conduction of force by muscle

Strains and sprains

Dislocations and subluxations

A dislocation is when the articular (joint) surfaces are no longer in contact;

Bone has some degree of elasticity. A fracture results from stress/force

Fractures are classified as stable or unstable. Stable fractures are unlikely to

1. Injured extremities should be handled gently, minimise movement of

SOFT SPLINT NON-RIGID SPLINTS

HARD-RIGID AND SEMIRIGID SPLINTS

PILLOWS, BLANKETS and IMPROVISED SOFT SPLINTS

Bandages are used to give support to an injured area or apply pressure to an

Slings are used to:

BROAD ARM SLINGS

HIGH ARM SLINGS

Used to support an injured shoulder, clavicle or upper extremity, Collar and

All splints, regardless of size, adjustability, or other unique qualities,

SEMI RIGID FORMABLE SPLINTS

Aluminium Splints SAM Splints

The SAM splint is a durable aluminium splint wrapped in hypoallergenic

Wire Ladder Splints

Cardboard splints are generally made of either fluid-impervious plastic

PASG PNEUMATIC ANTISHOCK GARMENT

Traction splints are used to stabilize a fracture of the femur. Pulling on

Skin traction is applied by means of adhesive strapping stuck directly

The simplest form of fixed traction is a Thomas Splint. Originally

The Donway Traction Splint is designed to be fitted to a patient with no