Improvised Splinting: Field Materials and Technique

The Purpose of a Splint

A splint immobilizes a fracture to reduce pain, prevent further soft tissue damage from bone-end movement, and decrease bleeding from surrounding vessels. It is not a repair — it is stabilization for the journey to definitive care.

Three things a proper splint accomplishes:

1. Immobilizes the joint above and below the fracture
2. Maintains the extremity in a functional position (position that minimizes muscle tension and maximizes blood flow)
3. Remains in place without constricting circulation

Position of Function

The position of function is the natural resting position that minimizes muscle tension and maintains joint mobility if swelling causes temporary stiffness.

| Location | Position of Function | |---|---| | Wrist | Slight extension (20-30 degrees), thumb slightly opposed | | Elbow | 90 degrees of flexion | | Shoulder | Arm across chest in sling, elbow at 90 degrees | | Finger | Slight flexion, approximately 20-30 degrees at each joint | | Ankle | 90 degrees (foot perpendicular to leg) | | Knee | Slight flexion (10-15 degrees) — do not force a hyperextended leg to bend | | Hip / femur | Limb in anatomical position with traction if femoral shaft fracture |

Improvised Materials

Rigid Components

The rigid part of the splint provides the support:

• Folded magazine or newspaper: Roll tightly or fold to 3-4 layers. Excellent for wrist and forearm splints. Moldable when wet.
• Cardboard: Cut and fold to desired thickness and length. More rigid than magazine for longer splints.
• Branches and sticks: Smooth, straight, at least as long as the segment to be immobilized. Cut bark if irritating.
• Trekking poles, ski poles, tent poles: Excellent length, often adjustable.
• SAM splint (commercial aluminum foam splint): Pre-formed foam-covered aluminum that bends to any shape and maintains it. One of the highest-value items per ounce in a field medical kit. Buy several.
• Rolled clothing: Rolled tightly enough becomes semi-rigid. Not ideal but acceptable.

Padding Components

Every rigid object must be padded before it contacts the skin. Unpadded splints cause pressure sores within hours, and bony prominences (the back of the heel, the malleoli, the radial styloid) will develop full-thickness pressure ulcers if not padded.

• Clothing: Fold into strips, wrap around the limb before applying rigid material
• Sleeping bag material: Excellent padding — cut or tear sections
• Foam sleeping pad: Ideal. Cut strips 3-4 inches wide, wrap around limb.
• Socks: Stack over a bony prominence before splinting
• First aid kit foam or cotton batting

Securing Components

Once the padded rigid material is in place, it needs to be secured:

• Triangular bandages / cravats: Fold to 2-inch width. Three to four cravats secures most limb splints.
• Elastic bandage (ACE wrap): Excellent for securing. Start distal, work proximal. Overlap each wrap by 50%. Do not overwrap — snug, not tight.
• Torn strips of clothing: Cut along the grain, 2-3 inches wide, long enough to wrap around and tie.
• Duct tape: Functional but sticks to skin and hair. Apply over clothing or padding, not directly to skin.
• Paracord: Works but can constrict. Use with padding underneath. Do not tie directly over a bony prominence.

Splinting Technique: Step by Step

1. Check neurovascular status before splinting. Pulse, sensation, motor function distal to the injury. This is your baseline. Write it down if possible.

2. Prepare padding. Enough to cover all bony prominences and create a uniform layer around the injury site.

3. Prepare the rigid component. Cut to appropriate length — it must extend one joint above and one joint below the fracture. A forearm fracture needs a splint from the hand to above the elbow.

4. Position the limb. Move into position of function unless fracture position resists movement (do not force it) or unless no distal pulse requires you to attempt realignment.

5. Apply padding first. Wrap the limb in padding before the rigid material touches it.

6. Apply the rigid component. For most limb fractures, you can apply one rigid piece along the posterior (back) side of the limb or sandwich the limb between two pieces.

7. Secure with ties or wrap. Space ties every 3-4 inches. Tie or secure distal to the fracture, then proximal, then at the fracture level. Not over the fracture site itself.

8. Reassess neurovascular status. Immediately after securing. Check again at 15-30 minute intervals. If pulse diminishes or sensation decreases, loosen the splint immediately.

9. Elevate the injured limb when possible (above the level of the heart) to reduce swelling.

Common Fracture Locations: Specific Technique

Wrist Fracture (Distal Radius)

Most common fracture from falling on an outstretched hand.

1. Position the wrist in slight extension (20-30 degrees), thumb pointing upward
2. Cut a magazine or fold cardboard into a piece roughly 4 inches wide × 10 inches long
3. Fold to form an L-shape or trough that cradles the palm and forearm
4. Pad with rolled clothing
5. Apply to the palm side of the wrist and forearm
6. Secure with elastic bandage or cravats from fingers to mid-forearm
7. Create a sling to support the elbow at 90 degrees

Forearm Fracture (Radius and/or Ulna)

1. Immobilize in position of function: elbow at 90 degrees, wrist neutral
2. Apply padded rigid material along the entire forearm, wrist to elbow
3. Secure with wrapping
4. Apply sling

Ankle Fracture

1. Keep ankle at 90 degrees (perpendicular to leg)
2. The SAM splint or folded sleeping mat forms a U-shape under the heel and up both sides of the lower leg
3. Pad heels, malleoli (ankle bumps), and Achilles area heavily
4. Apply padding, then rigid material
5. Secure from toes to just below the knee
6. Do not cover the toes — they are your neurovascular check

Lower Leg Fracture (Tibia/Fibula)

1. Apply padding to entire lower leg
2. Rigid material on both sides or a posterior splint from foot to just below knee
3. Maintain ankle at 90 degrees
4. If available, use two trekking poles on either side secured with cravats
5. Check foot pulses (dorsalis pedis on top of foot, posterior tibial behind medial malleolus)

Femoral Shaft Fracture

This is the one fracture where traction splinting dramatically improves outcomes. Femoral shaft fractures cause 1-2 liters of blood loss into the thigh. Traction reduces bleeding and pain by realigning the fracture and reducing the volume of the hematoma.

Commercial traction splints (Sager, Hare, SLISHMAN) are the proper tool. Every trauma kit should have one.

Improvised traction:

1. Secure a padded stick or pole to the pelvis and down past the foot
2. Attach a loop to the ankle and attach it to the end of the pole
3. Twist to apply traction — the same principle as a windlass on a tourniquet
4. Apply just enough traction to reduce deformity and decrease pain
5. Secure the traction position before moving the patient

Traction splinting does not apply to: fractures near the hip joint, fractures near the knee, open femur fractures, pelvis fractures.

Finger Fractures

Buddy taping: tape the injured finger to the adjacent uninjured finger. Use a small pad of gauze or foam between the fingers to prevent skin-on-skin moisture problems. Tape at two points — at the base and tip of the finger. Do not tape over a joint.

For fractures that are clearly displaced or angulated, gentle longitudinal traction often reduces the fracture back to alignment. Apply traction firmly along the long axis of the finger, pulling toward the fingertip, for 30-60 seconds.

After Splinting: Monitoring

The most dangerous post-splint complication is compartment syndrome — increasing pressure within the muscle compartments as swelling increases. The splint limits the external expansion of swelling, causing internal pressure to build to levels that cut off blood flow.

Signs:

• Pain that increases rather than decreases after splinting
• Pain that is out of proportion to the injury
• Pain with passive stretch of the muscles (e.g., passively extending the fingers with a forearm fracture causes severe pain in the forearm)
• Tightness or firmness of the splinted compartment
• Decreased sensation or tingling

Response: Loosen or remove all wrapping immediately. If symptoms persist, remove the splint entirely. Reassess. Compartment syndrome is a surgical emergency.

For evacuations lasting hours or days, reassess splint fit every 2-4 hours. Swelling changes the fit. A splint that was appropriate 4 hours ago may be too tight now.