Fractures, Sprains, and Immobilization Techniques

Introduction

Fractures and sprains are common musculoskeletal injuries requiring prompt assessment and appropriate management. Fractures involve breaks in bone continuity, while sprains involve stretching or tearing of ligaments. Proper initial care including immobilization significantly reduces pain, prevents further injury, and improves outcomes.

Fracture Classification

Anatomic Classification

Fracture Type	Description	Example
Complete	Fracture fragments completely separated	Transverse, oblique, spiral
Incomplete (greenstick)	Partial fracture through one cortex, bone bent	Common in children
Simple (closed)	Skin intact over fracture site	Most fractures before treatment
Compound (open)	Bone communicates with external environment through wound	High-velocity trauma, requires urgent washout
Comminuted	Three or more fragments	High-energy trauma, osteoporosis
Segmental	Two separate fractures in same bone with intact segment between	High-energy trauma
Impacted	Bone fragments driven into each other	Hip fractures, proximal humerus
Pathologic	Fracture through abnormal bone (tumor, infection, osteoporosis)	Minimal or no trauma
Stress (fatigue)	Repetitive microtrauma exceeding bone’s repair capacity	Runners (metatarsal), military recruits (tibia)
Avulsion	Fragment pulled off by tendon/ligament	Patella, finger phalanges, pelvic apophyses
Intra-articular	Fracture extends into joint surface	Requires anatomic reduction

Fracture Displacement Description

Descriptor	Meaning
Displacement (% or mm)	Amount of offset between fracture fragments
Angulation (degrees)	Angle between distal and proximal fragments
Rotation	Rotational malalignment
Shortening	Loss of length due to overlap
Distraction	Gap between fragments
Impaction	Fragments driven together

Open Fracture Classification (Gustilo-Anderson)

Grade	Wound Size	Contamination	Soft Tissue Damage
I	<1 cm	Clean	Minimal
II	1-10 cm	Moderate	Moderate, no crushing
IIIA	>10 cm	Heavy	Extensive, adequate soft tissue coverage
IIIB	>10 cm	Heavy	Extensive, requires flap coverage
IIIC	Any	Heavy	Arterial injury requiring repair

Clinical Signs of Fracture

Sign	Description	Sensitivity
Deformity	Visible angulation, rotation, or shortening	High specificity
Swelling	Edema from bleeding and inflammation	Present in nearly all
Bruising (ecchymosis)	Blood tracking through tissue planes	Delayed hours to days
Tenderness	Point tenderness directly over fracture	Highly sensitive
Crepitus	Grating sensation with movement	Specific but not always present
Loss of function	Inability to bear weight or use extremity	Variable
Neurovascular deficit	Numbness, pallor, pulselessness, paresthesia	Emergency
Exposed bone	Bone visible through skin (open fracture)	Definite diagnosis

Splinting Principles

General Splinting Rules

Rule	Rationale
Splint joint above and below fracture	Prevents movement of fracture fragments
Pad bony prominences	Prevents pressure injuries
Maintain traction while splinting	Reduces pain, prevents further injury
Assess neurovascular status before and after	Document and detect compartment syndrome
Do not attempt to reduce open fractures in field	Cover with sterile dressing
Remove jewelry from affected extremity	Prevent constriction from swelling
Apply splint in position of function	Hand, wrist, ankle in neutral position

Types of Splints

Splint Type	Materials	Indications	Advantages
Rigid splint	Board, metal, plastic, cardboard	Any suspected fracture	Firm immobilization, easy to apply
Vacuum splint	Bead-filled sleeve that hardens when air evacuated	Multiple fractures, pre-hospital	Conforms to shape, even pressure
Air splint	Inflatable plastic splint	Forearm, lower leg	Lightweight, transparent (X-ray through)
Traction splint	Thomas splint, Sager splint	Femur fracture	Restores length, reduces pain, controls bleeding
SAM splint	Malleable aluminum with foam	Fingers, wrist, ankle	Lightweight, reusable, radiolucent
Buddy taping	Tape injured digit to adjacent	Finger/toe fracture or dislocation	Simple, functional
Sugar tong splint	Plaster slab from palm around elbow	Forearm, wrist fractures	Prevents pronation/supination
Posterior splint	Plaster slab posteriorly	Ankle, knee, elbow	Standard ED splint

Traction Splint Indications and Contraindications

Indications	Contraindications
Isolated femur fracture	Pelvic fracture or hip dislocation
Midshaft femur fracture	Knee injury (ligament, fracture near joint)
Pain control and hemorrhage reduction	Partial amputation (do not apply traction)
Transport >30 minutes	Proximal tibial fracture (may distract)

Specific Fracture Management

Upper Extremity

Fracture	Immobilization	Referral/Follow-up
Clavicle	Figure-of-8 bandage or sling	Most heal non-operatively; ORIF if skin tenting, neurovascular compromise
Proximal humerus	Sling and swathe	Most non-operative; PT after 2-3 weeks
Humeral shaft	Coaptation splint + sling, then functional brace	Radial nerve palsy (wrist drop) in up to 12%
Distal radius (Colles)	Sugar tong or volar splint	Common in older women; evaluate median nerve
Scaphoid	Thumb spica splint	High non-union rate; CT/MRI if negative X-ray
Metacarpal	Ulnar/radial gutter splint	Boxer’s fracture (5th MC neck) - splint in intrinsic plus
Finger proximal/middle phalanx	Buddy tape or volar splint	Mallet finger - extension splint only

Lower Extremity

Fracture	Immobilization	Key Considerations
Femoral neck/head	Not splinted (hip)	Urgent ortho; high complication rate (AVN)
Femoral shaft	Traction splint	Large blood loss (1-2L), fat embolism risk
Patella	Knee immobilizer	Displaced/communicated requires ORIF; simple may cast
Tibial plateau	Long leg posterior splint	Assess popliteal artery, compartment syndrome risk
Tibial shaft	Long leg posterior splint	Most common open fracture; compartment syndrome
Ankle (malleoli)	Posterior splint + stirrup	Assess syndesmosis, medial/lateral malleoli
Calcaneus	Posterior splint	Often from fall from height; associated with spine fractures
Metatarsal	Post-operative shoe or cast	5th metatarsal base (Jones fx) - high non-union
Toe	Buddy tape	Most heal well (subungual hematoma: trephinate nail)

Sprains and Ligament Injuries

Ankle Sprain Classification

Grade	Pathology	Physical Exam	Treatment
I	Stretching, microscopic tearing of ligament fibers	Mild tenderness, no laxity, full ROM	RICE, gradual return to activity
II	Partial macroscopic tearing	Moderate tenderness, some laxity, painful ROM	RICE, immobilization, PT
III	Complete ligament rupture	Severe tenderness, marked laxity, unable to bear weight	Immobilization +/- surgical repair, PT

RICE Protocol

Component	Description	Implementation
Rest	Limit weight-bearing and activity	Non-weight-bearing for 24-72 hours, then as tolerated
Ice	Cold therapy to reduce swelling and pain	20 minutes on, 20 minutes off, repeat 4-8x daily
Compression	External pressure to limit swelling	Elastic bandage (ACE wrap), distal to proximal
Elevation	Raise injured extremity above heart	Minimizes dependent edema, promotes venous return

Modification: PRICE and POLICE

Protocol	Components	Indication
PRICE	Protection, Rest, Ice, Compression, Elevation	Acute phase (first 48-72 hours)
POLICE	Protection, Optimal Loading, Ice, Compression, Elevation	Subacute phase (after 72 hours)
Optimal loading	Progressive weight-bearing and movement	Early controlled mobilization improves outcomes

Dislocations

Common Dislocations

Joint	Mechanism	Neurovascular Risk	Reduction
Shoulder (anterior 95%)	Abduction + external rotation	Axillary nerve (deltoid sensation), axillary artery	Stimson, Kocher, Milch
Shoulder (posterior)	Seizure, electrocution	Same as anterior	Traction with posterior pressure
Elbow	FOOSH (fall on outstretched hand)	Brachial artery, median/radial/ulnar nerves	Traction with countertraction
Hip (posterior)	Dashboard injury (MVA)	Sciatic nerve (foot drop), femoral head AVN	Allis maneuver
Hip (anterior)	Forced abduction + external rotation	Femoral artery/vein, femoral nerve	Traction with adduction
Patella	Direct blow, twisting	N/A	Gentle extension, medial pressure
Finger (PIP)	Axial loading during sports	N/A	Longitudinal traction with manipulation
Mandible	Yawning, trauma	Inferior alveolar nerve	Thumb on molars, downward pressure

Post-Reduction Management

Step	Action
1	Confirm reduction clinically (pain relief, improved ROM)
2	Confirm reduction radiographically
3	Assess neurovascular status and document
4	Immobilize joint (sling, splint, brace)
5	X-ray to rule out associated fracture
6	Plan follow-up and rehabilitation

When to Image

Ottawa Ankle Rules (for Ankle X-ray)

Criteria	Detail
Ankle X-ray indicated if:	Pain in malleolar zone AND any of:
- Bone tenderness at posterior edge/tip of lateral malleolus (6 cm)	OR
- Bone tenderness at posterior edge/tip of medial malleolus (6 cm)	OR
- Inability to bear weight immediately AND in ED (4 steps)
Foot X-ray indicated if:	Pain in midfoot zone AND any of:
- Bone tenderness at base of 5th metatarsal	OR
- Bone tenderness at navicular	OR
- Inability to bear weight immediately AND in ED
Sensitivity	Nearly 100% for clinically significant fractures

Ottawa Knee Rules

Criteria	Detail
Knee X-ray indicated if:	Any of:
- Age >55 years
- Isolated tenderness of patella (no other bone tenderness)
- Tenderness at fibular head
- Inability to flex to 90 degrees
- Inability to bear weight both immediately and in ED (4 steps)

Canadian C-Spine Rule

Criteria	Detail
X-ray not needed if:	All of:
- Age <65	AND
- No dangerous mechanism	AND
- No paresthesias in extremities	AND
- Able to rotate neck 45 degrees left and right
Dangerous mechanisms:	Fall from >1m or 5 stairs, axial load to head, MVA >100 km/h, recreational vehicle, bicycle collision

Compartment Syndrome

Diagnosis

Sign/Symptom	Description	Order of Appearance
Pain out of proportion	Severe pain, worsens with passive stretch of compartment muscles	Earliest sign (most sensitive)
Paresthesia	Numbness, tingling in distribution of nerves traversing compartment	Early
Paralysis	Weakness of muscles in compartment	Late (irreversible)
Pallor	Pale skin distal to compartment	Late
Pulselessness	Absent pulse distal to compartment	Very late (ominous)

Compartment Pressures

Measurement	Normal	Compartment Syndrome
Absolute compartment pressure	<10 mmHg	>30 mmHg (or within 20 mmHg of diastolic BP)
Delta pressure (DP = diastolic BP - compartment pressure)	>30 mmHg	<30 mmHg indicates fasciotomy needed
Tissue perfusion pressure	Normal	Reduced below threshold for cell survival

Management

Step	Action
1	Remove all circumferential dressings, splints, casts
2	Elevate extremity to heart level (do NOT elevate above heart)
3	Serial compartment pressure measurements
4	Emergent fasciotomy if pressures remain elevated
5	Wound management post-fasciotomy (delayed closure or grafting)

Pediatric Fracture Considerations

Feature	Difference from Adults	Clinical Implication
Greenstick fractures	Bone bends and breaks on one side	Splint in anatomic position
Buckle (torus) fractures	Bulging of cortex without complete break	Stable, heal rapidly
Physeal (growth plate) fractures	Classified by Salter-Harris	Risk of growth arrest
Plastic deformation	Bone bent without fracture	May remodel; significant deformity needs reduction
Periosteum	Thicker, stronger, heals faster	Closed reduction often sufficient
Remodeling potential	High (especially younger children)	Accept more angulation than adults
Non-accidental trauma	Suspect in inconsistent history, multiple healing fractures	Mandatory reporting
Supracondylar humerus	Most common pediatric elbow fracture	High compartment syndrome risk, neurovascular assessment critical

Salter-Harris Classification

Type	Description	Growth Arrest Risk
I	Transverse through physis, no metaphyseal or epiphyseal fragment	Low
II	Through physis + metaphysis (most common)	Low
III	Through physis + epiphysis into joint	Moderate
IV	Through metaphysis, physis, and epiphysis	High
V	Crush injury of physis	Very high (often diagnosed retrospectively)