Fractures and splinting

A fracture does not kill on its own. What kills is the bleeding associated with it, the vascular compromise from bone pressing against an artery, and the systemic consequences of delayed treatment — shock, infection, and compartment syndrome. Field splinting does not fix the fracture. It stops it from getting worse, reduces pain, controls some of the blood loss associated with bone movement, and makes transport possible.

Done correctly, it buys hours. Done poorly, it converts a manageable injury into an amputation.

Educational use only

This page provides general educational information for emergency preparedness scenarios when professional medical care is unavailable. It is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a qualified healthcare provider. Use this information at your own risk.

Identifying a likely fracture

You will rarely have an X-ray. Field assessment relies on mechanism of injury, physical findings, and functional testing.

Signs that strongly suggest a fracture

Point tenderness: Press gently along the bone with one fingertip. Localized, exquisite tenderness at a specific point on the bone — not just general soreness from a bruise — is the most reliable field indicator of fracture. In a normal bone, you can press along the full length without eliciting a single sharp pain point. In a fractured bone, there is a location where light pressure causes a noticeably different, sharper response.

Visible deformity: Angulation, rotation, or shortening of the limb compared to the other side. A femur fracture often presents with the thigh visibly shortened and rotated outward. A wrist fracture (Colles fracture from a fall onto an outstretched hand) produces a classic "dinner fork" deformity. Any visible abnormal shape is a fracture until proven otherwise.

Crepitus: A grating or grinding sensation felt when the injured area is gently palpated or when the limb is very gently handled. Do not deliberately move the limb to produce crepitus — you will cause additional injury and pain. If you feel it while gently repositioning the limb to splint it, you have your confirmation.

Swelling and ecchymosis: Significant swelling developing in the first hour after injury suggests deep tissue disruption. Bruising (ecchymosis) appears later — often not visible for 6–24 hours. Its absence does not rule out fracture.

Inability to bear weight: For lower extremity injuries, the inability to take a full step without pain is a meaningful indicator. Many fractures allow partial weight bearing initially — "I can walk a little" does not clear a suspected fracture.

Mechanism of injury: A fall from height, a motor vehicle collision, direct blunt impact, or a rotational force (ankle caught while falling) all produce fractures at predictable locations. A direct blow to the forearm produces a fracture at the impact point. A fall onto an outstretched hand commonly fractures the distal radius (Colles), scaphoid, or radial head. Understanding mechanism helps you know where to look.

Open versus closed fractures

Closed fracture: Bone is fractured but skin is intact. Manage with splinting, bleeding control (internal bleeding from femur fracture can be 1–2 liters / approximately 2–4 pints), and transport.

Open fracture: Bone or bone fragments have broken through the skin. This is a surgical emergency. The exposed bone and fracture site are now in direct contact with environmental bacteria. Do not attempt to push the bone back under the skin.

Cover the exposed bone or wound with a moist, clean dressing (sterile saline-soaked gauze is ideal). Control any bleeding with gentle pressure around — not directly on — the fracture site. Start antibiotics if available (amoxicillin or cephalexin). Treat this as an evacuation priority.

Open fracture infection risk

An open fracture exposes the bone directly to environmental bacteria. Osteomyelitis (bone infection) that develops from an untreated open fracture is extremely difficult to treat and can require bone removal. Immobilize, cover, control bleeding around the wound, and prioritize rapid evacuation above all other considerations.

Circulation, sensation, movement (CSM) check

Every splinting procedure begins and ends with a CSM check. This assessment verifies that the fracture or splint is not compromising blood supply or nerve function distal to the injury.

How to perform a CSM check

Circulation (C): 1. Find the pulse distal to the injury. For arm injuries: radial pulse at the wrist (press gently on the thumb side of the wrist crease). For leg injuries: dorsalis pedis pulse on the top of the foot (between the first and second toe tendons), or posterior tibial pulse behind the medial ankle bone. 2. If you cannot feel the pulse — especially after a significant deformity is noted — this is a vascular emergency. The bone may be compressing or lacerating an artery. This patient needs immediate surgical evaluation. 3. Check capillary refill: press firmly on the fingernail or toenail for 2 seconds, then release. Color should return to the nail bed within 2 seconds. Refill over 2 seconds indicates compromised circulation. 4. Assess skin color and temperature distal to the injury. Pale, cool, or blue-tinged skin beyond the fracture site suggests arterial compromise.

Sensation (S): 1. Ask the patient to close their eyes or look away. 2. Use a pin, toothpick, or fingernail to lightly touch the skin on the fingers (for arm injuries) or toes (for leg injuries). 3. Ask the patient if they can feel the touch and whether it feels the same as the other side. 4. Numbness or reduced sensation distal to the fracture indicates nerve compression or injury. This is a significant finding — document it.

Movement (M): 1. Ask the patient to wiggle their fingers (for arm injuries) or toes (for leg injuries) — not to move the injured limb itself. 2. Inability to move fingers or toes voluntarily suggests motor nerve involvement. 3. Note whether movement is symmetrical compared to the uninjured side.

When to perform CSM: Before splinting. After splinting. Any time the patient reports a change in sensation or increased pain. Every 30 minutes during transport.

Deteriorating CSM after splinting — specifically loss of pulse, increased numbness, or inability to move toes/fingers that were previously moving — means the splint is too tight. Loosen the wrapping immediately and reassess.

Field splinting principles

Before applying any splint, understand what you are trying to accomplish:

Immobilize the joint above and below the fracture. Splinting just the fracture site without controlling the joints above and below allows the bone fragments to move with every joint movement. A mid-shaft tibia fracture requires immobilization of both the knee and the ankle.
Pad all bony prominences. The natural shape of a splint against a limb creates pressure points at the ankle bones, heel, kneecap, elbow point, and wrist bones. Unpadded pressure over a bony prominence can cause pressure necrosis (skin breakdown) within 2–4 hours. Use cotton roll, foam padding, or layers of folded cloth at every bony prominence before the rigid splint contacts the limb.
Rigid core with soft padding between core and skin. The rigid layer (SAM splint, board, rolled newspaper, tent poles, sticks) provides immobilization. The padding layer (cotton roll, foam, folded clothing) protects the skin. The securing layer (bandage, torn strips of cloth) holds everything together. Never apply a rigid material directly to bare skin.
Secure firmly, not tightly. Wrapping causes swelling to become constricted as tissue swells inside the wrap. Wrap snugly enough to hold the splint in place but loose enough that you can slide one finger under the wrap throughout its length. Injured tissue will swell for the first 24–48 hours — leave room for this.
Anatomical position or position of function. Unless correcting a significant vascular deformity (see below), splint the limb in the position you find it or the position of function:
Hand and wrist: wrist slightly extended (cocked up 10–20 degrees), fingers gently curled as if holding a small ball
Ankle: neutral (90 degrees to the leg — foot pointing forward, not drooping)
Knee: slight flexion (15–20 degrees), not fully straight or bent

Correcting vascular deformity

If a displaced fracture has caused loss of distal pulse or circulation, a single attempt at gentle traction to restore alignment is justified before splinting. This is done by grasping the limb firmly distal to the fracture, applying steady longitudinal traction (pulling the distal fragment gently away from the proximal), and easing the limb toward anatomical alignment while maintaining traction. If alignment improves and the pulse returns, splint in this position. If no pulse returns, or if the patient's pain becomes unbearably severe, stop and splint in the best position available — evacuation is the priority.

Do not attempt this with open fractures, suspected spinal injuries, or hip fractures.

Splint by fracture location

Forearm and wrist fracture

Mechanism: typically a fall onto an outstretched hand (FOOSH). The distal radius is the most commonly fractured bone in adults. Classic presentation: "dinner fork" deformity at the wrist, diffuse wrist swelling, point tenderness over the distal radius.

SAM splint or padded-board technique:

Perform CSM check. Document findings.
Measure a SAM splint (or padded board) from 2 inches (5 cm) past the finger MCP joints to 3 inches (7.5 cm) below the elbow.
Mold the SAM splint into a gentle C-curve along its length (this adds rigidity).
Pad the volar (palm-side) surface of the forearm and wrist with cotton roll or folded cloth, especially over the wrist bones (ulnar and radial styloids).
Place the splint along the volar (palm) surface of the forearm, wrist, and palm. Position the wrist in neutral (neither bent up nor down) or very slight extension (10–15 degrees). Leave all five fingers free — do not wrap the fingers in the splint.
Secure with a 3-inch (7.5 cm) conforming bandage roll, starting at the palm and working proximally to just below the elbow. Wrap with even, moderate tension — no tight spots.
Apply a sling to support the forearm at 90 degrees and prevent pendulum swinging.
Perform CSM check. Document findings. Compare to pre-splint baseline.

Improvised splint: Three or four layers of folded newspaper or cardboard, rolled into a trough shape, padded with a folded t-shirt or socks. Secure with strips of torn cloth. Works adequately for immobilization but requires close monitoring for slippage.

Lower leg and ankle fracture

Mechanism: fall, twist, direct blow, high-energy impact. Ankle fractures are common from simple falls; tibial shaft fractures typically require higher energy.

Posterior slab with stirrup:

Perform CSM check. Check for dorsalis pedis and posterior tibial pulses.
Cut or fold a SAM splint (or moldable material) long enough to run from the bottom of the foot, up the posterior (back) surface of the leg, to just below the back of the knee.
Mold the SAM splint into a right-angle trough at the ankle end to accommodate the heel.
Pad the heel, both ankle bones (medial and lateral malleolus), and the back of the knee generously.
Place the posterior slab running up the back of the leg.
Create a stirrup: fold a second piece of splint material (or use a different SAM splint) into a U-shape that cups under the heel and extends up both sides of the ankle. This prevents rotational movement.
Position the ankle at 90 degrees (neutral, foot perpendicular to leg). Do not allow the foot to plantar-flex (point downward) — this is the position of compromise for the Achilles tendon and creates pressure issues.
Secure with conforming bandage. Start at the toe level and work upward.
Do not wrap the toes — leave them visible for circulation checks.
Perform CSM check. Verify dorsalis pedis pulse and toe movement.

Upper arm (humerus) and shoulder fracture

Mechanism: fall onto shoulder, direct blow, or pulling injury (shoulder dislocation). Humerus fractures can injure the radial nerve — look for wrist drop (inability to extend the wrist) as a sign.

Sling and swath:

A rigid splint is rarely needed for mid-shaft humerus fractures; the arm's own weight provides natural traction and the sling/swath provides the immobilization.

Perform CSM check. Check radial pulse (thumb side of wrist crease) and wrist extension.
Sling: Support the forearm at 90 degrees of elbow flexion using a triangular bandage, shirt, or improvised cloth. The sling runs from the hand to just above the opposite shoulder, distributing weight across the back of the neck. The elbow should be fully inside the sling — not hanging out the bottom.
Swath: A second bandage (or strip of cloth 4–6 inches / 10–15 cm wide) is wrapped around the sling and the torso, binding the arm gently against the body at chest level. This eliminates pendulum swinging and reduces rotational movement at the shoulder.
Check that the sling knot does not press on the back of the neck — pad it if so.
Verify the radial pulse and wrist sensation after sling and swath are in place.

Femur (thigh) fracture

Femur fractures carry major systemic risk — the thigh can accommodate 1–2 liters (approximately 2–4 pints) of blood from internal bleeding alone, which can produce hemorrhagic shock. The leg is typically shortened and externally rotated.

Improvised padded immobilization:

When a traction splint is unavailable, use the following:

Perform CSM check. Document findings.
Pad the inside of the thigh, knee, and both sides of the leg from hip to foot with folded clothing.
Position the uninjured leg alongside the injured one.
Tie the legs together at three points: just above the knee, at mid-thigh above the fracture, and at the ankle.
Do not apply ties directly over the fracture site.
Monitor the patient closely for shock — see bleeding control for shock assessment and management.

Traction splint (Slishman, Kendrick, SAGER, or improvised):

A traction splint applies continuous longitudinal traction to reduce femur fracture displacement and reduce the thigh compartment volume, which controls internal bleeding.

Traction splint contraindications — read before applying

Do NOT apply a traction splint in any of the following situations:

Open femur fracture — traction worsens wound disruption
Suspected hip fracture or hip dislocation — traction at the ankle worsens a hip injury
Suspected pelvic fracture — the same force pathway applies
Knee injury or suspected knee fracture — ankle strap placement loads a damaged joint
Ankle or foot fracture — the ankle strap is applied directly over the injury

When these contraindications exist, use padded immobilization and treat aggressively for shock.

Suspected spinal fracture

Any fall from height, axial loading injury (diving headfirst), high-speed motor vehicle collision, or mechanism that loads the spine directly must be treated as a potential spinal fracture until otherwise assessed.

Signs suggesting spinal injury: - Pain along the spine on palpation (midline tenderness) - Neurological findings: numbness, tingling, weakness, or paralysis of limbs - Bowel or bladder dysfunction after injury - Patient holding their head or neck abnormally - High-mechanism injury with altered level of consciousness

Field management: 1. Keep the patient still in the position found. Do not allow them to get up. 2. Manually stabilize the head and neck in neutral alignment. This means holding the head gently in the position that is most comfortable for the patient — do not forcibly straighten a neck that is held at an angle. 3. If available, apply a rigid cervical collar in the correct size. 4. Move only if the patient is in immediate danger (fire, drowning, unstable structure). Use a log-roll technique — maintain spinal alignment by keeping the head, shoulders, and hips moving as one unit. Requires a minimum of two people; three is better. 5. Transport on a rigid surface if available (backboard, door, flat board). Secure the patient to the board at the forehead, chest, and thighs with straps. 6. Prioritize rapid evacuation — spinal injury with cord compression is a true surgical emergency.

Compartment syndrome recognition

Compartment syndrome occurs when swelling or bleeding inside a fascial compartment (a tight sleeve of fibrous tissue surrounding muscle groups) raises the pressure inside that space high enough to compress blood vessels and nerves. It is a time-critical surgical emergency — if not relieved by fasciotomy (cutting the fascia) within 6–8 hours of onset, permanent muscle and nerve damage results.

Who is at risk: Tibial shaft fractures (most common), forearm fractures, crush injuries to limbs, circumferential burns, and any injury where significant swelling is trapped in a tight compartment.

The 6 P's — early and late signs

The 6 P's of compartment syndrome are sometimes taught as a complete list, but they are not equal. The first three are early, actionable signs. The last three are late signs that indicate irreversible damage is already occurring.

Sign	Timing	What it means
Pain out of proportion	Early — often the first sign	Severe pain that is disproportionate to the expected injury severity
Pain on passive stretch	Early — most sensitive field test	Pain in the compartment when you gently stretch the muscles within it (extend the fingers for forearm; extend the foot for lower leg)
Pressure sensation / tense compartment	Early	The skin over the affected compartment feels tight and "woody" or drum-like when pressed — much harder than the surrounding area
Paresthesia	Transitional	Numbness or tingling in the distribution of the nerve running through the compartment
Pallor	Late	Skin pallor distal to the affected compartment
Paralysis	Very late	Inability to move the extremity — indicates nerve death
Pulselessness	Very late	Loss of distal pulse — indicates arterial compression from extreme compartment pressure

Act on the early signs, not the late ones

Paralysis and pulselessness indicate irreversible damage that fasciotomy may not fully reverse. The actionable window for compartment syndrome is the first 2–3 signs — pain out of proportion, pain on passive stretch, and a tense compartment. If these are present, loosen all wrappings and splint material immediately. The splint itself may be creating the compartment syndrome if applied too tightly. If loosening does not relieve symptoms within 30 minutes, this patient requires surgical fasciotomy and must be evacuated urgently.

The passive stretch test (perform at every CSM check)

For lower leg compartment syndrome: 1. Hold the ankle with one hand. 2. Use your other hand to extend the toes (bend them backward, toward the shin). 3. If this produces disproportionate, sharp pain in the calf or lower leg — not just discomfort at the ankle — compartment syndrome must be considered.

For forearm compartment syndrome: 1. Hold the wrist with one hand. 2. Gently extend the fingers backward (toward the back of the hand). 3. Sharp pain in the forearm (not just the wrist) on finger extension is a positive finding.

Transport considerations

Getting a patient with a fracture to definitive care requires protecting the splint, monitoring CSM, and preventing secondary injury during movement.

Pre-transport priorities

Complete CSM check. Document baseline findings in writing if possible.
Manage pain: ibuprofen 400–600 mg (with food) or acetaminophen 500–1,000 mg provides meaningful pain reduction for fractures and makes transport more tolerable. Do not administer opioids in the field unless specifically trained and equipped.
Manage associated bleeding: femur and pelvic fractures may require active shock management during transport — see bleeding control.
Cover the patient to prevent hypothermia — fracture patients in pain and shock are at elevated risk.

During transport

Elevate the splinted extremity if possible — above heart level for arms, supported on a rolled blanket or pack for legs. Elevation reduces swelling.
Recheck CSM every 30 minutes during transport. Note any changes.
Communicate with the patient continuously if conscious. Changes in pain character, sensation, or the onset of numbness are early warning signs of vascular compromise or compartment syndrome.
Minimize re-positioning. Each unnecessary movement shifts fracture fragments and increases pain and internal bleeding.
For suspected spinal injury: maintain spinal precautions throughout transport. Avoid any flexion, extension, or rotation of the spine. Two-person carry with coordinated movement only.
Protect the splint from external impacts. A bumped splint that shifts can disrupt fracture alignment.

Field splint materials table

Material	Rigidity	Notes
SAM splint (commercial)	Medium-high	Best all-around; moldable to any shape; radiolucent
Cardboard (layered)	Low-medium	4–6 layers of corrugated cardboard approximate a SAM splint; available anywhere
Wooden boards (improvised)	High	Stiff and effective; cut to length; must be padded aggressively
Tent poles	Medium	Often the best rigid material in wilderness settings
Rolled newspaper (4–5 sheets)	Low-medium	Sufficient for wrist and forearm; adds padding around fracture site
Walking sticks or trekking poles	High	Good length for lower leg; must be padded at contact points
Magazines	Medium	Rolled into a tube; adequate for arm fractures

Fracture and splinting readiness checklist

Stock two SAM splints (one 36-inch (91 cm) for lower extremity; one 18-inch (45 cm) for upper extremity) in the home medical kit
Stock conforming bandage rolls (3-inch (7.5 cm) and 4-inch (10 cm)), elastic bandage, and cotton padding
Practice the CSM check on a family member until all three components are automatic — pulse location, capillary refill timing, and passive stretch test
Practice a wrist/forearm splint and sling-and-swath until you can apply both from memory
Know the traction splint contraindications by heart before you ever need to consider applying one
Know the three early signs of compartment syndrome: pain out of proportion, pain on passive stretch, tense compartment
Understand the log-roll technique and practice it before a spinal injury scenario requires it

Fracture management in the field is primarily damage control — stop the injury from getting worse, protect the neurovascular structures, and move the patient toward definitive care. Done correctly, field splinting reduces pain, controls blood loss, and preserves the option of full recovery. Done incorrectly, it creates compartment syndrome or vascular occlusion. The difference is padding, proper pressure, and consistent CSM reassessment.

For the bleeding associated with severe fractures, see bleeding control. For managing shock from femur or pelvic fractures, see shock.