Joint Immobilization

Joint Immobilization is included in this California-based EMT program as it is required for skills verification for California Registration.^[1]

In pre-hospital trauma calls, EMTs are often called upon to provide immobilization of limb and joint fractures to both protect the patient's limb from further harm, and to increase their comfort during transport. After you have performed your initial trauma assessment, and addressed any immediate threats to life, all fractures, dislocations and sprains should be splinted prior to moving the patient. These are essential skills for EMTs, as extremity fractures that impair circulation or nerve function in distal tissues are urgent conditions that require careful assessment, prompt transport and continuous reassessment to preserve function.

All splinting and immobilization should be performed with patient comfort and the protection of circulation and nerve function in mind.

Fracture vs. Dislocation[edit | edit source]

Differentiating between fracture and dislocation in the field is difficult and often impossible until radiographic pictures may be taken. Luxated (fully dislocated) and subluxed (partially dislocated) joints are similarly difficult to identify without imaging. Luckily, both joint fractures and joint dislocations are treated almost identically in the field; for this reason this page will speak of all injuries as dislocations. Just as there are many different types of fractures, there are several different types of joint dislocations (generally related to the direction of the dislocation), the treatment for which only truly changes when speaking of reduction of the dislocation. This page will cover the most commonly found joint dislocations in the prehospital environment without going too in depth into their etiologies and methods of reduction.

General Rules for Joint Immobilization[edit | edit source]

General rules that should be used before, during, and after any attempt at joint immobilization are found below:

1. Determine and record circulation, sensation, and motor status of the extremity distal to the injured joint. If there is significant deficit, follow local protocol in treatment. This is often either rapid transport or attempted reduction.
2. Determine if there is loss of range of motion of the extremity.
3. Secure the entirety of the bone above and below the joint, if possible. Most protocols call for the joint to be stabilized in the position found in the prehospital environment if circulation, sensation, and motion are intact.
4. Utilize pain control measures as indicated. For EMTs, these are primarily immobilization (which is in progress at this point) and cold/ice packs.
5. Re-check and record circulation, sensation, and motor status of the distal extremity following immobilization of the joint. Immobilization should have no negative effects on CSM, if a negative change has occurred, immediately remove the immobilization equipment and re-assess.
6. Follow local protocol regarding reduction of dislocated joints. Many protocols state that an injured joint be immobilized in the position it was found, but prolonged transport times or less restrictive protocols may allow for attempted reductions in the field for pain control, not just restoration of CSM.

Upper Extremity[edit | edit source]

Upper extremity dislocations are likely to need a sling and swathe, as described below. The sling and swathe may be the primary treatment for the injury or may be an additional stabilization measure based upon patient and injury presentation.

Sling and Swathe Application[edit | edit source]

1. Manually stabilize the limb with respect to the patient's chest and shoulder to avoid moving the injury site.
2. Assess Circulation, Motor, and Sensory (CMS) function in the hand/wrist of both the injured side and the opposite side for comparison.
3. Place a Sling to support the injured side:
   1. Place one end of the material for the sling (such as a cravat or triangular bandage) at the patient's neck on the uninjured side. Pass the other end behind the patient's neck towards the injured shoulder, down around the forearm on the injured side passing the end back up between the forearm and the patient's chest, and then across the patient's chest back to the starting point on the uninjured side.
   2. Ensure that the point of the triangular bandage is oriented towards the patients elbow. Tie a knot in this corner, creating a pocket to "catch" the elbow, or use the "safety pin" by folding the tip of the triangular bandage over the elbow and pin the material to the sling.
   3. Form the sling by lifting the ends of cravat and cradling the arm until the patient feels that their arm is being supported.
   4. Tie the ends of the sling behind the neck at that height, and place padding for comfort. The knot should be positioned on the side of the patient's neck, avoiding having the knot put pressure on the patient's spine.
4. Stabilize the arm to the torso with one or two swathes:
   1. Form a swathe by folding a cravat so that it is about 2-3" wide.
   2. For a humeral fracture, place a splint alongside the bone on the outside of the arm.
   3. Wrap the swathe around the injured arm's humerus (including the splint if using) and the torso and secure with a knot, leaving the other arm unrestrained.
   4. Wrap a second swathe around the torso and the forearm, and secure with a knot, holding the forearm to the chest wall. For splinted forearm injuries, this is the only swathe required.
   5. Pad under the knots and ensure that neither the swathes nor the knots pass over an injured area.
5. Recheck CMS function and note in the patient record. If placing the sling or swathe has resulted in a significant decrease in circulatory function, the bandaging or cravat securing the limb to the torso may need to be loosened or reapplied.

Shoulder Dislocation[edit | edit source]

Shoulder dislocations come in a variety of flavors, including dislocations of the clavicle (which is not a true shoulder dislocation) and should be treated with immobilization. Shoulder dislocations can happen in the anterior, posterior, superior, and inferior directions and are commonly caused by some manner of trauma causing the shoulder to "pop" out of its socket. Patients will be experiencing significant pain and possibly point tenderness to the anterior or posterior aspects of the shoulder. What makes these dislocations tricky is that there is no "proximal" bone to immobilize. Therefore, all efforts should be made to immobilize the limb in the position it was found in, providing that CSM is intact. This may be accomplished by utilizing pillows, blankets, or towels as padding to fill the voids between the arm and the body.

Elbow Dislocation[edit | edit source]

Elbow dislocations are painful and potentially serious injuries. If, for some reason, the limb is found in the anatomical position, it may be easily secured with long, rigid splints if CSM is not affected. Ideally, however the elbow should be secured in a 90° flexed position with the hand in a position of function. This is commonly accomplished with an A-frame splint described below. Following immobilization, a sling and swathe may be used.

A-Frame Splinting[edit | edit source]

A-frame splinting is used to secure an extremity that has a joint injury causing a "bend" and will serve to immobilize the joint in a single position with the long bones above and below it. There are several ways to perform an A-frame splint, one which may be used for both elbow and knee injuries will be discussed here.

You will need:

• x2 rigid splints of appropriate length.
• x2-3 cravats at minimum.
• Padding material as needed.

To perform the A-frame splint:

1. Check and record CSM distal to the injury on the injured extremity.
2. Have another rescuer or the patient immobilize the limb in a position of comfort for the patient with the limb flexed enough to allow for splinting.
3. Place one splint across both long bones proximal and distal to the injury and the other splint parallel to the first, on the other side of the limb. This creates the "A" shape of the splint with the splints creating the crossbar of the "A" and the limb creating the limbs. The injured joint is the point of the "A".
4. Use one cravat to tie the splints together if needed. For upper extremity splints this may not be necessary.
5. Use cravats to secure the splints to the extremity using a figure eight motion between each splint. Make sure to include the extremity or it will not be fully immobilized. Additional cravats may be needed if the limb is larger, like a leg. An easy way to make sure the extremity is included is to initially come up from under the extremity with the cravat on both sides before placing the initial figure eight.
6. Re-check and record CSM.

Finger Dislocation[edit | edit source]

Fingers that have been dislocated may be secured to the next finger using the "buddy system" for transport. These injuries, while painful, are rarely life threatening (it is only truly possible with significant time between injury and treatment).

Lower Extremity[edit | edit source]

Hip Dislocation[edit | edit source]

Hip dislocations are severe, painful injuries that cannot be treated in the field. The only true treatment for a hip dislocation is reduction or surgery in the hospital. As such, the prehospital provider's priority should be to stabilize the hip in the patient's position of comfort as long as CSM is intact. Hip dislocations can be difficult to differentiate from a proximal femur fracture or hip fracture. If there is any instability in the pelvis, a pelvic binder may allow for some analgesia and stabilization. Patients with hip injuries are often moved via scoop stretcher. Posterior hip dislocations are the most commonly found type of hip dislocation, and can be caused by a variety of sources, including MVCs where the patient's knee strikes the dashboard and force is transmitted up the femur. Always maintain a high index of suspicion for hip injuries if the patient's MOI indicates significant force on the hip or transmitted to the hip from other long bones.

Knee Dislocation[edit | edit source]

When a provider is called to assess a patient with a possible knee dislocation, it is important to know the difference between knee and patella dislocations. Most laypeople will use the terms interchangeably, but there are important differences between the two injury modalities.

Patella vs. Knee Dislocation[edit | edit source]

Patellar dislocations are dislocations of the patella, the bone that sits in front of the knee joint. A patellar dislocation is not considered a dislocation of the knee joint. A patellar dislocation is painful and will look like the patient's kneecap has been shifted one direction. Range of motion may be affected.

Knee dislocations are common sports injuries that can occur from rapid side to side movement or laterally transmitted force (from a low side tackle, for instance). Knee dislocations are more severe injuries than patella dislocations and can cause serious disruption of the nervous and vascular tissue around the joint. Knee joints can be dislocated anteriorly, posteriorly, laterally, and medially.

Despite their differences, patella and knee dislocations should be treated identically. Most patella and knee dislocations should be immobilized in an A-frame splint, but if the angulation of the knee is acute enough, a rigid splint may be placed posteriorly under the leg while the leg is stabilized by another rescuer in a position of comfort. Voids should be added and the limb splinted in a position of comfort.

Ankle Dislocation[edit | edit source]

Stabilization of ankle dislocations should follow the General Rules for Joint Immobilization found above.

Documentation[edit | edit source]

Documentation of limb immobilization should be included in the Patient Care Report (PCR) in the form:

• "Patient assessment reveals obvious deformity to the left elbow after bicycle accident. Left elbow immobilized with A-frame splint; left arm placed in sling/swathe. Padded cold pack placed over injured area. CSM intact before and after application. Patient ambulated without issue to gurney and loaded into ambulance."

Self Assessment[edit | edit source]

Tips and Tricks[edit | edit source]

• Ice packs may be incorporated into the splint so long as they are: easily removable, and are covered to prevent thermal damage.
• Gauze wrap may be used as a securement device alternative to tape; just be sure the gauze is secure and will not slip. Certain carboard splints come with premade holes for this exact purpose.

Additional Resources[edit | edit source]

TBD - extra videos to watch, links to other pages for more reading

References[edit | edit source]