Complications of fracture dislocation and their ED management

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You are a medical research assistant. Your task is to gather comprehensive textbook content on "complications of fracture dislocation and their ED (Emergency Department) management" from the available medical library. Use the query_library_db tool to search, then read_file to retrieve relevant content. Key books available: - ROSEN's Emergency Medicine: isbn 9780323757898 - Tintinalli's Emergency Medicine: isbn 9781260019933 - Rockwood and Green's fractures in adults: isbn 9781975211608 - Roberts and Hedges' Clinical Procedures in Emergency: isbn 9780323354783 Steps to follow: 1. Search headings_fts for relevant sections on fracture dislocation complications and ED management: ```sql SELECT title, book_title, '/textbooks/' || block_file_path AS file_path, line_number, para_line_ranges, para_count FROM headings_fts WHERE headings_fts MATCH 'fracture dislocation' ORDER BY rank LIMIT 15 ``` 2. Search paragraphs_fts for content on complications: ```sql SELECT book_title, section_heading, '/textbooks/' || block_file_path AS file_path, line_start, line_end, snippet(paragraphs_fts, 0, '>>>', '<<<', '...', 30) AS snippet FROM paragraphs_fts WHERE paragraphs_fts MATCH '"fracture dislocation" AND (complication OR neurovascular OR vascular OR nerve)' ORDER BY rank LIMIT 10 ``` 3. Search paragraphs_fts for ED management approach: ```sql SELECT book_title, section_heading, '/textbooks/' || block_file_path AS file_path, line_start, line_end, snippet(paragraphs_fts, 0, '>>>', '<<<', '...', 30) AS snippet FROM paragraphs_fts WHERE paragraphs_fts MATCH '"fracture dislocation" AND (reduction OR immobilization OR splint OR emergency)' ORDER BY rank LIMIT 10 ``` 4. Search for complications of dislocation generally in Rosen's Emergency Medicine: ```sql SELECT title, book_title, '/textbooks/' || block_file_path AS file_path, line_number, para_line_ranges, para_count FROM headings_fts WHERE headings_fts MATCH 'dislocation complication emergency' ORDER BY rank LIMIT 10 ``` 5. Read relevant sections from Rosen's Emergency Medicine around dislocation complications (file: /textbooks/9780323757898/9780323757898_block7.md, starting around the Anterior Dislocations section which was at line 1036): - read_file(file_path="/textbooks/9780323757898/9780323757898_block7.md", offset=990, limit=250) 6. Search for general fracture complications: ```sql SELECT book_title, section_heading, '/textbooks/' || block_file_path AS file_path, line_start, line_end, snippet(paragraphs_fts, 0, '>>>', '<<<', '...', 30) AS snippet FROM paragraphs_fts WHERE paragraphs_fts MATCH 'fracture complication AND (compartment syndrome OR avascular necrosis OR nerve injury OR vascular injury OR malunion OR nonunion)' ORDER BY rank LIMIT 10 ``` 7. Read the Tintinalli TOC for fracture/dislocation sections: ```sql SELECT heading, block_file_path, line_number, level FROM v_toc WHERE book_isbn = '9781260019933' AND (heading LIKE '%fracture%' OR heading LIKE '%dislocation%' OR heading LIKE '%Fracture%' OR heading LIKE '%Dislocation%') LIMIT 20 ``` 8. Based on the results above, read the most relevant sections from the textbooks (up to 3 read_file calls, 250 lines each). Please return a COMPREHENSIVE synthesis of all findings covering: A. General complications of fracture-dislocations (immediate, early, late) B. Specific complications by region/type where available (shoulder, hip, elbow, spine, etc.) C. ED assessment and management principles D. Neurovascular assessment and monitoring E. Indications for emergency reduction and surgical referral F. Any relevant images or diagrams found Include exact file paths and line numbers where content was found so the main agent can follow up if needed.

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Complications of Fracture-Dislocation and Their ED Management

Overview

Fracture-dislocations are injuries in which a dislocation occurs simultaneously with a periarticular fracture. They are more complex and potentially more dangerous than isolated fractures or dislocations, carrying a higher risk of neurovascular injury, instability, and long-term disability.

General Complications

1. Neurovascular Injuries (Immediate)

The most critical immediate complication. Neurovascular assessment must precede and follow every reduction attempt.

Axillary nerve injury — most common nerve injured in anterior glenohumeral dislocation; occurs in <10% of cases. Usually neuropraxic; expectant management with good prognosis for recovery.
Axillary artery injury — less common but limb-threatening; suggested by expanding hematoma, absent distal pulses, or signs of ischemia. Requires urgent vascular surgery consultation.
Brachial plexus injury — can accompany shoulder dislocations, particularly in high-energy trauma.
Radial nerve — at risk in humeral shaft fractures, particularly with Holstein-Lewis fractures.
Sciatic nerve / femoral vessels — at risk in hip dislocations.
Popliteal artery — at high risk in knee dislocations (up to 40% incidence in some reports).

ED approach: Document neurovascular status (sensation, motor function, distal pulses, capillary refill) before and after any manipulation. Any vascular compromise is an emergency requiring immediate reduction and vascular surgery.

2. Associated Fractures (Immediate)

Fractures dramatically increase the complexity of management:

Greater tuberosity fracture with anterior shoulder dislocation — changes the risk profile; associated with decreased recurrence risk. Reduces with the shoulder in many cases; persistent >5 mm displacement after reduction requires surgical fixation.
Hill-Sachs deformity — impaction fracture of the posterolateral humeral head from the anterior glenoid rim; increases recurrence risk.
Bankart lesion — avulsion of the anteroinferior glenoid labrum (bony or soft-tissue); primary cause of recurrent instability.
Glenoid rim fracture — increases recurrence risk.
Proximal humerus fractures — fracture-dislocations of the shoulder (2-, 3-, 4-part) involve simultaneous fracture and displacement; these are surgical emergencies if vascular supply to the humeral head is compromised.

3. Compartment Syndrome (Early, within hours)

Can occur after any significant limb fracture or crush injury.
Classical signs: Pain out of proportion, pain with passive stretch, tight/woody compartment, paresthesias, paralysis (late).
ED management: Remove all constrictive bandaging/splints; measure compartment pressure. Compartment pressure >30 mmHg (or within 30 mmHg of diastolic BP) → emergency fasciotomy.
Do not wait for all 5 P's (pulselessness is a late sign).

4. Vascular Injury (Immediate/Early)

Posterior knee dislocation carries the highest risk of popliteal artery injury of any dislocation.
Hip dislocation can injure the femoral vessels.
Signs: Limb pallor, mottling, absent pulses, expanding hematoma, bruit/thrill.
ED management: Immediate reduction to relieve vascular compression; CT angiography or surgical exploration. Vascular surgery consultation.

5. Recurrent Dislocation (Late)

Strongly associated with young age and specific structural injuries (Hill-Sachs, Bankart, glenoid rim fracture).
In anterior shoulder dislocation: recurrence rate 79–100% in patients <30 years; rates decline with increasing age.
Presence of a greater tuberosity fracture is paradoxically protective against recurrence.
ED management: Treat the acute episode; orthopedic referral for definitive stabilization (Bankart repair in young athletes).

6. Rotator Cuff Tears (Early/Late)

Especially common after primary shoulder dislocation in patients >40 years (increases to 80% in patients >60 years).
Supraspinatus tears mimic axillary nerve injury (both cause failure to abduct).
ED management: Clinical suspicion; arrange MRI/ultrasound as outpatient. Orthopedic referral.

7. Avascular Necrosis (Late)

Disruption of blood supply to articular bone.
Most significant with: femoral head (posterior hip dislocation), humeral head (4-part fracture-dislocations), talus (subtalar dislocation).
Incidence in posterior hip dislocation increases with delay to reduction: <6 hours → much lower risk; >6 hours → significantly higher risk (~20–50%).
ED management: Prompt reduction is the most critical intervention to reduce AVN risk.

8. Malunion / Nonunion (Late)

Result of inadequate reduction or fixation.
Not an acute ED concern but should inform the urgency of orthopedic referral.

9. Post-traumatic Arthritis (Late)

Cartilage damage at the time of injury, or from imperfect reduction, predisposes to degenerative arthritis.
Not manageable in the ED; discussed with patients during follow-up.

Specific Fracture-Dislocations and ED Management

Shoulder (Glenohumeral) Fracture-Dislocation

Most common major joint dislocation. 96–98% are anterior.

Complications:

Axillary nerve injury (<10%)
Axillary artery injury
Rotator cuff tear (very common in elderly)
Hill-Sachs deformity, Bankart lesion
Greater tuberosity fracture (present in ~15–35%)

ED Assessment:

Classic "squared-off" shoulder, arm held in abduction
AP + trans-scapular Y + axillary lateral radiographs
Pre-reduction neurovascular exam (axillary nerve: sensation over deltoid; axillary artery: radial pulse)

ED Management:

Analgesia — IV opioids ± procedural sedation (propofol, ketamine, midazolam + fentanyl) or intra-articular lidocaine (10–20 mL of 1% lidocaine).
Closed reduction — multiple techniques:
- Cunningham technique — patient seated, massages own muscle; no analgesia required
- Stimson technique — prone positioning with weights
- External rotation method — gentle ER with elbow at 90°
- Milch technique — arm elevated with traction
- Traction-countertraction — most common but requires sedation
Post-reduction: Repeat X-ray (confirm reduction, identify occult fracture). Repeat neurovascular exam.
Immobilization: Sling for 1–4 weeks depending on age.
Disposition: Orthopedic follow-up in 1–2 weeks. Young athletes need Bankart evaluation. Associated greater tuberosity fracture with >5 mm post-reduction displacement → urgent orthopedic referral.

"Rotator cuff tears are especially common in primary dislocations in patients older than 40 years old, increasing to 80% in patients over 60 years old." — Rosen's Emergency Medicine, p. 654

Hip Fracture-Dislocation

Most commonly posterior (dashboard injury in MVCs).

Complications (time-sensitive):

Sciatic nerve injury (~10–15%) — foot drop; assess prior to reduction
Avascular necrosis of femoral head — risk rises sharply after 6 hours
Femoral head fracture (Pipkin classification)
Acetabular fracture — if large posterior wall fragment, joint unstable after reduction

ED Management:

IV analgesia + procedural sedation (this is a major joint requiring significant force or relaxation).
Allis maneuver (most common): Patient supine, hip and knee flexed to 90°, inline traction with countertraction on pelvis.
Stimson gravity technique (alternative): Prone, hip at table edge, downward pressure.
Post-reduction: CT scan to check concentric reduction and identify loose bodies or acetabular/femoral head fractures.
CRITICAL: Reduction within 6 hours to minimize AVN risk.
Disposition: Hospital admission. Orthopedic surgery for all hip fracture-dislocations.

Elbow Fracture-Dislocation

The elbow is the second most commonly dislocated major joint in adults. Posterior dislocation is most common.

Key fracture-dislocation patterns:

"Terrible Triad" — posterior elbow dislocation + radial head fracture + coronoid fracture. Highly unstable; high complication rate.
Posterior Monteggia — ulna fracture + radial head dislocation.
Trans-olecranon fracture-dislocation — very unstable.

Complications:

Brachial artery injury — must check radial pulse before and after reduction
Median nerve injury
Ulnar nerve injury
Heterotopic ossification (late)
Stiffness / loss of range of motion (very common)
Complex fracture-dislocations (Terrible Triad) have high re-dislocation rates with closed management alone

ED Management:

Neurovascular exam: Brachial and radial pulses, median/radial/ulnar nerve function.
X-rays: AP and lateral elbow (assess for radial head, coronoid, olecranon fractures).
Reduction of simple elbow dislocation: Supinate forearm → traction on wrist, countertraction on distal humerus → flex elbow while pushing olecranon anteriorly. Requires procedural sedation.
Post-reduction: Check stability in full range of motion. Obtain X-ray.
Terrible Triad / complex fracture-dislocations → operative management (cannot be managed conservatively in ED). Urgent orthopedic consultation.
Immobilization: Posterior splint at 90° of flexion for simple dislocations.

"Obesity and complex fracture-dislocations around the elbow can make closed management very challenging." — Rockwood & Green's, block8

Ankle Fracture-Dislocation

Weber B/C fractures with dislocation → skin at high risk of pressure necrosis from the talus.

Complications:

Skin necrosis/pressure injury from displaced talus (may occur within 1–2 hours)
Peroneal/tibial nerve injury
Vascular compromise (posterior tibial artery)
Open fracture (bone may tent or pierce skin)

ED Management (URGENT):

Immediate reduction — do not wait for formal imaging if skin is compromised/blanched. Reduce first, X-ray after.
Technique: Traction + foot manipulation while countertraction on lower leg.
Short posterior splint/plaster backslab with U-slab.
Neurovascular recheck post-reduction.
Orthopedic admission for all fracture-dislocations of the ankle.

Spine Fracture-Dislocation

Most dangerous fracture-dislocation. Can involve any spinal level; thoracolumbar junction (T12–L2) and cervical spine are most common.

Complications:

Spinal cord injury (complete or incomplete)
Cauda equina syndrome (lumbar levels)
Neurogenic shock — hypotension + bradycardia (not tachycardia) due to loss of sympathetic tone
Vascular injury (vertebral artery in cervical injuries)

ED Management:

Immobilization — spine precautions, hard collar for cervical injuries.
ABC management first — neurogenic shock: IV fluids + vasopressors (norepinephrine preferred). Avoid hypotension (MAP ≥85 mmHg targeted in complete cord injury).
CT spine is the primary imaging modality in trauma. MRI if neurological deficit or ligamentous injury suspected.
Urgent neurosurgery/spine surgery consultation for all fracture-dislocations.
Avoid high-dose methylprednisolone — no longer recommended as standard of care.
Foley catheter (urinary retention), DVT prophylaxis.

Key ED Principles for All Fracture-Dislocations

Step	Action
1. Neurovascular assessment	Document pulses, sensation, motor function before ANY manipulation
2. Analgesia/Sedation	IV opioids; procedural sedation (propofol, ketamine) for major joint reduction
3. Imaging	X-rays pre-reduction to identify fracture pattern; CT for complex injuries
4. Reduction	Prompt reduction (especially hip ≤6 hrs, ankle with skin compromise immediately)
5. Post-reduction check	Repeat X-ray + neurovascular exam
6. Immobilization	Appropriate splint/brace in functional position
7. Disposition	Orthopedic consultation for all fracture-dislocations; admission for hip, spine, Terrible Triad, open injuries, vascular compromise

Indications for Emergency Orthopedic/Surgical Consultation

Any open fracture-dislocation
Vascular injury / absent pulses post-reduction
Compartment syndrome
Irreducible dislocation (soft tissue interposition)
Hip fracture-dislocation (AVN risk)
Cervical/thoracolumbar fracture-dislocation (spinal cord)
Terrible Triad elbow
Ankle fracture-dislocation with skin compromise
Knee dislocation (popliteal artery risk)

Sources: Rosen's Emergency Medicine: Concepts and Clinical Practice (9780323757898), p. 653–660 | Rockwood and Green's Fractures in Adults, 10th ed. (9781975211608)

Basic principles of splinting and traction. Principles of splinting fracture of long bone

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Basic Principles of Splinting and Traction — and Splinting of Long Bone Fractures

Part 1: Principles of Splinting

Definition and Purpose

A splint is an external device that immobilizes an injured extremity. Unlike a circumferential cast, a splint is non-circumferential and therefore accommodates post-injury swelling — this makes it the preferred modality in the acute/ED setting.

The rationale for immobilization is threefold:

Haemostasis and swelling control — a well-padded splint applies stabilization and compression to soft tissues, reducing further bleeding and swelling.
Soft tissue protection — prevents further injury to an already traumatized soft tissue envelope from mobile fracture fragments.
Pain relief and safe transport — reduces patient discomfort and facilitates transport and radiographic evaluation.

"Immobilization of the joints above and below the fracture is generally recommended to ensure adequate stability and prevention of a lost reduction." — Sabiston Textbook of Surgery, p. 773

General Principles of Splinting

Principle	Detail
Neurovascular assessment	Document pulses, sensation, and motor function before and after every splint application
Immobilize one joint above and one below	Ensures the fracture site is fully controlled; prevents rotation
Adequate padding	Bony prominences (malleoli, olecranon, fibular head) must be well padded to prevent pressure necrosis
Appropriate position	Each splint has a specific functional position (see below per region)
Mold the splint	Counteract the natural tendency of the fracture to displace back into deformity
Non-circumferential	Leaves room for swelling for 48–72 hours post-injury
Post-application X-ray	Postreduction radiographs are required to confirm maintained reduction
Convert to cast later	After swelling subsides (2–3 weeks), splints are exchanged for circumferential casts in the outpatient setting

Splinting Materials

Plaster of Paris:

Calcium sulfate hemihydrate impregnated bandage
Exothermic setting reaction (warn the patient of warmth)
Sets in ~5–10 minutes; weight-bearing strength in 24–48 hours
Easily molded; inexpensive
Heavier than fiberglass; degrades with moisture

Fiberglass:

Lighter, stronger, water-resistant
Sets faster (~3–5 minutes)
Less moldable than plaster
More expensive

Layers of splint construction (inner → outer):

Stockinette (optional — protects skin)
Cotton/synthetic cast padding (Webril) — several layers, extra over bony prominences
Plaster or fiberglass slab (8–10 layers of plaster; fewer of fiberglass)
Compressive wrap (bias bandage or elastic/ACE wrap) — applied without circumferential tension

Circumferential Cast vs. Splint in the Acute Setting

"Application of a circumferential cast is rarely indicated in the acute treatment of adult fractures, especially because soft tissues in the injured extremity will continue to swell for 48 to 72 hours after injury. A circumferential cast that does not allow room for swelling can be too constrictive and could potentially lead to pressure necrosis or compartment syndrome." — Sabiston, p. 775

Exception — when a cast is the definitive treatment (most pediatric fractures, some nondisplaced adult fractures): the cast should be bivalved — cut longitudinally on opposite sides — to allow for swelling. After swelling subsides (2–3 weeks), it is overwrapped at the first clinic visit.

Molding — Critical Technique

Every splint should be actively molded to maintain reduction. Fractures have a deforming force (muscle pull, gravity) that drives displacement back to the original position.

Fracture	Molding Direction
Humeral shaft	Valgus mold — prevents varus deformity from deltoid pull
Dorsally displaced distal radius	Volar-directed mold — counters extensor pull
Ankle fractures with mortise disruption	Neutral ankle position; U-slab + posterior slab
Metacarpal/phalangeal fractures	Intrinsic-plus position (70–90° MCP flexion, IP extension)

Part 2: Splinting of Long Bone Fractures — By Region

1. Humeral Shaft Fractures

Splint type: Coaptation (U-slab) splint
- Runs from the axilla, under the elbow, and up the lateral arm to the shoulder
- Gravity assists in maintaining alignment (hanging arm effect)
- Arm hangs at the side in neutral
Position: Elbow 90°, forearm neutral (hanging)
Alternative: Functional brace (Sarmiento brace) — if minimal swelling, can apply acutely in ED
Immobilizes: Shoulder and elbow
Note: Valgus mold to counteract varus deforming force

2. Forearm Fractures / Wrist Fractures

Splint type: Sugar tong splint
- Runs from the distal palmar crease volarly, around the elbow (with the elbow at 90°), and to the dorsal MCP joints
- Prevents pronation and supination of the forearm, and immobilizes both wrist and elbow
- Finger traps used to apply gravity traction during application
Position for wrist/distal radius: Wrist in slight flexion and ulnar deviation (for Colles' fracture after reduction); slightly extended for Smith's fracture
For isolated wrist injuries: Short-arm splint (volar slab) may suffice for nondisplaced distal radius
Mold: Volar-directed mold for dorsally displaced (Colles') fractures

3. Elbow Fractures

Splint type: Posterior long arm splint
- Runs from posterior forearm, around the elbow, up the posterior humerus
Position: Elbow at 90° flexion, forearm in neutral or slight pronation

4. Femoral Shaft Fractures

Splint type: Traction splint (Hare, Thomas, Sager splint)
- Commercially produced device
- Applies longitudinal traction via padded proximal ring on the ischial tuberosity and distal traction via an ankle hitch
- Restores femoral length, controls rotation, reduces pain and blood loss
- Helps control bleeding by limiting the volume the thigh can expand into
Key complications of traction splints: Pressure ulcers at the ischial tuberosity and ankle/heel
Indication: Isolated femoral shaft fractures (mid-shaft); NOT for proximal or distal femur fractures, knee injuries, or open fractures with contamination

5. Tibial Shaft / Ankle / Foot Fractures

Splint type: Short leg splint — posterior slab + U-slab (stirrup/U component)
- Posterior slab: applied from behind the calf, under the heel, to the metatarsal heads
- U-slab/stirrup: medial and lateral slabs crossing the ankle
- Together they resist all ankle motion
Position: Ankle in neutral (90°) — critical to prevent equinus contracture
- Knee slightly flexed (30°) during application — relaxes gastrocnemius pull
- Gravity traction: patient in figure-4 position across the bed (ipsilateral side down) — relaxes gastrocnemius, assists in maintaining fibular length and medial malleolus reduction
Extension to long leg: Side slabs added from knee to proximal thigh → long leg splint for tibial plateau/shaft fractures or knee injuries

6. Hand / Metacarpal / Phalangeal Fractures

Splint type: Long finger splint, ulnar/radial gutter splint, thumb spica
Position — intrinsic-plus: MCP joints 70–90° flexion, IP joints in extension
- Prevents shortening of collateral ligaments → prevents contracture
Thumb fractures (Bennett's, Rolando's): Thumb spica splint
Ulnar metacarpal (4th, 5th): Ulnar gutter splint
Radial metacarpal (2nd, 3rd): Radial gutter splint

Part 3: Principles of Traction

Definition

Traction is the application of a pulling force along the long axis of a bone to reduce and/or maintain reduction of a fracture. It counteracts the deforming forces of muscle pull that drive shortening and displacement.

Types of Traction

Type	Mechanism	Indications	Pros	Cons
Skin traction	Adhesive/foam straps on skin transmit force	Temporary; hip fractures in elderly pre-op (comfort)	Non-invasive	Limited force; skin breakdown risk
Skeletal traction	Transosseous pin (Kirschner wire or Steinmann pin) + traction bow + weights	Femoral shaft, pelvis, acetabulum, polytrauma	Directly controls bone; effective for prolonged use	Invasive; infection risk at pin site
Traction splint	External frame (Hare, Thomas, Sager) with ischial ring + ankle hitch	Femoral shaft fracture (prehospital and ED)	Controls pain and bleeding; maintains length; fast	Pressure ulcers; indirect control; not length stable

Skeletal Traction

Pin placed through distal femur or proximal tibia:
- Distal femur: better for controlling femoral shaft fractures; avoids the knee joint
- Proximal tibia: easier to place; used for femoral and pelvic fractures
Technique: Strict aseptic technique; local anaesthesia; pin passed from medial → lateral through the bone perpendicular to the long axis; traction bow attached; weights applied
Weight: Typically ~10% of body weight (adjusted by X-ray)
Indications: Unstable pelvic ring fractures, acetabular fractures, femoral shaft fractures, polytrauma patients awaiting surgery, intraarticular fractures to offload cartilage

Skin Traction

Foam boots/adhesive applied to skin; traction weights ≤2–3 kg
Limited by skin tolerance
Used for short-term comfort (e.g., elderly hip fractures pre-operatively)
Not used for definitive fracture management

Traction Splint (Hare / Thomas / Sager)

Primary use: Femoral shaft fractures in the prehospital or ED setting
Mechanism: Padded proximal ring seats on the ischial tuberosity → countertraction; distal ankle strap applies traction distally
Effect: Restores limb length, reduces muscle spasm, decreases pain, reduces blood loss (thigh compartment volume is limited)
Contraindications:
- Proximal or distal femur fractures (near the joint)
- Associated knee, ankle, or foot injuries
- Pelvic fractures (may worsen)
- Open fractures with gross contamination

Part 4: Reduction Principles (Preceding Immobilization)

"Reduction maneuvers follow the same general set of principles for all fracture and dislocation types. First, in-line traction is applied to the limb after sedation is administered... If the soft tissue envelope is intact, in-line traction alone may produce satisfactory alignment through ligamentotaxis. In most cases, the deformity must be recreated and exaggerated to allow for appropriate mobilization and reduction." — Sabiston, p. 773

Step-by-step:

Adequate analgesia/sedation — hematoma block (local anaesthetic), IV opioids, or procedural sedation
In-line traction — applied along the long axis of the limb
Recreate and exaggerate the deformity — unlocks the fragments
Reduce — reverse the deformity (usually by manipulation and rotation)
Ligamentotaxis — for articular and periarticular fractures, traction through intact soft tissue can reduce the fracture indirectly
Mold and splint — immediately after reduction, before loss of muscle relaxation
Postreduction X-ray — confirm alignment
Repeat neurovascular exam — document post-reduction status

Summary Table: Splint Type by Fracture Location

Fracture Location	Splint Type	Joints Immobilized	Position
Phalanges	Long finger / gutter splint	MCP + PIP	Intrinsic-plus
Metacarpals (2nd–3rd)	Radial gutter	Wrist + MCP	Intrinsic-plus
Metacarpals (4th–5th)	Ulnar gutter	Wrist + MCP	Intrinsic-plus
Thumb/1st metacarpal	Thumb spica	Wrist + 1st CMC	Thumb abducted
Distal radius (Colles')	Sugar tong	Wrist + elbow	Wrist slight flexion/UD
Forearm	Sugar tong	Wrist + elbow	Neutral forearm
Elbow	Posterior long arm	Elbow + wrist	Elbow 90°
Humeral shaft	Coaptation (U-slab)	Shoulder + elbow	Elbow 90°, arm at side
Femoral shaft	Traction splint	Hip + knee	Neutral
Tibial shaft / plateau	Long leg splint	Knee + ankle	Knee slightly flexed, ankle 90°
Ankle / foot	Short leg splint (posterior + U)	Ankle	Neutral (90°)

Sources: Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice (9780443124341), pp. 764–776 | Rosen's Emergency Medicine (9780323757898)

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