Save Lives Like a Combat Medic: How to Splint a Lower-Leg Fracture

by A Manly Guest Contributor on November 29, 2012 · 18 comments

in Manly Skills, Outdoors, Survival

Editor’s note: This is a guest post from former Army medic Bruce A. West.

You’re miles from any civilization at a lookout point on a large boulder with a friend, taking in the beautiful fall scenery, when your buddy slips and falls to the ground. They’re holding their leg and screaming in pain; their tibia (shin bone) is sticking out of the skin, and blood is quickly escaping the wound. You run to their aid and put an improvised tourniquet on them to stop the bleeding. Now you need to get them out of the woods quickly, but you’ve got to do something about that fractured leg before you move them. What do you do?

When you’re in the wilderness you don’t always have all the gear you need to save lives — let’s face it, few of us are strong enough to carry an entire ambulance’s worth of supplies on our backs. You don’t have pre-made braces, crutches, or cast-making material on hand, and you probably don’t have the tools to properly set a broken bone. What you do have is a first aid kit (maybe), a pocket knife, the clothes on your back, and the woods around you. These are all the tools you need for a makeshift splint that could mean the difference between life and death.

Never mind all the rules you’ve learned about first aid, or all the technical gear you wish you had. You simply need to improvise. These techniques aren’t pre-made, and they certainly aren’t pretty. They’re passed down through years of combat medics’ experiences, and they’re proven to save lives.

Knowing how to treat a broken limb is one of the easiest and most important improvised first aid skills you can learn. Different kinds of fractures are treated differently, so today we will just focus on those in the lower leg (tibia and/or fibula). In future articles, I will explain how to handle other kinds of fractures (upper leg and arm). Lower leg fractures are common, and severe breaks can even be life threatening. I’ll provide all the steps you need to know to perform this potentially lifesaving technique.

Your Lower-Leg-Splinting Battle Plan

If there are other people with you, have them call 911. If you’re alone with the victim, make sure they’re breathing, their heart is beating, and they have no major bleeding, and then call 911 yourself.

Assuming you’re in the middle of nowhere with no phone signal, you’re probably going to have to move your patient to get reception – and you may need to travel just to be in a place where rescue workers can find you. But you can’t move someone with an unsplinted, severely fractured limb. Follow these steps to brace their broken leg:

Step 1: Scene Safety and Body Substance Isolation

In military medicine, civilian medicine, and basic first aid the most important consideration is safety of the rescuer. Don’t treat anyone if you’re in harm’s way. Now, you’re not worried about guns and bombs, such as in military medicine, but you should consider other threats: your patient broke their leg from a fall…are you in a position to fall yourself? If you’re at risk, address your threat first, and then care for the patient. In this case, you may need to drag your patient to level ground (despite their fracture or bleeding) before you can safely treat them. Then, before you do anything, protect yourself from disease by wearing gloves (or even plastic bags).

Step 2: Expose the Wound & Assess the Patient

Before you treat a patient you have to assess them in order of most important functions to least — and treat them as you encounter problems. It’s always important to make sure your patient is breathing and that their heart is beating. You may have taken first aid and learned to remember your ABCs: Airway, Breathing, and Circulation. This is a great mnemonic device in a medical situation, but in major trauma this order of procedures can cost a life. In the Army we taught an acronym called MARCH, which stands for:

  • Major Hemorrhaging
  • Airway
  • Respirations
  • Circulation
  • Head Injuries, Minor Hemorrhaging, Hypothermia/Shock

ALWAYS address major bleeding first — if they’re losing a lot of blood and you’re worried about doing CPR, you’ve already lost them. In this case of open fractures (broken bones protruding through skin), blood loss is a major concern. You’ll need to apply a tourniquet. So, assess and treat any major bleeding, then do your ABCs, or “-ARCH.”

The best and only way to know where your victim’s wounds are is to expose them. In major trauma, do NOT focus only on the spots you know are hurt — there could be other injuries you’re not seeing because they’re masked by clothing. There’s an old saying in medicine, “A happy trauma patient is a naked trauma patient.” You can’t fix anything you’re unaware of. I advise undressing your patient entirely (you can always redress them later — as long as you don’t cover any wounds).

Step 3: Manually Stabilize the Fracture

You’re not a doctor (unless you are), and this isn’t the movies, so you won’t be setting your victim’s broken bone. You need to leave it in the position you found it in, and you need to keep it still (so the broken bone doesn’t cause more internal damage, i.e.: severed arteries; torn muscles, ligaments, tendons, etc.). You’re going to splint it, but before you do, it’s good practice to manually stabilize the broken limb while you prepare your homemade splint.

If you aren’t alone with the victim, have someone hold the broken limb in place. Manual stabilization is that simple; complicated name, easy execution. They’re in pain, and they may be moving around; have someone hold their limb still to prevent further aggravation of the injury. This can really only be done if you have help; if it’s just you and the victim, limb immobilization will have to wait until you’ve applied your splint.

Step 4: Check for PMS

Before you splint the limb, you need to assess their PMS. This means you check below the fracture for:

  • Pulse
  • Motor Control
  • Sensory Feeling

Check for tibial pulses (on the inside of the ankle, just behind the bump commonly referred to as the “ankle bone”), or for a dorsal pedal pulse (on top of the foot); have them wiggle their toes, and make sure they feel you touching their feet (pinch their pinky toe, ask them which toe you’re touching). Here’s a short video on how to locate these pulses:

If there was an exposed fracture and you used a tourniquet, you won’t find a pulse below the injury, and there may be little motor control or feeling. In less extreme cases, checking for PMS is important. If they had circulation, movement, and feeling to the hand/foot before you installed the splint, you want them to have the same sensations afterwards. Thus, you’ll repeat this step later.

Step 5: Select Your Splint

If you fracture your leg during a bartitsu fight with another distinguished gentleman, have your friend splint it with your umbrella.

Here is your opportunity to get creative. You need to improvise a splint.

Grab some thick sticks, a hiking pole or walking stick, the frame from inside a backpack, an axe handle — anything rigid will do. You simply need two objects, preferably the length of the limb (or at least the length of the affected half) to splint each side – for even more support, extend a longer outer splint up to the victim’s armpit.

Next you need something to tie your braces to the limb with. Again, get creative. You can use belts, shirt sleeves/torn strips from t-shirt, bandanas/handkerchiefs (just another one of their many uses!), a shemagh/scarf, rope from a survival bracelet, even a tie! It matters not what you use, but how you use it.

Step 6: Apply the Splint

Get everything into place before you tighten it down. Start by laying your ties in place under the limb — for a leg, you can carefully slide the tying devices through the void below the knee and ease them back and forth until you’ve slid them into place. Place one by the ankle, one below the fracture, one below the knee, one above the knee, and so on. Don’t place one directly on the knee — and definitely don’t place one around the wound!

Once you have your ties in position, place your splints on either side of the limb on top of the tying devices.

Starting at the bottom and working your way toward their body, tie the splint to their leg. For more support, if you have time and a long enough strap, you may wrap the ankle strap around their foot; this immobilizes the foot, preventing the victim from creating unnecessary pain by bending their ankle, which causes the leg muscles and tendons to place stress upon the tibia and fibula. You may also place padding between the splint and the patient’s body for comfort (this can be in the form of torn cloth, acrylic sleeping bag stuffing, spare socks, etc.) But if your top priority is getting someone out of the woods as quickly as possible, you don’t need to waste time on it; their leg is already uncomfortable.

In the end, you want the ties to be snug, but not too tight. The idea is to hold the braces to the leg, but not to cut off circulation. Remember this rule of thumb: you should be able to easily slide two fingers side by side between the ties and their limb.

Step 7: Assess and Treat Remaining Injuries

Great! The victim’s fractured limb is splinted! But, they’re far from lying in a warm and comfortable hospital bed awaiting powdered eggs. Aside from simply getting them to a hospital, there are other things to consider before they’re truly safe.

First, check their affected limb again, and make sure they have PMS. If they did before and they don’t now, you likely need to readjust your splint (again, unless you’ve applied a tourniquet).

Next, assess them again: Do they have an open airway, and are they breathing? Do they have a pulse? Are they bleeding? Any exposed wounds? In this case, yes! There are exposed wounds. The victim has an open fracture, meaning open flesh and exposed bone, which can lead to severe infection. You’ve already stopped the bleeding with the tourniquet; now its time to protect the wound from the elements. If you have sterile gauze in your first aid kit, now is the time to use it — if you don’t have gauze, use soft cloth from a shirt. Cover the wound entirely, and secure it in place with another handmade tie (making sure not to tie it too tightly so as not to cause pain).

Now would also be the time to assess for shock. In the event of such a severe fracture, shock is very likely. Look for:

  • Cool, clammy skin (moist, cool, and pale)
  • Cyanosis (blueing of skin)
  • Weakness
  • Confusion
  • Rapid Breathing
  • Unconsciousness

To treat the victim for shock, lay them on their back and keep them warm. Cover them with clothes, coats, blankets, a sleeping bag, or even a pile of leaves or pine needles — whatever you have available, just get them warm.

Step 8: Get Help!

If 911 hasn’t been called yet, do so now. If you still can’t call 911, it’s time to move. Never leave your patient behind. If they can hop on one foot as you aid them, do it — but this may not be possible. In such a case, it’s time to summon your inner fireman — carry that person, and go find help.

_________________________

Bruce A. West served as an Army medic in the Iraq war. He taught over 500 soldiers how to save lives in a class called Combat Lifesaver, and will be sharing his knowledge here on AoM in a series on important first aid/first responder skills every man should have. Bruce also recently started Geared Magazine, an outdoor gear and instructional site with a focus on survival and preparation.

{ 18 comments… read them below or add one }

1 Isaac November 29, 2012 at 11:10 pm

Very interested, good knowledge for a hiking enthusiast like myself.

2 Kevin L November 29, 2012 at 11:34 pm

Interesting article! I hope I don’t ever encounter this situation, but having a general idea of what to do would be far better than an erroneous action.

3 Nick S. November 30, 2012 at 12:13 am

Cool. A very good skill to know, but what one I never learned…

4 James B November 30, 2012 at 12:36 am

Good article, great info.

Bruce does a great job of spelling out every step from patient assessment, treatment, and even how to prevent future problems (Shock). But there is an easier way. And it works in all environments, I.E deserts, ice, high mountains.

Do everything Bruce said, just tie his legs together. It is called an anatomical splint, as long as the patient has another leg you always have a brace.

Pain is the best splint there is!

Again great Article, and carry on 68W brother!

5 Max November 30, 2012 at 5:35 am

To check for blood circulation you can also check the nails. If you press on the nail-bed, it turns white. It should return to pink within 2-4 seconds.

That’s how I learned it.

6 dannyb278 November 30, 2012 at 9:36 am

Brings back memories of basic training at Ft. Knox.

Also why i carry at least 3 bandanas in my pack when out in the field.

7 Marc November 30, 2012 at 10:13 am

Very well put, but, for heaven’s sake, DO NOT EVER MAKE A TORNIQUET UNLESS AMPUTATION OR TOTALLY CRUSHED LIMB. This is not a battlefield, in which you need to run away as fast as possible. Do you want your patient to lose its limb and be your fault? I certainly don’t. I can not assess wether this is a life over limb situation, so I’ll stick to what I learnt to be safe. Indirect pressure (in the “legpit”) or direct if indirect doesn’t work. By the other things, it’s definitely the way to go. I wish I had this diagrams in my consuelor training course, instead of letting me figure it for myself, only to recieve mockery from the instructor (ok, now the patient is wishing that you and your whole family were dead).
Oh, and call 911 first of all and tell them EXACTLY what you are going to do and repeat it several times. You don’t want to be sued by angry parents (if working with children) for ruining their brats’ leg, or something to the sort because it can’t be proved that you did the right thing.

8 Bone Doctor November 30, 2012 at 4:32 pm

Very good read but I agree with Marc, as an actual orthopaedic surgeon I am a little mifted at what the Army teaches their medics. In advance trauma life support airway is always the top concern. It can take hours to bleed out (unless pulsatile from neck, thigh, or elbow level) and it takes 3 mins to become brain dead. Tourniquets should only be used if you think the limb injury is a life or amputation situation, we get plenty of “medic placed” tourniquets that end up cosingt a guy his leg. The moral of the comment is Airway first unless they are exsanguinating before your eyes and only tourniquet if you think they will die. Pressure on a wound works fine unless your are dealing with a major carnage type injury (explosions, near amputations, massive crush) open fractures have very little risk of “bleeding out”.

9 a November 30, 2012 at 4:44 pm

As a civilian medic with about a decade of street experience im just gonna say this-

Forget the tourniquet.

Unless they’re spurting bright red arterial blood, then by all means knock yourself out.

Otherwise do exactly what the man says.

10 Blake December 2, 2012 at 1:23 am

As others have said a tourniquet is a last resort, it should only be used if a major artery is severed.
The trick with the nail bed is one I will remember, I can feel my own pulse in my fingers (high blood pressure) so it’ll be something for me to remember.

11 Matt December 2, 2012 at 3:43 pm

I had a lower tib upper fib fracture in a fight in the summer, it’s been 7 months, I’m just now starting to be able to move my toes. Do Not Move the Broken Parts. It is easily life threatening, you will do a lot of permanent damage. If you can’t get cell service, either go get it, or prepare for someone to lose a limb. At 20 I almost lost my leg to a break. I’ve got a few friends with the same injury, and all the doctors said it would be at least a year before I was back to normal. I’ve got 4 screws (2 heads of the screws stick out of my bone and get bumped on everything) and a 16-20 inch metal rod hammered into my leg. By the way, they literally hammer it into your leg, and when you wake up from surgery you can tell that’s exactly what happened. They had to give me the maximum doses of 3 painkillers every 2 3 and 4 hours, to even get me to sleep because I was in the hospital, for 11 days. I also had to have 2 skin grafts because they waited too long to set the bone and the xray technician improperly handled my leg and injured it further. The only reason I didn’t lose my leg was because I was in so much pain I couldn’t pass out. My lower leg looked like it had 3 knee sized joints.

Moral of the horror story, Don’t their injury unless you’re both prepared to live with someone losing their limb.

12 Mr. Medic December 3, 2012 at 8:15 am

I’m currently a combat medic and former EMT. The advice here is extremely useful and also very accurate (it is *how* we do
things…this is dead-on how it’s still taught). One of the things, though, is we aren’t taught MARCH anymore in Whiskey school (the MOS qualifier is 68W, or 68-Whiskey, so we call it “Whiskey school” sometimes)

We are instead taught, H-A-B-C’s which is essentially the same thing; Hemorrhaging, Airway, Breathing, and Circulation.

MARCH is still a useful way of doing things and *will* still work (and is actually more thorough since it’s inclusive of
immediately checking for head injuries)

Basically the practice of medicine; do what best works for you, the patient, and the situation based on your scope of
knowledge and what is a generally accepted method of doing things.

If you want to be highspeed, after you’re finished splinting the leg, you can be useful and gather a further patient
history for the EMT’s. Remember the acronym, SAMPLE (Patient history) and OPQRSTU (pain assessment):

S- Signs and symptoms
Basically what you see and what they are expressing
A- Allergies
For both medications and food
M-Medications they are taking
P- Past pertinent medical history
Have they broken this leg before? Any heart/breathing/diabetes problems?
L- Last oral intake
When and what did they last eat
E- Events leading up
What they were doing when this happened? Did they fall? Were they kicked? Hit by a car? etc…

OPQRSTU
O-Onset
How long ago did this happen/was it a sudden pain?
P-Provocation
What makes this feel worse? If you bend it, walk on it, etc
Q-Quality
What kind of pain is it? Sharp, dull, stabbing, achy, etc
R-Radiation
Does the pain go anywhere else?
S- Severity
On a scale form 0 to 10, 0 being no pain and 10 being the worst imaginable, how much pain are you in?
T-Time
How long has the pain been going on for
U- You
What have *you* (the patient) done to make this pain go away? Any medications, etc?

As stated in the article, just remember if you were not fully trained on specific treatments, DO NOT DO THEM. NEVER do something you saw on TV. Ever. You can end up making the situation worse and you can face legal repercussions.

13 EMT man December 4, 2012 at 10:29 am

As an EMT I agree with most of this. The only part I have HUGE contention with is when to call 911. If the person is conscious, call 911 as soon as you know what the problem is! If the person is unconscious, take 10 seconds to determine if the person has a pulse and is breathing then call 911. The only time you should delay 911 is if you happen upon someone down (unwitnessed) and you do not have access to a phone or the probability of a phone will be more likely in the future I.e a person walking by etc…

I cannot stress enough how important it is to get that going ASAP. It takes a BARE MINIMUM of 3 minutes for an ambulance dispatch in a normal city environment but town or rural environments can take up to 15 minutes depending on size and
Your location!!! DO NOT WAIT. Even if you put them on speaker or call and get the words “ambulance NOW” out before you run away its worth it!

Be safe y’all.

14 Jarhead Survivor December 7, 2012 at 7:20 am

Man, this brings back memories. I broke my ankle on the Appalachian Trail about ten years ago in the 100 mile wilderness up in Maine. I wrote about it here if anybody’s interested: http://www.shtfblog.com/broken-leg-in-the-100-mile-jarhead-survivors-story/

I really need to follow through and get my EMT training.

15 Cometary December 7, 2012 at 9:29 am

Good information. Here’s something that the Special Forces Medics train with and is available to everyone now.

http://www.dustoffmedical.com

16 Birch December 16, 2012 at 8:49 am

Even If you don’t have reception, call 911 and text someone who can call for you. It may get through enough to get help on its way.

17 MaddMedic February 26, 2013 at 4:14 pm

As a 20 plus year EMS provider, 17 years as a medic and one whom has been teaching LEOs, FFers etc for the last 4. I think I will point a few contacts at the State Patrol Training Center to this article.
Tourniquet if bright red blood spurting…
I know all to well how that works, as I had a mishap with a machete in the BWCA a couple of years ago…Applying said tourniquet with my 18 yo son’s help saved my bacon..
Again nice write up.

18 Lord Isaac of Glencoe March 16, 2014 at 8:00 pm

To everyone saying that you should call 911 first, you should remember the scenerio. Open-fracture , which more than likely means heavy, even arterial, bleeding. Your hiking, which paints a portrait of some measure of isolation from “civilization”. Depending on how bad the bleeding is, in some injuries one can fatally bleed out with five minutes. So even if your only five minutes away from medical attention, you’re screwed at that point. So get that tourniquet on quick! And for those who are so worried about losing a limb from employing a tourniquet, I suggest you reread Step 3 on another article posted here entitled “Save Lives Like a Combat Medic: How to Use a Tourniquet to Control Major Bleeding”. Then when your done reading that, remember this, TOURNIQUETS ARE NOT CONCRETE…meaning a tourniquet doesn’t have to be applied forever. If you employ one, and soon after realize that tightly wrapped compression bandage can hold the job, then apply that second bandage and slowly remove your tourniquet. I’m not a Medic, however i am a Marine who has gone through, Advanced CLS (combat lifesaver) and D-Moc, not to mention our Corpsman was a hardcharger the never let us spend a mintue in peace without a quiz on what we do when injured. Have a good night gents.

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