A fracture in a grid-down scenario is a serious problem that becomes a catastrophic one if managed wrong. The fracture itself is rarely the immediate threat to life — the hemorrhage around a major fracture, the neurovascular damage from improper handling, and the infection risk from an open fracture are the killers. Field management of fractures focuses on three goals: prevent further injury, manage the associated bleeding, and immobilize for transport or healing. That is the entire job. Do those three things correctly and you have done what field medicine can do.
FRACTURE TYPES — WHAT MATTERS IN THE FIELD
Closed fracture — The bone is broken but the skin is intact. The injury is contained. Primary concerns: swelling and bleeding into the tissue around the fracture site, and neurovascular injury from bone ends.
Open (compound) fracture — The bone has broken through the skin, or a wound over the fracture site communicates with the bone. This is a dramatically more serious injury. Infection risk is high. Bone that has been exposed to the environment is at risk for osteomyelitis (bone infection) — a severe, difficult-to-treat condition. Open fractures require immediate wound management in addition to fracture care.
What you cannot determine in the field: Whether a fracture is displaced (bone ends misaligned), comminuted (shattered into multiple pieces), or involves joint surfaces. These distinctions affect definitive treatment and surgical decisions but do not change field management significantly.
ASSESSMENT
Assess before you treat. Moving a fracture without understanding what you have can cause injury.
Signs of fracture:
- Mechanism of injury consistent with fracture (significant force, fall from height, direct impact)
- Pain at the injury site, worsening with movement or palpation
- Deformity — visible angulation, shortening, or rotation of the limb compared to the uninjured side
- Swelling and bruising at the injury site, developing within minutes to hours
- Inability or reluctance to use the injured part
- Crepitus — a grinding or crackling sensation or sound when the injury site is gently palpated — do not deliberately elicit this, but note it if present
Neurovascular assessment — critical, do not skip: Before and after any splinting, assess:
- Pulse — Can you feel a pulse distal to (below) the injury? For an arm fracture, feel at the wrist. For a leg fracture, feel at the ankle or top of the foot.
- Motor function — Can the patient move their fingers or toes below the injury?
- Sensation — Can the patient feel you touching their fingers or toes below the injury?
Absent pulse, absent motor function, or absent sensation below a fracture indicates neurovascular compromise — the fracture is pressing on or has injured the blood vessels or nerves supplying the limb. This is a limb-threatening emergency. Gentle traction (pulling the limb into alignment) sometimes restores circulation and must be attempted. If it does not restore the pulse, the patient needs surgical care urgently.
Document your neurovascular assessment before and after splinting. If function deteriorates after splinting, the splint is too tight.
GENERAL SPLINTING PRINCIPLES
Splint it as it lies. Do not attempt to reduce (realign) fractures in the field unless neurovascular compromise requires it. Moving bone ends causes pain, additional bleeding, and potential neurovascular injury. Splint the limb in the position found.
Immobilize the joint above and below the fracture. A mid-shaft tibia fracture requires immobilizing both the knee above and the ankle below. This prevents rotation and movement at the fracture site.
Pad the splint. Any rigid splinting material must be padded before contact with the skin. Unpadded rigid material over a swelling limb creates pressure sores rapidly and can cause pressure necrosis within hours. Use clothing, foam, bandaging material — anything soft between the rigid splint and the skin.
Check neurovascular status after splinting. If the pulse is absent or sensation is diminished after splinting, loosen the splint immediately.
Elevate when possible. Once splinted, elevate the injured limb to reduce swelling and pain.
SPLINTING MATERIALS
Commercial:
- SAM Splint — Aluminum core with foam padding. Moldable to any position. Lightweight and packable. The standard field splint. Stock several in multiple sizes ($8-15 each).
- Vacuum splints — Excellent but expensive and bulky. Less practical for basic preparedness.
- Traction splints (Kendrick, Sager) — For femur fractures specifically. See the femur section below.
Improvised: Any rigid material padded adequately works. Sticks, boards, tent poles, rolled sleeping pads, cardboard layered and rolled — all are functional splinting materials when properly padded and secured. The key is rigidity and adequate padding, not the specific material.
Secure improvised splints with: strips of cloth, triangular bandages, strips cut from clothing, elastic bandages, or any material that holds without cutting into the limb. Check circulation after securing.
SITE-SPECIFIC MANAGEMENT
Upper Extremity Fractures (arm, wrist, hand)
Forearm fractures: SAM splint or rigid material along the volar (palm) surface from the hand to the elbow, padded and secured. Sling to support the arm against the body. Swathe (wrap around the body) to limit shoulder motion if needed.
Upper arm (humerus) fractures: A sugar-tong splint (from shoulder, under the elbow, back up to the shoulder) or a simple sling and swathe. Immobilize the shoulder and the elbow.
Wrist and hand fractures: Splint in the position of function — wrist slightly extended, fingers slightly curled as if holding a ball. A rolled bandage in the palm with the hand splinted over it achieves this.
Lower Extremity Fractures (leg, ankle, foot)
Tibia and fibula (lower leg): Splint from below the knee to below the heel, padded, with the ankle at 90 degrees. Two SAM splints (medial and lateral) with the foot supported are effective. Improvised: two padded boards, medial and lateral.
Ankle fractures: Same as lower leg. Stirrup splint (U-shaped, running under the heel and up both sides) with a posterior splint providing additional support.
Foot and toe fractures: Buddy taping (taping the injured toe to an adjacent uninjured toe) is appropriate for toe fractures. Stiff-soled shoe or sandal for foot fractures.
Femur (thigh bone) fractures — High Priority
Femur fractures are not like other long bone fractures. The femur is surrounded by large muscle compartments that can accommodate significant hemorrhage — a closed femur fracture can result in 1-3 liters of blood loss into the thigh, enough to produce hemorrhagic shock. This is a life-threatening injury.
Traction splinting is the field standard for femur fractures. Traction pulls the fracture ends apart slightly, reducing pain and — critically — reducing the volume of the compartment, which limits hemorrhage. Traction splints (Kendrick, Sager, improvised traction splint) are the tool. An improvised traction splint can be constructed from two rigid poles longer than the leg, secured with improvised traction using strips of cloth — the principles are the same as commercial devices but execution requires practice. Learn to improvise this before you need it.
Counter-indications to traction: pelvic fractures, open femur fractures with significant soft tissue injury, knee injuries. Do not apply traction if any of these are present or suspected.
Absent traction capability: splint the leg in the position found with the best available padding and rigid support. Control any external bleeding. Monitor for shock. Transport is the priority.
Open Fractures — Additional Management
Do not attempt to push bone back into the wound. Cover exposed bone with a moist sterile dressing — saline-moistened gauze if available. Control bleeding with direct pressure around (not on) the bone end. Begin infection management immediately — irrigation around the wound site, not directly onto exposed bone. Antibiotics if available should begin as soon as possible. See Infection Management.
Spinal Fractures
If spinal fracture is suspected (mechanism of injury, neck or back pain after trauma, any neurological symptoms), immobilize the spine before movement. Log roll technique for any necessary movement. Improvised cervical collar from a rolled blanket or clothing secured around the neck. Full-length spine board improvised from a door, a flat piece of wood, or a lashed-together frame of branches. Movement without spinal precautions in a patient with a spinal fracture can convert a stable fracture to an unstable one and cause irreversible neurological injury. If in doubt, treat as a spinal injury.
PAIN MANAGEMENT
Fractures are extremely painful. Pain management is not secondary — pain causes splinting of the breath, which leads to pneumonia in immobile patients, and uncontrolled pain impairs healing and immune function.
Ibuprofen (anti-inflammatory, reduces swelling) and acetaminophen (analgesic) together provide meaningful pain control for fractures. Use them both, at appropriate doses, on a schedule rather than waiting for pain to peak. Ice or cold pack applied over a cloth barrier reduces swelling and pain in the first 24-48 hours for accessible fracture sites.
WHAT TO STOCK
- 4-6 SAM splints in various sizes (finger, small, medium, large)
- Triangular bandages (6-8) — for slings and securing splints
- Elastic bandages (4-6, 3-inch and 4-inch)
- Rolled gauze for padding
- Ibuprofen and acetaminophen in quantity
- Kendrick traction device (KTD) if budget allows ($50-70) — for femur fractures specifically
WHERE TO SOURCE
SAM splints — Amazon, North American Rescue, and most first aid suppliers. Buy in bulk — $8-15 each. Stock a variety of sizes.
Kendrick traction device — North American Rescue, Bound Tree Medical, and Amazon. $50-70. Worth the investment if you have training in its use.
Triangular bandages — Amazon and any pharmacy or first aid supplier. Inexpensive, multipurpose, stock a dozen.
Cross-reference: Shock — Recognition & Response | Wound Packing | Infection Management | Improvised Stretcher