Cervical spine immobilization
When traumatic brain injury is suspected, the neck must be handled with utmost care, as polytrauma is extremely common. Immobilization is performed at the slightest suspicion of injury. There are several main fixation methods:
- Cotton-gauze roll. This is the simplest method to execute, but the least effective. The casualty is carefully laid supine on a stretcher (strictly on their back). The cotton-gauze roll is carefully placed under the head so that the patient's occiput rests precisely in the center opening of the roll.
- Schanz collar. This is a cotton-gauze or cardboard-cotton-gauze fixation bandage. This method is significantly more effective. Proper fixation requires clear support points: superiorly, the bandage rests against the external occipital protuberance and both mastoid processes, while inferiorly it fits snugly against the chest. The main criterion for correct application: the casualty should find it difficult to open their mouth.
- Standard cervical collars. These are special rigid collars equipped with convenient fasteners. Today, they are the modern standard of care because they are applied with minimal time and provide reliable rigid fixation. They have practically displaced obsolete methods from clinical practice, such as the plywood splint and Bashmakov bandage (a complex structure of curved wire ladder splints).
Transportation in spinal and pelvic injuries
Severe traumatic brain injury is frequently accompanied by injuries to other areas, including the axial skeleton. Transportation of such patients has strict limitations. It must be carried out exclusively on a rigid surface (spinal board).
In situations where a specialized board is unavailable, carrying a patient simply on a soft stretcher is strictly prohibited. In this case, an improvised rigid structure—pre-assembled from securely fastened wide boards or sturdy slats—must be placed on the standard canvas stretcher. This will prevent spinal flexion and secondary spinal cord injury.
Rules for applying the Dietrichs splint
If there is a concomitant femoral injury, a Dietrichs splint is used. The application technique involves a strict sequence of steps:
- Footpiece fixation. This is the first stage of limb preparation.
- Placement of the inner bar. The bar rests against the perineum. Important: when applying pressure, compression of the genitals must be strictly avoided. A traction cord is passed through a special opening in the distal support of this bar.
- Placement of the outer bar. The upper end of the structure rests directly in the axillary region.
- Connecting the bars. The elements are securely connected to each other beneath the casualty's foot.
- Fixation to the trunk. This is performed using special straps or gauze bandages at no less than 5 points: the chest, pelvis, upper third of the thigh, knee joint, and lower third of the lower leg.
- Traction and final fixation. First, fixation is applied to the points located proximal to the fracture site (for a femoral shaft fracture, the top three points; for a hip joint injury, two points). Then, by turning the windlass, limb traction is applied. The windlass stick is securely locked, after which fixation at the distal points is completed.
Alternative: If a Dietrichs splint is unavailable, a combination of Cramer splints is used. The same levels and 5 points of fixation are observed, however, the immobilization is performed without traction, making this method less effective.
Immobilization of the lower leg bones and foot
Due to the high mobility of tibial bone fragments, there is a critical risk of skin perforation from the inside by sharp bone edges. A justified approach is immobilization from three sides using a combination of wire ladder splints.
- Posterior splint. Applied from the upper third of the thigh to the tips of the toes. Important rule: the foot must be fixed strictly at a right angle (90°) to the longitudinal axis of the lower leg.
- Lateral splints. The structure is reinforced with two additional wire ladder splints on the lateral and medial sides of the lower leg. The use of wooden splints is permitted, but less effective.
If only the ankle joint and foot are injured, the boundaries of ladder splint immobilization extend from the tips of the toes to the knee joint (at the level of the fibular head).
Briefly: answers to topical questions
In what position is a patient with a pelvic fracture transported on a rigid spinal board?
Transportation of a patient with a pelvic fracture on a rigid spinal board is carried out in the supine position with the legs in a "frog" posture (Volkovich position).
Features of positioning the casualty:
- Leg position — semi-flexed at the hip and knee joints.
- Thigh position — knees abducted, thighs externally rotated.
- Foot position — feet brought together.
- Additional fixation — a bolster made of clothing, a blanket, or a duffel bag must be placed under the knees (in the popliteal fossa).
What types of modern rigid standard cervical collars exist?
Modern standard cervical collars are described as special rigid collars with fasteners; they are applied with minimal time and have almost completely replaced the plywood splint and Bashmakov bandage. The source does not list specific types of modern standard cervical collars by name. For external cervical spine fixation specifically, the thoracic cranial brace, traction orthosis, and rigid and semi-rigid orthoses are mentioned separately.
What medical therapy must obligatorily precede the application of transport splints in fractures?
The application of transport splints in fractures must obligatorily be preceded by adequate analgesia.
For medical therapy at all stages of care, the following are used:
- General narcotic analgesics — to relieve severe pain syndrome.
- General non-narcotic analgesics — for complete pain relief and ensuring psycho-emotional comfort.
Starting from the stage of primary medical and emergency medical care, systemic analgesia can be supplemented by performing local novocaine blockades.
The fixation points of the Dietrichs splint are easy to remember from top to bottom by major body segments: Chest — Pelvis — Thigh — Knee — Lower leg (5 points in total).
Class and exam questions
How to quickly check if a Schanz collar is applied correctly?
The main criterion for correct application is the restriction of mandibular mobility: the casualty should find it difficult to open their mouth. Meanwhile, the bandage must firmly rest against the external occipital protuberance and mastoid processes superiorly, and against the chest inferiorly.
Why is it mandatory to apply splints on three sides in lower leg fractures?
This is due to the high degree of mobility of the tibial bone fragments. Three-sided fixation (posterior, lateral, and medial) prevents the risk of skin perforation from the inside, which could turn a closed fracture into an open one.
Can a Dieterichs splint be replaced with Kramer splints?
Yes, in the absence of a Dietrichs splint, the use of a combination of Cramer splints is permitted. In this case, the same five fixation points are observed, but the procedure is performed without axial limb traction, which reduces the overall effectiveness of immobilization.
In what position is the foot fixed during lower leg injuries?
There is a strict rule: the foot must be securely fixed by the posterior ladder splint strictly at a right angle (90 degrees) relative to the longitudinal axis of the lower leg.
What else to study on this topic
- Criteria for selecting rigid standard cervical collars and the technique for fitting them to the patient's size.
- Features of creating an improvised board for transportation in pelvic injuries.
- Algorithm for performing axial traction using the windlass of the Dietrichs splint.
- Modeling the posterior ladder splint from the upper third of the thigh to the tips of the toes.
- Anatomical landmarks when applying lateral splints to the ankle joint (level of the fibular head).
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