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You’re half way into a backpacking trip in Wyoming’s Wind River Range, when a hiking partner slips on a wet scree slope, injuring her knee. She can bear weight, but needs some support to hike out. She also injured her wrist as she tried to catch herself. Now what?

Below are a few guidelines and techniques for constructing improvised splints. We strongly urge you to take a wilderness first aid course, as the techniques described below will be of little use without good assessment skills and sound judgment.

Basic Principles:

• Be creative.

  Almost anything can be used for making a splint: sticks, packs, pads, clothing, camp chairs, or anything else that can provide some support. For improvised splints, your motto should be, “What would MacGyver do?” which by the way, is a good mantra for all occasions. That said, there are a few items that will make your job easier.

  • Something to tie stuff with.
    The old standby for this is a cravat (a large triangular piece of fabric). You can make them by cutting up clothing or any fabric you can spare. Cravats are fantastic for two reasons: they make sling and swaths much easier (see below); and they can be spread out over a large surface area, making the splint much more comfortable. If you think your patient isn’t worth sacrificing your precious Patagonia Capilene, there are alternatives. Spare webbing or cordage is always good, as is twisted duct or athletic tape.
  • A semi-rigid sheet of... anything.
    Probably the single most useful piece of backcountry splinting material is a foam sleeping pad. In fact, they make more comfortable splints than beds. If you don’t have a foam pad, the framesheet of your pack will work, as will your self-inflating mattress, or even a sleeping bag (sleeping bags are especially good, although they tend to make the unlucky soul hot).
• Splint in the position of function.

  Like many medical terms, position of function is a fancy name for a common sense principle: splint the injury in a position that’s comfortable and natural. For an upper extremity injury, the injured person will generally be holding the injured arm in toward his chest, cradling it with the uninjured arm. You’ll be splinting the arm in this position. For a lower extremity injury, strive to make the splint as comfortable as possible, and in line with the patient’s body.

• Use padding, then use a little more.

  In a backcountry scenario, your patient will probably be wearing the splint for a long, long time, and in some cases, several days. In the backcountry, you’ll have loads of time. Take advantage of that time and be anal. The entire splint should be well padded, especially if the splint involves a rigid component, like a stick or trekking pole.

• The splint should be adjustable.

  During a long evacuation, even the best splints need a little love once in a while. Use releasable knots (like you do with your shoelace), so they are easy to undo and retie if need be.

• Fingers and toes should be accessible.

  You don’t want to make an injury worse by cutting off circulation, sensation, or motion. Check the circulation in the toes or hand (by checking the pulse, or if you don’t know how do that, by observing skin temperature and color). Ask the patient to wiggle his or her fingers then to squeeze your hand. Ask her if she has any tingling or weird sensations. Apply the splint, then recheck everything mentioned. If anything changes for the worse, reevaluate your splint. Remember, evacuating an injured person in the backcountry takes a while. The extra ten minutes to make a quality splint is nothing compared to the multiple hours (or days) it will take to hike out. Take the time to do it right.

• Immobilize
  • For injured joints (busted knees, elbows, ankles) immobilize bones above and below the injury.
  • For long bone injuries (broken arms, legs), immobilize the joint above and below the injury

  Now that we have the rules out of the way, let’s look at some techniques you can use to splint common musculoskeletal injuries.

Wrist, Hand, and Forearm Injuries

The Sling and Swath
The sling and swath is used for all upper extremities. The sling supports the injured extremity and immobilizes the lower arm, while the swath functionally immobilizes the shoulder and keeps the arm from “chicken winging” outward.

• Pad and size.
  An inner splint (a semi rigid sheet under the forearm) helps, but isn’t strictly necessary. Use a SAM splint (a commercial splint that comes in many outdoor first aid kits) or cut out a section of foam and fold it in half. It’s a good idea to measure your splints against the uninjured extremity before applying them. Make sure you put a layer of padding between the splint and the arm.

  

  Wrap a layer of clothing around the arm before applying the splint to the forearm.

• Apply the splint to the arm.
  Secure it by tying cravats or wrapping fabric, gauze, etc, from the back of the hand all the way to the elbow with an Ace bandage, cravats, or strips of cloth. Make sure the splint supports the hand, and there is something for your injured friend to hold, a rolled up bit of cloth works well, or the end of the splint. *TIP: make sure you wrap your cravat, gauze, etc, over the back of the hand, then between the thumb and first finger, then back under the split. This helps secure the hand to the splint and prevents the patient’s wrist from flopping around.

  

  Secure the inner splint to the arm with wide cravats, strips of fabric, or an ace bandage.

• Take a cravat and tie an overhand knot a few inches from the apex of the triangle. This creates a pocket for the elbow to sit. Have the patient put his hand over his heart, as if he were saying the pledge of allegiance. Pass the sling around his elbow, tying the two swath ends together around the shoulder. Pad under the knot.

  

  The sling. Note the position of the arm.

• Tie a cravat (or wrap strips of fabric, etc) around the injured arm and secure it to the other side of the body. The swath should be fairly low (covering the injured person’s elbow), and the wider the better. No chicken winging should be possible. Pad under any knots, as these will become uncomfortable pressure points during a long evacuation.

  

  The sling with a hoody used as a swath.

• For a humerus fracture (upper arm injury) A fractured humerus hurts like hell. The humerus is a long bone, and the tricep and bicep are fairly large muscles (especially if you’ve got guns like mine). When a humerus breaks, the tricep and bicep pull the broken ends together, which is extremely painful. You can counteract this by creating gentle traction. Place the splint on the upper arm, and secure it with either an Ace bandage, gauze, or a few cravats. If you’re using cravats make sure to tie one below, and one above the injury, not on the injury itself (this could be very painful). Now make a sling, but do not support the patients elbow. The goal here is to comfortably support the forearm, but let gravity pull on the upper arm a bit, providing a bit of gentle traction. Finish off the splint with double swaths, which should immobilize the shoulder.
  
  A sling and swath for an upper arm injury. The sling does not support the end of the elbow, and the shoulder is immobilized with 2 swaths.

• For a collarbone injury Just make a sling and swath, no inner splint required.
• For a elbow injury The only difference here is that you’ll have to make sure that there is no pressure on the elbow and that the entire elbow area is extremely well padded. A good technique for this is to create an upper arm splint (like in the humerus example) but slide the splint down the arm so that it sticks out below the elbow. Pad the elbow area well, then apply a sling and swath like normal.

  

  The inner splint positioned for an elbow dislocation or fracture.

Knee, Lower Leg, and Ankle Injuries

Decide whether the injury is usable or unuseable.
Can the injured person bear weight? Is there any way they will be able to walk out? You better hope so, otherwise you’re going to have to call for search and rescue, or make your own stretcher (see the note at the end of this article). If you’ve ever tried to carry someone out of the backcountry, you know it’s a royal pain in the butt and should be avoided if possible.

Usable knee injuries
A good splint for a usable knee injury limits lateral (side to side) motion of the knee, but still allows for a bit of flex, which makes walking possible. A sleeping bag, pad, or even a tent fly folded over itself many times will make a good frame for a knee splint.
*TIP: Constructing a lower extremity splint is easiest with two people. Have your helper cradle the lower leg and foot with her hand and forearm and grasp the injured person’s thigh to move the leg up and down, or have the injured person help you.

• Size the splint. It should extend part way up the thigh and part way down the lower leg. The length will partially depend on the extent of the knee injury. The more severe, the longer you will want to make the splint. In the picture, we used a foam pad folded in half. A piece of webbing was folded into the pad, along the top (we’ll return to this later).
• Place cravats (or whatever you’ll use to tie the splint) under the splint so there ready to go.
• Pad the splint

• Move the splint under the patient’s leg and have your helper bend the splint around the leg. Pad any void spaces and under the knee. Keeping a slight bend in the knee from the start makes the splint slightly articulated, and makes the splint much more comfortable for the patient.
• Bend the splint around the knee, creating a frame, and secure the splint with cravats. Keep the cravats as wide as possible over the leg, and avoid placing a cravat over the knee itself. All knots should be on the outside of the leg.
• The webbing in the example goes around the shoulder. This helps keep the splint from sliding down.

  

Usable Ankle Injuries
The splint for an ankle injury depends on how severe it is. Often, simply leaving the boot on and having the patient walk carefully with a trekking pole is all that is required. For people who chronically roll their ankles, prevention is key. Make sure they wear tall supportive boots or tape their ankle before going out. For more severe injuries, try the following splint.

• Pad the patient’s ankle. Cut out a piece of foam pad (or use a SAM splint) to use as an inner splint. This splint should extend from just above the bottom of the heel to mid calf.
• The ankle hitch secures the splint to the foot. Lay a long cravat (or two tied together) in an S-shape over the front of the ankle. Pull the tails of the S around the back of the ankle and through the newly created loops. Tighten the hitch by pulling down on both ends, then tie the ends of the cravat together on the outside of the foot. There should now be a stirrup on the instep of the patients boot.

  
  

  Preparing the ankle hitch. Note the stirrup created under the instep of the boot.

• Wrap up the splint (from ankle to calf) with cravats, an ace bandage, or strips of fabric.

• A figure eight locks the heel into place, providing great stability. Take a cravat and lay it behind the heel. Now take the ends and cross them in front of the patient’s ankle, then down under the foot, then back over the front of the ankle in a figure eight pattern. Do this two more times, or until the patient says her ankle feels secure, then tie the ends of the figure-eight together. You now have a solid walking ankle splint. Note: The only down side of this splint is that you don’t have access to the patients foot to check circulation. Ask him to wiggle his toes and occasionally take the splint off.

  
  

  The finished walking ankle splint with figure eights.

Unusable Leg Injuries (knee injuries, lower leg injuries)
Unusable knee injuries require a longer, stiffer splint that immobilizes the ankle.

• Follow the same procedure as the usable injury example, but this time the splint should extend to the upper thigh several inches below the crotch (have the patient put the splint in place if you two don’t know each other well) and down past the foot. Again, a foam sleeping bad is perfect for this.

• Apply the splint following the same procedure as in the usable knee injury example. Now you’ve made a fairly rigid frame, but still have a bunch of extra pad, and the patient’s ankle is still flopping around like a dead fish. Don’t worry. Place a cravat at the bottom of the pad, and roll the cravat up into the pad until you hit the patient’s foot. Now, bend the ends of the pad up and tie them together with the cravat (or any sort of lashing), creating a boot. Thread another cravat through the one you just tied and secure this one around the ankle.

  

• Pad any gaps around the ankle, and finish by wrapping an ace bandage or a few more cravats around the lower part of the splint. Bomber!

  

  A finished unusable knee, ankle, or lower leg splint.

A note on other lower extremity splints:
It’s possible to make a sweet backcountry traction splint for a femur fracture which would make even MacGyver all hot and bothered, but that’s beyond the scope of this article. If you want to learn, take a Wilderness First Responder or Wilderness EMT course. In fact, I personally think anyone venturing into the backcountry should at least have a Wilderness First Aid course, if not a WFR.

A note on improvised stretchers:
If an injury is not useable, you’ll either have to call search and rescue, or carry the victim out yourself on a make shift stretcher. With enough materials for lashing and five or six people, you can make a surprisingly stable litter out of a few sturdy logs and a bit of creative engineering. Just remember to make absolutely sure the stretcher will hold the victims weight. If you want to learn more, take a Wilderness First Responder or EMT course. Do you see a pattern emerging here?

The last word:
The above tips and techniques show you a few ways to make splints, but by no means are they definitive. As long as a splint makes the patient more comfortable and prevents further injury, you’ve achieved the goal. Remember: be creative, practice, and take a first aid course.