A 19-year-old woman with a closed deformity to her left forearm has no distal pulse and is 45 miles from hospital. Which action is appropriate?

• A. Begin transport at once, gently manipulate her arm en route until distal circulation is restored, and apply an air splint.
• B. Make one attempt to restore distal circulation by applying gentle manual traction in line with the long axis of the limb.
• C. Apply an air splint to her forearm, keep arm below the level of her heart, place an icepack over the injury, and transport.
• D. Splint her entire arm with rigid board splints, elevate the limb above the level of her heart, and transport immediately.

Answer: (B)

When a closed deformity with no distal pulse is present, the top priority is to restore arterial flow by addressing a mechanical cause of obstruction. The best action is to perform one gentle realignment of the limb, in line with the long axis, to relieve the deforming force and improve perfusion. This should be done carefully and only once to minimize the risk of further injury to nerves, vessels, or soft tissue. After that single realignment, immobilize the limb in its new position with a splint and proceed with rapid transport to a facility capable of managing vascular injuries. The goal is to restore circulation quickly without repeated or forceful manipulation that could cause additional damage. Elevation, cold therapy, or prolonged manipulation do not address the perfusion issue and can delay definitive care, especially given the long transport distance.