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02-03-02, 19:20
MANAGEMENT OF DISLOCATIONS AND FRACTURES
IN THE WILDERNESS ENVIRONMENT
By
Joseph B. Serra, M.D.
Orthopedic Medical Group
Stockton, California
MANAGEMENT OF DISLOCATIONS & FRACTURES
IN THE WILDERNESS ENVIRONMENT
GENERAL COMMENTS
Trauma to the musculoskeletal system, in the form of disloca-
tions and fractures, is on the increase due simply to the
fact that there are more people involved in the wilderness
experience of remote travel, climbing, cross-country skiing,
trekking, and major expeditions. The fractures and disloca-
tions are the same as those seen in the urban and hospital
setting; however, there are distinct differences in methods
of diagnosis and acute management. It is a well known fact
that the sooner a dislocation is reduced, or the sooner
a fracture is realigned and splinted, the more comfortable
and stable the victim will be. This presentation is directed
at physicians, nurses, paramedical personnel, trek leaders,
and anyone else who is involved in remote travel where
transport to a medical facility is not available, for whatever
reason. These may include distance, environmental risk
factors or extreme terrain. In the situation where acute
management and early transport is feasible, this should
be the treatment of choice. Fractures should be realigned
as well as possible and splinted prior to transport; the
area of question involves dislocations. I would advocate
reduction of the more common dislocations as soon after
injury as possible, if the rescuer is comfortable with
attempting a reduction and if the victim is agreeable.
Identification of the injury as a dislocation or fracture;
good clinical judgment regarding management; a good common
sense approach to the problem are all important factors.
These will be discussed and demonstrated.
DISLOCATIONS
Dislocations of most joints may be easily identified and
are quite incapacitating to the victim. Some of the major
advantages in early reduction of dislocations are as follows:
1. Reduction is easier immediately after injury, before
swelling and muscular spasm have developed.
2. Reduction most often results in dramatic relief of pain.
3. Transport of the victim is easier after reduction.
4. Immobilization of the injured joint is much easier and
stable after reduction.
5. Safety of the entire party may be jeopardized during
the evacuation of a victim with a major joint dislocation.
6. Early reduction reduces the circulatory and neurologic
risks to the involved extremity.
DIAGNOSIS
The major joints discussed are the shoulder, elbow, digits,
hip, knee, patella, and ankle. There are many helpful signs
in identifying a dislocation. There is nearly always restriction
of motion; obvious deformity in comparison with the
uninvolved extremity; often a typical, identifiable posture
of the dislocated joint that the victim will maintain to
minimize pain. Crepitus or grating of bone fragments;
and gross instability are generally absent.
The provider of care or rescuer should not be concerned
about causing additional damage to any fractures associated
with a dislocation. At times, there are avulsion type
fractures within the joint that has dislocated, but these
fractures will generally be improved in alignment with
reduction of the dislocation. The same is true of vessel
and nerve impairment associated with a dislocation; reduction
will reduce the impingement and traction injury to these
structures, as well. In the situation in which there is
a major long bone fracture associated with a dislocation,
the dislocation. may not even be diagnosed, in view of the
more apparent major fracture. In these cases, splinting
of the fracture is the treatment of choice and the dislocation,
for all practical purposes, becomes a secondary issue and
will, most likely, not be identified until x-rays are obtained.
DIAGNOSTIC TIPS FOR SPECIFIC JOINTS
SHOULDER - Anterior-inferior dislocation of the shoulder is
most common, accounting for 95% of shoulder dislocations.
Victim will stabilize the upper extremity in the most comfort
able position; usually with the upper arm held away from
the body and supported by the uninvolved arm. The dislocated
extremity cannot be brought across the chest wall, i.e.
sling position. Observe and palpate the involved shoulder,
comparing it with the uninvolved side. There will be a
loss of normal contour to the deltoid and a palpable defect
where the humeral head should be. Check circulation, motor
and sensory function to the hand and, also, sensory function
along the outer aspect of the shoulder, and document findings.
Mechanism of injury most,commonly external rotation, abduction
and extension. In the case of recurrent anterior dislocations,
the victim will identify the problem and can be quite helpful
in its reduction.
ELBOW - Obvious deformity is present when compared with
uninvolved side. Restricted, painful motion is present.
Most commonly posterior with resultant bony prominence
of the olecranon process.
DIGITS - Obvious deformity at the joint with limited
motion are main findings.
HIP - The majority of dislocations are posterior. -The
involved extremity will be moderately flexed, internally
rotated and adducted. Any attempt to extend the extremity
for splinting or easier transport will be resisted by the
victim and mechanically impossible to obtain. The mechanism
of injury is most often a fall in which. the hip is flexed
and the forces are transmitted longitudinally through the
knee and femur, driving the femoral head posteriorly from
the acetabulum - a dashboard injury is a good example.
Anterior dislocations of the hip are less common and usually
occur as the result of a fall directly on the lateral side
of the hip, driving the femoral head anterior and medially.
The posture is extension or mild flexion with external
rotation and abduction of the thigh. Again, it is nearly
impossible to bring the hip into full extension and neutral
position.
PATELLA - Most often occur laterally with the knee held
in moderate flexion for comfort. Position of patella in
comparison to uninvolved side is diagnostic. May be recurrent
with usual mechanism pivoting on a partially flexed, weight
bearing .knee.
KNEE - Truly a disaster with the probability of major
ligamentous disruption. Vascular impairment is a major
threat. Peripheral pulses, motor and sensory function at
the foot and ankle should be evaluated and documented.
The knee may not be dislocated at the time of initial examina-
tion, but gross instability is the major clue.
ANKLE - Vascular impairment to the foot is a major risk.
Associated fractures are common. Prompt reduction or the
best improvement of alignment should be performed immediately.
METHODS OF REDUCTION
SHOULDER - Two methods will be discussed: The abduction
traction method, and the prone traction method. The first
is steady traction applied to the shoulder with the upper
arm abducted 90°. The victim is supine and, preferably,
at waist level. Continual communication with the victim
regarding the procedure and the need for relaxation is
vital. Gently bring the upper arm 90° away from the side
of the body; have an assistant apply countertraction in
the axilla; while you gently apply traction using your
body weight as the traction force. Create a loop, utilizing
a jacket or shirt with the arms tied together, avalanche
cord, belt or webbed strapping. With the victim's elbow
flexed 90°, the loop is placed in the antecubital fossa
and around the waist of the reducer. Then, leaning back
steadily, adequate traction is applied to the shoulder.
Padding in the antecubital fossa and axilla prevents damage
to neurovascular structures. Gentle, steady leaning" backward
using your body weight creates the traction to reduce the
shoulder. Continue traction for two to three minutes, while
gently internally and externally rotating the humerus,
all the while communicating with the victim to attain-maximum
relaxation. Reduction is usually signalled by a clunking
of the humeral head into the glenoid and noticeable relief
of the victim. Proof of reduction is the ability to bring
the arm across the chest wall. The extremity is immobilized
with a sling and swathe.
The prone traction method consists of the victim in a prone
position with the arm hanging downward and a 15-20 pound
weight secured to the wrist. Relaxation is extremely impor-
tant. This may require 15-20 minutes and, at times, is
not feasible in rainy, cold, windy weather.
In first dislocation, immobilization is recommended for
three weeks to allow adequate soft tissue healing. In
recurrent dislocations, the victim will usually decide
when to start using the shoulder again. Individual circum-
stances will dictate the need for evacuation of the victim.
ELBOW - Traction applied to the forearm with the elbow
in a partially flexed position while countertraction is
applied to the upper arm by an assistant. Slow, steady
pull with medial or lateral pressure, if appropriate.
Reduction is successful if the elbow can be flexed to 90°.
Elbows can be quite difficult to reduce; give it your best
try, but don't be disappointed if not successful. If not
reduced, splint in a position most comfortable to the victim.
Check peripheral pulses.
DIGITS - Reduction of phalanges is accomplished by traction
applied to a partially flexed digit while actually pushing
the base of the dislocated phalanx back into place. This
is more successful than attempting to apply straight traction
to the digit. After reduction and if the victim desires,
buddy tape the reduced digit so that partial function can
be maintained. Don't attempt reduction of a dislocated
metacarpophalangeal joint of the index finger, since open
reduction of this dislocation is necessary. Dislocation
of the metacarpophalangeal joint of the thumb is often
quite difficult to reduce, but should be attempted. In
open dislocations, thoroughly cleanse the wound and proceed
with reduction; leave the wound open; and apply a sterile
dressing. Antibiotic therapy, if available, is indicated.
HIP - Although reducing a dislocated hip may be difficult
and painful to the victim, it is worth doing, if at all
possible. The victim will be more comfortable after reduc-
tion, transport is facilitated, and impairment of circulation
to the femoral head is reduced. Demerol, Morphine or Valium
given intravenously is quite helpful, if available. Two
people are required with one applying countertraction to
the pelvis as the other reduces the dislocation. The victim
is placed supine on the ground; the involved hip and knee
are gently and slowly flexed to 90°. The reducer straddles
the victim and applies steady traction in an upward direction.
Victim's lower leg is placed between rescuer's thighs;
hands locked behind the knee; and as the rescuer assumes
a sitting position while applying traction upward, significant
leverage is applied to the hip. This position also allows
for internal and external rotation of the hip, as needed.
The anterior dislocation is reduced by steady, gentle,
longitudinal traction with internal and external rotation.
Once reduced, the injured extremity must be splinted to
the uninvolved extremity and the victim transported in
a supine position.
PATELLA - Everyone should learn to do this reduction
because it is so easy; provides immediate relief; and converts
the victim to an ambulatory state. The knee will be partially
flexed with the patella laterally displaced. Gently extend
the knee and gently push the patella back towards its normal
position. Splint the knee in extension from ankle to groin.
Various materials are appropriate, including Ensolite pad
wrapped around the leg, down parka wrapped in circular fashion
several times around the knee, metal pack stays, or tree
branches. It is safe for the victim to walk and far better than
attempting to carry the victim. An ice axe or ski pole
is a helpful crutch.
KNEE - Apply gentle traction to realign the joint as
well as possible. Generally, this is easily done due to
the massive ligamentous disruption. The advantages are
reduction of vascular impairment. Splint the entire extremity;
check pulses and document findings. The victim must be
carried.
ANKLE - Dislocations of the ankle are almost always
associated with fractures. The fractures and dislocated
joint both benefit by reduction of the deformity as soon
as possible. Circulation may be compromised and peripheral
pulses should be evaluated.
Apply gentle traction to the foot and ankle, using the
victim's leg as the counter traction, and this will signifi-
cantly improve the alignment. Anatomical alignment is
not necessary. By improving alignment, splinting is more
stable and comfortable. These fracture-dislocations may
be well splinted with a down parka or other comparable gear,
having the affect of a pillow splint and being securely
wrapped or pinned in place.
FRACTURES
GENERAL COMMENTS
Diagnostic skills are most important in the suspected fracture
and management should be dictated by the circumstances
at hand. The needs of the victim must be considered in
relation to his/her desire to ambulate on a suspicious
ankle injury; the ability and availability of people to
carry; the type of terrain involved in transport; and the
need or desire of the victim to continue carrying a load.
Fracture deformities should be reduced as well as possible
and adequate splinting applied. Rest, elevation, ice and
compression are part of basic fracture care. Improvisation
is often required for splinting techniques and there are
usually many materials available to be used. These include
skis, ski poles, Ensolite pads, metal pack frames, straps,
webbing, rope, tree branches, parkas, and maps, to mention
a few.
UPPER EXTREMITY FRACTURES
SHOULDER GIRDLE - Gently palpate towards the area of
pain; compare with uninvolved side; look for deformity:
Sling is adequate immobilization. Ice, snow, cold compresses
are helpful to reduce pain and swelling.
HUMERUS - The shaft of the humerus is palpable throughout
its entire length along the inner aspect of the upper arm.
Any area of point tenderness with significant trauma should
be considered a. fracture until checked radiologically.
Apply sling and swathe. If there is obvious deformity
in the humeral shaft, allow gravity, to realign the fracture
and apply appropriate splinting. Check radial nerve function
by asking the victim to extend wrist, digits and thumb,
and document findings.
ELBOW - May be grossly unstable. Apply appropriate
splint, posterior and/or U-shaped, with elbow approximately
80-90°, and then sling.
FOREARM - Realign as well as possible and splint joint
above and below; U-shaped splint is best. Check peripheral
pulses. Sling, elevate and ice, if available.
WRIST - These are best splinted in the position found,
unless there is a compromise of circulation. Place the
hand in a position of function with soft material, such
as rolled up glove or socks, in the palm.
HAND OR PHALANX - Realign and splint in position of
function with all joints in a partially flexed, relaxed posi-
tion. Example would be holding a rolled Ace bandage in
the palm of the hand. Digits should not be splinted in
an extended position due to rapid onset of joint stiffness.
Consider buddy taping, whenever feasible, to allow for
partial usage of digits.
LOWER EXTREMITY FRACTURES
PELVIS - Pelvic fractures are suspected when there has
been significant trauma to the pelvic region and tenderness
to palpation over bony prominences. Crepitus is usually
not present. Pain with weight bearing may' also suggest
an acetabular fracture. Suspected pelvic fractures require
transport, unless pain and tenderness are mild over pubis
or ischium, in which case, this may be a small, stable
fracture and the victim may desire to ambulate with the
aid of ice axe or ski pole. The general rule would be
to transport victim with a suspected pelvic fracture.
If the trauma is massive, be aware of the possibility of
shock due to retroperitoneal bleeding.
HIP - Symptoms are pain, inability to bear weight.
Fractures of the femoral neck may not reveal any deformity
or instability, but rather pain with hip motion. Unstable
hip fractures often reveal shortening and external rotation
of the extremity. Immobilization of the injuredextremity
to the uninjured with padding between the thighs and under
the knees is usually sufficient. If there is significant
pain with transport, then traction may be helpful.
FEMORAL SHAFT - All femoral shaft fractures require
traction to provide stability, reduce hemorrhage, prevent
further vascular damage, and reduce, pain. Temporary traction
should be applied as soon as the injury is diagnosed.
There are excellent lightweight traction devices which
are available and should be strongly considered as standard
equipment for expeditions. The Kendrick and Sager splints
are very good; lightweight, easy to apply, and very efficient.
Become familiar with their usage to facilitate their usage,
if the need should arise. If makeshift traction is to
be used, become familiar with the materials you plan to
use and practice applications prior to their field applica-
tion. It is difficult to remember the necessary steps.
A rule of thumb for the amount of traction is 10% of body
weight; but an equally good indicator is when the victim
feels comfortable and the fracture feels more stable.
Flex both knees 5-10° with padding beneath the knees.
This will not affect the traction and makes transport much
more comfortable. Monitoring peripheral pulses and sensibil-
ity should be done every thirty minutes and documented.
An extended transport over very difficult terrain requires
a minimum of eight to ten people to alternate in carrying
the victim and also to carry packs. Therefore, if there
is reasonable alternative, including helicopter evacuation,
it should be strongly considered. Keep the victim warm
and monitor for shock during all transport or while awaiting
rescue.
PATELLA - Patellar fractures result from direct trauma
to the patella. If there is tenderness, but no palpable
defect or deformity, the knee can be wrapped in a cylinder
splint, composed of an Ensolite pad or foam mattress pad,
and the victim be allowed to ambulate, if possible. Ice
axes or ski poles are helpful.
TIBIA - These fractures are often easily diagnosed due
to deformity, crepitus and immediate swelling. Gently
correct angular deformities and apply adequate splinting.
An U-shaped splint running from the inner knee beneath
the foot'. as a stirrup and up the outside of the leg to
the knee with adequate wrapping is an excellent tibial
splint. In an open fracture, the area should be gently
cleansed with Betadine or any other antiseptic available or
with soap and water; a sterile bandage or the cleanest
available material placed over the wound and the fracture
then treated with realignment and splinting. Broad spectrum
antibiotic therapy is indicated, if available. The victim
should not bear weight with a suspected tibial fracture.
FIBULA - In suspected fibular fractures, the victim
may be allowed to ambulate once the fracture is adequately
taped, wrapped or splinted. Walking aids are helpful.
ANKLE - Swelling and tenderness about the ankle may
denote a fracture if directly over bony prominences. They
are sometimes difficult to differentiate from ankle sprains.
As a general rule, the fracture tenderness immediately
after injury is over bone and not ligament. Therefore,
treat all ankle injuries as if there may be a fracture
involved. The ankle should be securely taped or wrapped
and an U-shaped, stirrup splint applied. Weight bearing
should be at the discretion of the victim, if the pain
is not severe. A victim barely able to place weight on
an injured ankle, should be advised not to do so.
TARSALS & PHALANGES - These are often stable fractures
and, with adequate wrapping, weight bearing may be allowable,
as tolerated. Walking aids are most helpful.
SPLINT MATERIALS
In addition to improvised splinting materials, there are
commercial products available which provide excellent immobi-
lization and are lightweight. The Sam splint is an excellent
addition to any wilderness pack. For more extended travel
and major expeditions, air splints should be considered.
The zippered variety with screw type air tube is most
efficient. Keep in mind the variations in pressure, due
to gain or loss in altitude, and monitor circulation on
an hourly basis. They do provide excellent immobilization
and stabilization of many fractures. The adult long leg
and adult long arm sizes are adequate
The commercially available air stirrup splint for ankle
injuries is excellent and lightweight. This splint will
often allow the victim to ambulate in relative comfort
and stability.
All splints add weight to your medical pack but, if needed,
their efficiency to provide adequate splinting and comfort
far outweigh the disadvantages.
SUMMARY
Fractures and dislocations do occur in the wilderness environ-
ment. An understanding of the injury and quick, efficient
handling of the problem will often convert a very painful,
unstable and difficult injury into one which can be managed
more comfortably for the victim and all concerned.
IN THE WILDERNESS ENVIRONMENT
By
Joseph B. Serra, M.D.
Orthopedic Medical Group
Stockton, California
MANAGEMENT OF DISLOCATIONS & FRACTURES
IN THE WILDERNESS ENVIRONMENT
GENERAL COMMENTS
Trauma to the musculoskeletal system, in the form of disloca-
tions and fractures, is on the increase due simply to the
fact that there are more people involved in the wilderness
experience of remote travel, climbing, cross-country skiing,
trekking, and major expeditions. The fractures and disloca-
tions are the same as those seen in the urban and hospital
setting; however, there are distinct differences in methods
of diagnosis and acute management. It is a well known fact
that the sooner a dislocation is reduced, or the sooner
a fracture is realigned and splinted, the more comfortable
and stable the victim will be. This presentation is directed
at physicians, nurses, paramedical personnel, trek leaders,
and anyone else who is involved in remote travel where
transport to a medical facility is not available, for whatever
reason. These may include distance, environmental risk
factors or extreme terrain. In the situation where acute
management and early transport is feasible, this should
be the treatment of choice. Fractures should be realigned
as well as possible and splinted prior to transport; the
area of question involves dislocations. I would advocate
reduction of the more common dislocations as soon after
injury as possible, if the rescuer is comfortable with
attempting a reduction and if the victim is agreeable.
Identification of the injury as a dislocation or fracture;
good clinical judgment regarding management; a good common
sense approach to the problem are all important factors.
These will be discussed and demonstrated.
DISLOCATIONS
Dislocations of most joints may be easily identified and
are quite incapacitating to the victim. Some of the major
advantages in early reduction of dislocations are as follows:
1. Reduction is easier immediately after injury, before
swelling and muscular spasm have developed.
2. Reduction most often results in dramatic relief of pain.
3. Transport of the victim is easier after reduction.
4. Immobilization of the injured joint is much easier and
stable after reduction.
5. Safety of the entire party may be jeopardized during
the evacuation of a victim with a major joint dislocation.
6. Early reduction reduces the circulatory and neurologic
risks to the involved extremity.
DIAGNOSIS
The major joints discussed are the shoulder, elbow, digits,
hip, knee, patella, and ankle. There are many helpful signs
in identifying a dislocation. There is nearly always restriction
of motion; obvious deformity in comparison with the
uninvolved extremity; often a typical, identifiable posture
of the dislocated joint that the victim will maintain to
minimize pain. Crepitus or grating of bone fragments;
and gross instability are generally absent.
The provider of care or rescuer should not be concerned
about causing additional damage to any fractures associated
with a dislocation. At times, there are avulsion type
fractures within the joint that has dislocated, but these
fractures will generally be improved in alignment with
reduction of the dislocation. The same is true of vessel
and nerve impairment associated with a dislocation; reduction
will reduce the impingement and traction injury to these
structures, as well. In the situation in which there is
a major long bone fracture associated with a dislocation,
the dislocation. may not even be diagnosed, in view of the
more apparent major fracture. In these cases, splinting
of the fracture is the treatment of choice and the dislocation,
for all practical purposes, becomes a secondary issue and
will, most likely, not be identified until x-rays are obtained.
DIAGNOSTIC TIPS FOR SPECIFIC JOINTS
SHOULDER - Anterior-inferior dislocation of the shoulder is
most common, accounting for 95% of shoulder dislocations.
Victim will stabilize the upper extremity in the most comfort
able position; usually with the upper arm held away from
the body and supported by the uninvolved arm. The dislocated
extremity cannot be brought across the chest wall, i.e.
sling position. Observe and palpate the involved shoulder,
comparing it with the uninvolved side. There will be a
loss of normal contour to the deltoid and a palpable defect
where the humeral head should be. Check circulation, motor
and sensory function to the hand and, also, sensory function
along the outer aspect of the shoulder, and document findings.
Mechanism of injury most,commonly external rotation, abduction
and extension. In the case of recurrent anterior dislocations,
the victim will identify the problem and can be quite helpful
in its reduction.
ELBOW - Obvious deformity is present when compared with
uninvolved side. Restricted, painful motion is present.
Most commonly posterior with resultant bony prominence
of the olecranon process.
DIGITS - Obvious deformity at the joint with limited
motion are main findings.
HIP - The majority of dislocations are posterior. -The
involved extremity will be moderately flexed, internally
rotated and adducted. Any attempt to extend the extremity
for splinting or easier transport will be resisted by the
victim and mechanically impossible to obtain. The mechanism
of injury is most often a fall in which. the hip is flexed
and the forces are transmitted longitudinally through the
knee and femur, driving the femoral head posteriorly from
the acetabulum - a dashboard injury is a good example.
Anterior dislocations of the hip are less common and usually
occur as the result of a fall directly on the lateral side
of the hip, driving the femoral head anterior and medially.
The posture is extension or mild flexion with external
rotation and abduction of the thigh. Again, it is nearly
impossible to bring the hip into full extension and neutral
position.
PATELLA - Most often occur laterally with the knee held
in moderate flexion for comfort. Position of patella in
comparison to uninvolved side is diagnostic. May be recurrent
with usual mechanism pivoting on a partially flexed, weight
bearing .knee.
KNEE - Truly a disaster with the probability of major
ligamentous disruption. Vascular impairment is a major
threat. Peripheral pulses, motor and sensory function at
the foot and ankle should be evaluated and documented.
The knee may not be dislocated at the time of initial examina-
tion, but gross instability is the major clue.
ANKLE - Vascular impairment to the foot is a major risk.
Associated fractures are common. Prompt reduction or the
best improvement of alignment should be performed immediately.
METHODS OF REDUCTION
SHOULDER - Two methods will be discussed: The abduction
traction method, and the prone traction method. The first
is steady traction applied to the shoulder with the upper
arm abducted 90°. The victim is supine and, preferably,
at waist level. Continual communication with the victim
regarding the procedure and the need for relaxation is
vital. Gently bring the upper arm 90° away from the side
of the body; have an assistant apply countertraction in
the axilla; while you gently apply traction using your
body weight as the traction force. Create a loop, utilizing
a jacket or shirt with the arms tied together, avalanche
cord, belt or webbed strapping. With the victim's elbow
flexed 90°, the loop is placed in the antecubital fossa
and around the waist of the reducer. Then, leaning back
steadily, adequate traction is applied to the shoulder.
Padding in the antecubital fossa and axilla prevents damage
to neurovascular structures. Gentle, steady leaning" backward
using your body weight creates the traction to reduce the
shoulder. Continue traction for two to three minutes, while
gently internally and externally rotating the humerus,
all the while communicating with the victim to attain-maximum
relaxation. Reduction is usually signalled by a clunking
of the humeral head into the glenoid and noticeable relief
of the victim. Proof of reduction is the ability to bring
the arm across the chest wall. The extremity is immobilized
with a sling and swathe.
The prone traction method consists of the victim in a prone
position with the arm hanging downward and a 15-20 pound
weight secured to the wrist. Relaxation is extremely impor-
tant. This may require 15-20 minutes and, at times, is
not feasible in rainy, cold, windy weather.
In first dislocation, immobilization is recommended for
three weeks to allow adequate soft tissue healing. In
recurrent dislocations, the victim will usually decide
when to start using the shoulder again. Individual circum-
stances will dictate the need for evacuation of the victim.
ELBOW - Traction applied to the forearm with the elbow
in a partially flexed position while countertraction is
applied to the upper arm by an assistant. Slow, steady
pull with medial or lateral pressure, if appropriate.
Reduction is successful if the elbow can be flexed to 90°.
Elbows can be quite difficult to reduce; give it your best
try, but don't be disappointed if not successful. If not
reduced, splint in a position most comfortable to the victim.
Check peripheral pulses.
DIGITS - Reduction of phalanges is accomplished by traction
applied to a partially flexed digit while actually pushing
the base of the dislocated phalanx back into place. This
is more successful than attempting to apply straight traction
to the digit. After reduction and if the victim desires,
buddy tape the reduced digit so that partial function can
be maintained. Don't attempt reduction of a dislocated
metacarpophalangeal joint of the index finger, since open
reduction of this dislocation is necessary. Dislocation
of the metacarpophalangeal joint of the thumb is often
quite difficult to reduce, but should be attempted. In
open dislocations, thoroughly cleanse the wound and proceed
with reduction; leave the wound open; and apply a sterile
dressing. Antibiotic therapy, if available, is indicated.
HIP - Although reducing a dislocated hip may be difficult
and painful to the victim, it is worth doing, if at all
possible. The victim will be more comfortable after reduc-
tion, transport is facilitated, and impairment of circulation
to the femoral head is reduced. Demerol, Morphine or Valium
given intravenously is quite helpful, if available. Two
people are required with one applying countertraction to
the pelvis as the other reduces the dislocation. The victim
is placed supine on the ground; the involved hip and knee
are gently and slowly flexed to 90°. The reducer straddles
the victim and applies steady traction in an upward direction.
Victim's lower leg is placed between rescuer's thighs;
hands locked behind the knee; and as the rescuer assumes
a sitting position while applying traction upward, significant
leverage is applied to the hip. This position also allows
for internal and external rotation of the hip, as needed.
The anterior dislocation is reduced by steady, gentle,
longitudinal traction with internal and external rotation.
Once reduced, the injured extremity must be splinted to
the uninvolved extremity and the victim transported in
a supine position.
PATELLA - Everyone should learn to do this reduction
because it is so easy; provides immediate relief; and converts
the victim to an ambulatory state. The knee will be partially
flexed with the patella laterally displaced. Gently extend
the knee and gently push the patella back towards its normal
position. Splint the knee in extension from ankle to groin.
Various materials are appropriate, including Ensolite pad
wrapped around the leg, down parka wrapped in circular fashion
several times around the knee, metal pack stays, or tree
branches. It is safe for the victim to walk and far better than
attempting to carry the victim. An ice axe or ski pole
is a helpful crutch.
KNEE - Apply gentle traction to realign the joint as
well as possible. Generally, this is easily done due to
the massive ligamentous disruption. The advantages are
reduction of vascular impairment. Splint the entire extremity;
check pulses and document findings. The victim must be
carried.
ANKLE - Dislocations of the ankle are almost always
associated with fractures. The fractures and dislocated
joint both benefit by reduction of the deformity as soon
as possible. Circulation may be compromised and peripheral
pulses should be evaluated.
Apply gentle traction to the foot and ankle, using the
victim's leg as the counter traction, and this will signifi-
cantly improve the alignment. Anatomical alignment is
not necessary. By improving alignment, splinting is more
stable and comfortable. These fracture-dislocations may
be well splinted with a down parka or other comparable gear,
having the affect of a pillow splint and being securely
wrapped or pinned in place.
FRACTURES
GENERAL COMMENTS
Diagnostic skills are most important in the suspected fracture
and management should be dictated by the circumstances
at hand. The needs of the victim must be considered in
relation to his/her desire to ambulate on a suspicious
ankle injury; the ability and availability of people to
carry; the type of terrain involved in transport; and the
need or desire of the victim to continue carrying a load.
Fracture deformities should be reduced as well as possible
and adequate splinting applied. Rest, elevation, ice and
compression are part of basic fracture care. Improvisation
is often required for splinting techniques and there are
usually many materials available to be used. These include
skis, ski poles, Ensolite pads, metal pack frames, straps,
webbing, rope, tree branches, parkas, and maps, to mention
a few.
UPPER EXTREMITY FRACTURES
SHOULDER GIRDLE - Gently palpate towards the area of
pain; compare with uninvolved side; look for deformity:
Sling is adequate immobilization. Ice, snow, cold compresses
are helpful to reduce pain and swelling.
HUMERUS - The shaft of the humerus is palpable throughout
its entire length along the inner aspect of the upper arm.
Any area of point tenderness with significant trauma should
be considered a. fracture until checked radiologically.
Apply sling and swathe. If there is obvious deformity
in the humeral shaft, allow gravity, to realign the fracture
and apply appropriate splinting. Check radial nerve function
by asking the victim to extend wrist, digits and thumb,
and document findings.
ELBOW - May be grossly unstable. Apply appropriate
splint, posterior and/or U-shaped, with elbow approximately
80-90°, and then sling.
FOREARM - Realign as well as possible and splint joint
above and below; U-shaped splint is best. Check peripheral
pulses. Sling, elevate and ice, if available.
WRIST - These are best splinted in the position found,
unless there is a compromise of circulation. Place the
hand in a position of function with soft material, such
as rolled up glove or socks, in the palm.
HAND OR PHALANX - Realign and splint in position of
function with all joints in a partially flexed, relaxed posi-
tion. Example would be holding a rolled Ace bandage in
the palm of the hand. Digits should not be splinted in
an extended position due to rapid onset of joint stiffness.
Consider buddy taping, whenever feasible, to allow for
partial usage of digits.
LOWER EXTREMITY FRACTURES
PELVIS - Pelvic fractures are suspected when there has
been significant trauma to the pelvic region and tenderness
to palpation over bony prominences. Crepitus is usually
not present. Pain with weight bearing may' also suggest
an acetabular fracture. Suspected pelvic fractures require
transport, unless pain and tenderness are mild over pubis
or ischium, in which case, this may be a small, stable
fracture and the victim may desire to ambulate with the
aid of ice axe or ski pole. The general rule would be
to transport victim with a suspected pelvic fracture.
If the trauma is massive, be aware of the possibility of
shock due to retroperitoneal bleeding.
HIP - Symptoms are pain, inability to bear weight.
Fractures of the femoral neck may not reveal any deformity
or instability, but rather pain with hip motion. Unstable
hip fractures often reveal shortening and external rotation
of the extremity. Immobilization of the injuredextremity
to the uninjured with padding between the thighs and under
the knees is usually sufficient. If there is significant
pain with transport, then traction may be helpful.
FEMORAL SHAFT - All femoral shaft fractures require
traction to provide stability, reduce hemorrhage, prevent
further vascular damage, and reduce, pain. Temporary traction
should be applied as soon as the injury is diagnosed.
There are excellent lightweight traction devices which
are available and should be strongly considered as standard
equipment for expeditions. The Kendrick and Sager splints
are very good; lightweight, easy to apply, and very efficient.
Become familiar with their usage to facilitate their usage,
if the need should arise. If makeshift traction is to
be used, become familiar with the materials you plan to
use and practice applications prior to their field applica-
tion. It is difficult to remember the necessary steps.
A rule of thumb for the amount of traction is 10% of body
weight; but an equally good indicator is when the victim
feels comfortable and the fracture feels more stable.
Flex both knees 5-10° with padding beneath the knees.
This will not affect the traction and makes transport much
more comfortable. Monitoring peripheral pulses and sensibil-
ity should be done every thirty minutes and documented.
An extended transport over very difficult terrain requires
a minimum of eight to ten people to alternate in carrying
the victim and also to carry packs. Therefore, if there
is reasonable alternative, including helicopter evacuation,
it should be strongly considered. Keep the victim warm
and monitor for shock during all transport or while awaiting
rescue.
PATELLA - Patellar fractures result from direct trauma
to the patella. If there is tenderness, but no palpable
defect or deformity, the knee can be wrapped in a cylinder
splint, composed of an Ensolite pad or foam mattress pad,
and the victim be allowed to ambulate, if possible. Ice
axes or ski poles are helpful.
TIBIA - These fractures are often easily diagnosed due
to deformity, crepitus and immediate swelling. Gently
correct angular deformities and apply adequate splinting.
An U-shaped splint running from the inner knee beneath
the foot'. as a stirrup and up the outside of the leg to
the knee with adequate wrapping is an excellent tibial
splint. In an open fracture, the area should be gently
cleansed with Betadine or any other antiseptic available or
with soap and water; a sterile bandage or the cleanest
available material placed over the wound and the fracture
then treated with realignment and splinting. Broad spectrum
antibiotic therapy is indicated, if available. The victim
should not bear weight with a suspected tibial fracture.
FIBULA - In suspected fibular fractures, the victim
may be allowed to ambulate once the fracture is adequately
taped, wrapped or splinted. Walking aids are helpful.
ANKLE - Swelling and tenderness about the ankle may
denote a fracture if directly over bony prominences. They
are sometimes difficult to differentiate from ankle sprains.
As a general rule, the fracture tenderness immediately
after injury is over bone and not ligament. Therefore,
treat all ankle injuries as if there may be a fracture
involved. The ankle should be securely taped or wrapped
and an U-shaped, stirrup splint applied. Weight bearing
should be at the discretion of the victim, if the pain
is not severe. A victim barely able to place weight on
an injured ankle, should be advised not to do so.
TARSALS & PHALANGES - These are often stable fractures
and, with adequate wrapping, weight bearing may be allowable,
as tolerated. Walking aids are most helpful.
SPLINT MATERIALS
In addition to improvised splinting materials, there are
commercial products available which provide excellent immobi-
lization and are lightweight. The Sam splint is an excellent
addition to any wilderness pack. For more extended travel
and major expeditions, air splints should be considered.
The zippered variety with screw type air tube is most
efficient. Keep in mind the variations in pressure, due
to gain or loss in altitude, and monitor circulation on
an hourly basis. They do provide excellent immobilization
and stabilization of many fractures. The adult long leg
and adult long arm sizes are adequate
The commercially available air stirrup splint for ankle
injuries is excellent and lightweight. This splint will
often allow the victim to ambulate in relative comfort
and stability.
All splints add weight to your medical pack but, if needed,
their efficiency to provide adequate splinting and comfort
far outweigh the disadvantages.
SUMMARY
Fractures and dislocations do occur in the wilderness environ-
ment. An understanding of the injury and quick, efficient
handling of the problem will often convert a very painful,
unstable and difficult injury into one which can be managed
more comfortably for the victim and all concerned.