Physical Address
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Fractures and dislocations
A bone fracture (break) can be simple (one clean break) or comminuted (multiple breaks or shattered) ( Fig. 58 ). Furthermore, it might be closed (skin intact) or open (“compound,” with the skin broken, often with the bone visible in the wound). An open fracture is highly prone to infection. A fracture might be associated with injuries to adjacent nerves and blood vessels.
Fractured bones. A, Simple fracture (one break). B, Comminuted fracture (multiple breaks). C, Closed fracture (skin unbroken). D, Open, or compound, fracture (skin broken).
A broken bone or dislocation (displacement of a bone at the joint) should be suspected whenever there has been sufficient force, if a snap or crack was heard, if the victim cannot move or bear weight on the body part, or if an injured body part is painful, swollen, discolored, or deformed. Pain with a broken bone tends to be instantaneous, constant, and worsened considerably with motion, which might also create a grating sensation and noise. If something is deformed or “grates” with movement, apply a splint. A broken or dislocated bone should be compared with the normal opposite limb; asymmetry is a key sign of a significant injury.
It’s helpful to use a standardized approach to examining an injured limb, to be certain that the examination is complete and nothing significant overlooked:
- 1.
When examining an injury, always begin with an uninjured area and work toward the injury, so that the victim’s response to pain doesn’t interfere with your exam. Ideally, injuries should be examined at skin level.
- 2.
Otherwise, begin your examination at the furthest point of the limb and work your way back to the origin. For instance, for the upper extremity, examine the fingers, hand, wrist, forearm, elbow, upper arm, and shoulder, in that order.
- 3.
Have the victim attempt to move each joint voluntarily through an active range of motion. Note what is painful. If voluntary range of motion is limited by manifestations of an injury (e.g., pain, swelling, deformity, weakness), then very gently attempt passive range of motion (e.g., assist the victim). Take care to stop if there is an obstruction or the victim objects.
- 4.
A small child with a fracture or dislocation will not use the affected body part and will cry vigorously with the slightest manipulation. Pain and swelling in the vicinity of a joint of a child should be assumed to be a fracture or dislocation.
- 5.
If necessary, manage a dislocation (described in various sections later) and then apply a splint. Take care during application of the splint to not reproduce the dislocation.
If you think that a bone might be broken, it’s best to treat it as a break until an x-ray can be obtained or the situation shows obvious marked improvement (which usually requires 4 to 6 days).
Because of the force necessary to break or displace a bone, any person with a fracture or dislocation should be examined carefully for other injuries. All fractures and some dislocations cause a certain amount of bleeding, which can be significant. For instance, it’s possible to lose 500 to 750 mL of blood at the site of a humerus fracture, 500 mL to 1 L from a tibia fracture, 1 to 2 L from a femur fracture, and more than 1 L from a broken pelvis. Be prepared to treat the victim for shock (see page 70). Don’t manipulate a broken limb unnecessarily, even if circulation to the limb seems normal; excess motion increases the risk of damage to the bones, nerves, and blood vessels.
If the skin has been disrupted in the vicinity of the broken bone, the fracture is open. The bone end might or might not be visible through the wound, and bleeding might be minor or major. If a victim has sustained an open fracture, is alert enough to swallow liquids, and is more than 6 hours distant from a medical facility, administer penicillin, erythromycin, amoxicillin, or cephalexin 500 mg by mouth every 4 hours. Rinse the wound with tap water or disinfected drinking water to remove any obvious dirt (and thus, bacteria), and then cover it with a sterile dressing. Don’t vigorously scrub or irrigate the wound. Unless there are signs of loss of circulation (coldness, blue color or paleness, numbness) or it’s necessary to realign the limb to allow splinting and evacuation, don’t try to reposition the injury or to push the bone back under the skin. If you must manipulate the limb, rinse any visible bone with clean water (avoid scrubbing the bone itself), and then allow the bone to slide under the skin without touching it. While holding traction (pulling on the end portion of a limb in a longitudinal axis to achieve correct anatomic alignment), immediately apply a splint (see page 86) to prevent further motion and damage.
In general, it’s unwise to manipulate an injured limb more than necessary. If the extremity is minimally deformed, but the circulation is intact (normal pulses, sensation, temperature, and color) you may be able to securely splint it in the position in which you found it. On the other hand, if the circulation to an extremity is obviously absent (the extremity is numb, cold, and blue or pale), if the victim is in extreme discomfort, or if gross deformity prevents moving the victim out of a dangerous situation or prevents the application of a good splint, then an attempt to restore the part to a normal position is justified. Early realignment is easier than delayed realignment, can alleviate a major amount of pain, helps control blood loss into the surrounding soft tissues, can decrease the incidence of fat emboli (fat from the bone marrow entering the bloodstream and causing severe illness), and often allows easier splinting and transport. Be advised, however, that relocation of a fracture or dislocation might be difficult and transiently very painful for the victim. If you’re going to attempt to realign a limb, it should be done as soon as possible after the injury (preferably, within 3 hours), before swelling and increasing pain and muscle spasm make the maneuver impossible. If there is no deformity, splint the injured body part in the “position of function” (the position it would assume if it were at rest) ( Fig. 59 ).
Position of function (normal anatomic resting position). Unless otherwise specified, the upper and lower limbs should be bandaged and/or splinted in these positions. A, Upper extremity. B, Lower extremity.
To attempt to reposition a displaced body part, apply steadily increasing traction (pulling force) to the injury along the normal axis of alignment while applying countertraction above the injury. Don’t forcefully lever the bone or snap a bone back into position with a quick, forceful motion. To gain mobility in a deformed area, it’s sometimes necessary to gently rock the body parts or slightly accentuate the deformity (“distract” the joint to create maneuvering space between the bones) while applying continuous traction away from the body ( Fig. 60 ). This allows the dislocated part to clear any obstruction and slip back into position. If the part is repositioned, it should be held in place while you splint it. Often the easiest way to do this is to fasten it, with padding in between, to a normal bone nearby, such as finger-to-finger, or leg-to-leg. After such maneuvers, check to see that circulation has been restored.
Traction in line to reposition deformed fractures.
Compartment syndrome
Within the limbs (legs, arms, forearms, feet, hands, and fingers), there are “compartments” defined by inelastic boundaries of tough connective tissue, or fascia. These compartments contain bones, groups of muscles, blood vessels, and nerves. If swelling occurs within a compartment—typically caused by bleeding, continuous excessive external pressure, or a crush injury—the pressure can exceed 20 mm of mercury, which diminishes circulation to the compartment and rapidly causing tissue death. The most common cause of compartment syndrome in a wilderness enthusiast is swelling surrounding a broken bone or associated with a severe blunt injury, such as occurs after a fall. The lower leg and forearm are the most common sites. Compartment syndrome is rare following snakebite (see page 359), because most of the swelling following a bite is confined to superficial soft tissues.
Signs and symptoms include the “5 Ps”: pain, pallor (pale color of the skin), pulselessness (although pulses might be present), paresthesia (numbness and tingling), and paralysis of the affected body part. Severe pain seems out of proportion to the injury. The underlying tissue feels extremely tight, and pain is increased markedly with external pressure. Stretching the muscles that run through the compartment causes worsened pain. There might be decreased sensation or tingling in those skin areas supplied by the nerves that run through the compartment—for example, decreased sensation to pinprick or light touch on the top of the foot in the web space between the great and second toes because of pressure on the deep peroneal nerve, which runs through the anterior leg compartment. The limb might become pale or show a bluish tinge. When pulses become diminished or lost, the situation has become severe, and the limb will be weak or become useless (paralyzed). Very rarely, a compartment syndrome can occur in the gluteal region.
Field treatment involves elevation of the affected limb, splinting, padding to protect against further injury, and rapid evacuation. A true compartment syndrome must be treated with surgery to open the compartment and allow the pressure to be reduced. Severe damage can occur within 6 hours of the onset of the syndrome or can be delayed by hours or days as the limb swells, so it’s important to frequently reexamine (every 30 minutes for the first 2 hours; every hour for the next 12 hours; every 2 hours for the next 24 hours; then every 4 hours for the next 48 hours) the person who has suffered an injury that makes them vulnerable to a compartment syndrome. Carefully take down splints as necessary to evaluate limbs at skin level. Expect to adjust improvised splints frequently to account for swelling, movement, stretching of materials. Build splints using knots and materials that are secure but can be undone and reapplied to facilitate monitoring. Don’t administer aspirin to the victim. Cold packs are of limited, if any, benefit; never immerse a limb in ice water.
Splints and slings
A splint should be applied to any broken bone, bad sprain, or severely lacerated body part after gross deformity is corrected, to maintain proper position and immobilize the injured part (or parts) so that it cannot be displaced. This prevents further nerve, blood vessel, and muscle damage, and keeps broken bone ends from grating against each other or from poking through the skin. A sling-and-swathe combination (see Fig. 73 ) helps to further immobilize a limb. Pain can be lessened or relieved by eliminating unnecessary motion, allowing more rapid transport.
These general guidelines should be followed in the application of splints:
- 1.
Practice, practice, practice!
- 2.
Carry splints or materials to allow improvisation, such as tape, knife, parachute cord, safety pins, wire, and plastic cable ties. Closed-cell foam (e.g., Ensolite) is a superb material for padding an improvised splint.
- 3.
Examine every suspected fracture at skin level to see if it is open or closed (see page 83). Control bleeding (see page 60) and apply a dressing if necessary.
- 4.
Check the circulation below the fracture site by inspecting pulses, skin color, sensation, and movement of fingers and toes. In the arm, check the radial and brachial pulses; in the leg, check the popliteal, dorsalis pedis, and posterior tibial pulses (see Fig. 17 ).
- 5.
Remove all constrictive jewelry (watches, bracelets, rings, and so forth). Left in place, these can become inadvertent tourniquets on swollen limbs and fingers (see page 471).
- 6.
Splint the joint above and below the injury. For instance, to keep the knee from moving, you often need to prevent motion at the ankle, knee, and hip. There will be times when this is difficult but do the best you can.
- 7.
If possible, fashion the splint first on an uninjured body part or on a bystander to work out sizing and design challenges and then transfer it to the injured area. This lessens manipulation of the injured part and minimizes pain associated with splinting.
- 8.
If the scene is safe, splint the fracture(s) before the victim is moved.
- 9.
Splint the body part in a “position of function.” For the hand, this would be like holding a soda can; for the wrist, straight or slightly bent upward; for the elbow, bent at a right angle; for the hip, slightly flexed; for the knee, straight or slightly bent; and for the ankle, bent at close to 90 degrees.
- 10.
When applying a splint, try not to move or displace the injured area. Use clothing pulled tightly against the skin for a grip, or place hands above and below the estimated break in a bone in order to apply traction and maintain alignment while handling the limb. Take care to apply the splint in a way that it doesn’t cut off the circulation. Watch what you’re doing at all times so that you can observe the position of the bone(s).
- 11.
Pad the splint properly by filling empty space to allow even pressure and stability, protect all bony prominences, alleviate pressure points, and immobilize injuries as best as possible. This can be done with foam, a sleeping pad, pack material, or clothing. Be mindful to NOT sacrifice items of clothing that you may need to stay protected from the elements.
- 12.
Administer appropriate pain medication. If the injury is closed (skin unbroken) and there are no signs of decreased circulation, apply ice or snow packs intermittently (10 minutes “on” alternated with 10 minutes “off”) to the swollen area. Don’t apply snow or ice directly to the skin; protect the skin with cloth. Elevate the injured part as much as possible, to minimize swelling.
- 13.
After a splint is applied, check the limb periodically to make certain that swelling inside the splint has not cut off the circulation. Partially take down splint as needed to evaluate at skin level. This is particularly important in cold weather, in which numbness can be a confusing factor. Expect to adjust splints frequently during extended patient care scenarios.
- 14.
Insist that all victims seek medical evaluation when they return home, to be certain that all bones are properly aligned and that no further intervention is needed.
Splints can be fashioned from sticks, cardboard, foam pads, rolled newspapers, pack frames, ski poles, paddles, ice axes, or other similar objects ( Fig. 61 ). Foldable or rollable wire splints can be constructed by cutting 6 inch by 30 inch (15 cm by 76 cm) and 18 inch by 36 inch (46 cm by 91 cm) pieces of ⅛ inch or ¼ inch (3 mm or 6 mm) wire mesh and covering the sharp edges with adhesive or duct tape. Fasteners can include belts, triangular bandages, tape, elastic wraps, shirtsleeves, and blankets. Slings can be fashioned from triangular bandages, cravats, sheets, ropes, and vines.
An inflatable air splint is sometimes less desirable, in that it can attain only one shape and might create circulation problems by exerting too much pressure on injured tissues. If you use an air splint, be sure that it has a mechanism to adjust for volume expansion (heat and high altitude). When stored at freezing temperatures, it should be kept partially inflated so that any frozen moisture (from inflating breaths) within the air bladder doesn’t cause the walls to adhere.
The SAM Splint has become a standard item for the outdoor first aid kit. The core of the SAM Splint is a long rectangle of “O” temper, ultrathin aluminum alloy. The covering layers are made of dermatologically safe closed-pore foam. The splint is available in a standard size of 4¼ inches by 36 inches, which rolls easily to become a 3 inch by 4¼ inch cylinder. It can be shaped to splint a great number of body parts. The splints also come in a 5½ -inch wide XL version, in prepackaged lengths of 18 inches and 9 inches, and as a finger splint that measures 3¾ by 1¾ inches. Appendix Four shows common applications of the SAM Splint.
To learn more about specific splints and slings, read about the specific injuries in the following sections.
Taping
Taping techniques are usually mastered by athletic trainers. It’s not likely that outdoor adventurers will be carrying the padding, foam prewrap, benzoin spray, and athletic tape necessary to complete a comprehensive taping of large joint injuries or to tape for injury prevention. However, just in case the supplies are handy, instructions for taping appear with a few specific injuries. In general, taping does not supply the same amount of support as does splinting. The most common tape is white athletic tape. A very useful product is self-adherent elastic wrap, such as Coban. Adhesive tape can be applied directly to skin, but it will lose adhesion if the skin is not shaved first. If you shave, do so very carefully to avoid nicks and the possibility of creating a site(s) for infection. Plus, when tape is removed from hairy skin, it can be quite painful. Be very careful when applying tape to an acutely injured body part, because swelling underneath the constricting tape can cause circulation problems. Avoid leaving gaps in the tape because this leads to blisters. Try to apply the tape in a way that follows the skin contours and avoids wrinkles and try to overlap the tape a half-width on successive wraps or strips. If there are any small cuts, skin nicks, or abrasions, always cover these with antiseptic ointment and a bandage before taping. Avoid tension over bony prominences. Taping a sprained ankle each morning on an extended hiking trip can require many rolls of tape (approximately ½ roll per application). If you anticipate needing tape for an expedition, then consider having each participant carry a simple first aid kit that includes one roll of tape and pool group resources as needed.
Specific injuries
The major bones of the skeleton are illustrated in Fig. 62 . Check Appendix Four for instructions on how to use the SAM Splint for specific injuries. These design principles can also be applied using alternative materials.
Neck
If a fracture of the cervical spine is suspected because of neck pain, weakness or loss of feeling in an arm or leg, tingling in an arm or leg, loss of bladder or bowel function indicative of spinal cord injury, inability to turn/flex/extend the neck, or high energy mechanism of injury (e.g., a victim who has fallen, is unconscious, and has a face or head injury), you must immediately stabilize the head and neck to protect the spinal cord. Initially, this can be done by a rescuer holding the victim’s head in a neutral alignment ( Fig. 22 and 23 ). Further spine stabilization can be achieved by taping the head to a backboard or stretcher, by applying a rigid collar (which can be fashioned from a SAM Splint, as in Fig. 321 ), or by placing sandbags or their equivalent on either side of the head (see Fig. 24 ). Another technique is to use the padded hip belt of an inverted backpack (see Fig. 25 ). It may be necessary to move the victim’s head and neck to reposition in order to allow the victim to breathe, to apply a c-collar and backboard, and to evacuate. Gentle traction in line can be used to carefully align the head and neck to an anatomically neutral position of function. Straighten the head and neck in small, controlled movements. Stop if there is severe pain or any resistance. Once a neutral alignment has been achieved, the spine should be stabilized and protected from movements out of neutral. (See page 33).
For the ambulatory, cooperative victim with minor neck discomfort, a thick pad (rolled towel, jacket) can be placed posteriorly at the base of the neck. Secure this by wrapping tape or cloth around the forehead, and then cross it over the pad and bring it back out under the armpits to be tied across the chest (see Fig. 26 ). Alternatively, use a thick removable waistband from a backpack or a rolled Ensolite pad or a rolled jacket in a horse-collar configuration. Soft-collar techniques should not be relied on to hold the neck immobile; they merely offer gentle support.
If the victim must be moved or turned on their side (most commonly to allow vomiting or to place insulation beneath him), hold their head fixed between your forearms while you hold their shoulders with your hands or hold the victim’s head with your palms on either side of skull and fingers extending over cheeks and jaw and “logroll” the victim using as many rescuers as possible to avoid unnecessary head, neck, and spine motion.
Logrolling the victim (see Figs. 27 and 28 )
- 1.
The first rescuer approaches the victim from the head and keeps the head and shoulders in a fixed position so that the neck doesn’t move.
- 2.
The second rescuer extends the victim’s arm (on the side over which the victim is to be rolled) above the victim’s head. The first rescuer might use this arm to help hold the victim’s head in proper position or maintain a secure grip on head with hands or forearms. Alternatively both arms can be crossed at the chest or kept at the victim’s sides.
- 3.
All rescuers work together to roll the victim without moving the neck. The head holder is in charge and initiates synchronized movements with verbal commands.
Alternative methods for moving a victim with a suspected spine injury include the lift and slide and the straight lift. See Transport of the Injured Victim on page 453.
An alert victim with a broken neck or severely torn ligament will usually have enough discomfort from the injury and muscle spasm to force them to hold their neck still. However, someone with a head injury or who is under the influence of alcohol or drugs might feel no pain and can have an undetected serious injury that will be worsened by motion. Persons with severely altered mental status are at a significant risk, so should be presumed to have a broken neck and handled accordingly.
Any victim with a suspected neck fracture should be transported on a firm board, in a scoop stretcher or on a vacuum mattress, if possible. (See Fig. 63 and Fig. 271 and Transport of the Injured Victim on page 453).
See page 33 for more discussion on stabilizing suspected spine injuries.
Extended time on hard backboards and litters can cause pressure injuries and in general these devices should be used for extrication and transportation, not for prolonged stabilization. During an extended rescue situation, a victim should be taken off a hard backboard and litter using the same careful movement techniques described previously and placed on flat, padded, insulated surface.
“Clearing” a cervical spine
It’s sometimes as important to know when an injury is absent as it is to recognize when it is present. This is true in the case of a broken neck.
The “Canadian C-Spine Rule” can assist with determining who might have suffered a significant cervical spine injury. Persons with a high risk for a broken neck are greater than or equal to 65 years of age; fall from a height greater than or equal to 3 feet; fall down five or more stairs; receive a direct blow to the top of the head; are in a motor vehicle accident characterized by high speed, rollover, or passenger ejection; are in a motorized recreational vehicle accident; have numbness/tingling in an arm or leg; or resist turning the head without assistance to either side to a distance of 45 degrees in angle from the midline (facing forward).
“Clearing” the spine means determining that there is likely not a broken neck. Steps to take to determine the presence or absence of a broken neck should be done only if the victim is awake and alert, not intoxicated or otherwise with an altered mental status, is cooperative, and is not distracted (in particular, by pain from another area of the body). To decide that such a person does not have a broken neck, trained medical professionals are taught to do the following actions in precisely the order listed:
- 1.
Ask if there is any numbness, tingling, or other abnormal sensation in any arm or leg (which could be attributed to a spinal cord injury). If there is, then you should not “clear” the cervical spine.
- 2.
Ask if the victim has any pain in their neck. If there is pain, then you should not “clear” the cervical spine.
- 3.
Feel each bone (vertebra) in the neck beginning from just below the skull to the first few bones in the upper back (thoracic spine). If there is pain, then you should not “clear” the cervical spine.
- 4.
Have the victim voluntarily turn their head to the right to a distance of 45 degrees. Instruct them to stop if they feel any pain. If there is pain, then you should not “clear” the cervical spine.
- 5.
Have the victim voluntarily turn their head to the left to a distance of 45 degrees. Instruct them to stop if they feel any pain. If there is pain, then you should not “clear” the cervical spine.
- 6.
Have the victim tilt their head backward, extending the neck. Instruct them to stop if they feel any pain. If there is pain, then you should not “clear” the cervical spine.
- 7.
Have the victim touch their chin to their chest. Instruct them to stop if they feel any pain. If there is pain, then you should not “clear” the cervical spine.
If you complete this evaluation without the victim complaining of neck pain or stiffness, then you can be reasonably certain that they don’t have a broken neck. If unable to “clear” the cervical spine then treat the victim as if they have a spine injury as discussed on pages 33 and 88.
Skull and face
See page 72. If there is a fracture of the skull, the victim might demonstrate black eyes (“raccoon eyes”), bruising behind the ears (“Battle’s sign”), or cerebrospinal fluid (CSF; clear or watery blood-tinged fluid) leaking from the nose or ears. If CSF is seen to be leaking from the nose or ears, then elevate the head 30 to 60 degrees from the flat position if there is no reason to not do so (such as a suspected spine fracture). If you suspect a spine fracture, then place the victim on backboard first and then elevate the head of the backboard (see Fig. 63 ). One way to differentiate CSF from blood is to collect the dripping fluid onto a white gauze, cloth, or towel. Blood coalesces in the center (like the yolk of an egg) and becomes surrounded by a “halo” (band) of clear or pink-tinged fluid (CSF). If there are fractures of bones in the face, there will usually be swelling and pain of the overlying soft tissues. If the fracture(s) is severe, the upper teeth when grasped might move. If swelling is severe around the nose, breathing might be impaired. If the bones around the eye socket are broken, there might be double vision or inability of the affected eye (or eyes) to traverse its full range of motion. If there is a fracture of the bones that comprise the orbit, the eye might appear to be sunken in the face and/or the victim might complain of double vision worsened when looking up.
Nose
See page 215.
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