Chapter 3 Musculoskeletal Injuries This chapter describes how to recognize and treat injuries to the musculoskeletal system, and the best methods for preventing problems of this nature: Recognize signs and symptoms of simple and compound fractures. Be able to realign and splint fractures in the wilderness setting. Identify and treat life-threatening musculoskeletal injuries. Be able to properly manage dislocations, strains, and sprains. 25
Case 1 You are biking on a single-track trail with a friend. You come around a bend and hear a call of distress. You slow your bike to a halt as you look to your right, where the edge of the trail turns into a downward slope. Lying on his right side, amongst a pile of scattered boulders, is a middle-aged man. His bike is about seven feet uphill from him. As you go through your initial assessment, you notice him favoring his left shoulder. The patient is very sensitive to movement of the area, complaining of severe pain. The left shoulder appears to be dislocated anteriorly. Further examination shows that he is neuro-vascularly intact over the left arm and hand. 1) What is your approach to these injuries? 2) Would you reduce this man s shoulder in this case? 3) When would you consider doing a reduction in the field? 4) What other important assessments do you need to make? Case 2 At the tail end of an intense day of hiking on day five of your eight day backpacking trip, one of your group members abruptly stops and grabs the front of her left knee. You remove her pack and have her sit in a comfortable position. She explains that she was jumping off a three foot ledge and twisted her knee upon impact, as the lateral side of her left foot landed unsteadily on a small rock. She heard a popping sound when the injury occurred. You begin your exam by noticing that her left knee appears to be swollen when compared to her uninjured right knee. 1) What is the next step in your examination? 2) What tests will you perform to assess the patient? 3) How would you determine if she requires evacuation? 26
General The most commonly sprained major joint is the ankle. The shoulder is the most commonly dislocated major joint. Anterior dislocation of the shoulder is the most common type of shoulder dislocation, occurring in over 90% of shoulder dislocations. While uncommon, posterior shoulder dislocations appear most often with a direct blow to the anterior shoulder or after a seizure or electrical / lightning injury. A posterior hip dislocation occurs in about 85% of hip dislocations. The distal phalange is the most commonly fractured phalange. An open pelvic fracture with associated GI and/or GU injuries carries a 50% mortality rate. Basic Fracture Management A fracture is any break or crack in a bone. In an open (compound) fracture, the bone is broken and there is a wound through the skin at or near the fracture site. This may happen when the broken bone cuts through the skin, or when an object breaks the skin as it fractures the bone. A major concern with an open fracture is contamination and infection of the bone at the fracture site. In a closed fracture, the bone is broken but the skin is not punctured. If left untreated or mishandled, a closed fracture can become an open fracture. If a fracture is suspected, do not try to move the injured area to test for pain. If you are not sure if the injury is a fractured bone or a sprained ligament, splint the extremity and assume it is fractured. Symptoms and Signs of Fracture In the wilderness, you must rely on your physical examination to best determine whether a bone is fractured. Pain and tenderness Pain and tenderness to palpation over a specific point of the bone. Reproduction of pain when the area of concern is stressed by applying pressure on both sides, but not touching the area, as if trying to bend it. Deformity: an unusual or abnormal shape, position, or movement of the bone or joint. Compare the injured limb with the uninjured limb on the opposite side. Inability to use the extremity: if the victim cannot move the limb or joint, or is unable to bear weight on it, a fracture should be suspected. Swelling and bruising: rapid swelling with black and blue discoloration at the fracture site. False joint: motion at a point in a limb where no joint exists. Bone snap: victim may have heard or felt a bone snap. Crepitus: the grinding of bones that can sometimes be heard or felt when touching or moving a fractured bone. Realignment of an Open Fracture After thorough irrigation of the wound, straighten the limb by pulling on it below the fracture in a direction that will straighten it. This should be done while someone else holds the limb above the fracture. Although risk of infection is present, it may be necessary to replace the exposed bone back into the wound during traction for proper realignment. This is a case where proper wound care, including copious irrigation, is essential before reducing the fracture. While continuing to hold the limb straight, apply a splint to prevent further motion. Cover the wound with a sterile dressing, then bandage. Realignment of a Closed Fracture In general, it is not wise to straighten a fractured limb unless circulation or neurological status distal to the site of injury is diminished or gross deformity makes it impossible to splint and transport. Realignment is easier if it is done soon after the injury before swelling and pain make it more difficult. 27
Straighten the limb by pulling on it below the fracture in a direction that will straighten it. This should be done while someone else holds the limb above the fracture. While continuing to hold the limb straight, apply a splint to prevent further motion. Reevaluate the circulation to ensure it has been restored or improved and not been worsened by the manipulation. Splinting Splints reduce pain and help to minimize bleeding by preventing movement of the fracture ends and nearby joints. Improperly loose splints can allow the fracture ends to shear or compress nearby vessels and nerves. A splint applied too tightly can lead to circulation and neurological problems at or distal to the splint. In general, a splint should be long enough to immobilize the joints above and below the fracture site. Another reason for splinting a fracture is to protect the injury while transporting the victim out of the wilderness. Reducing pain can make the transportation process much more efficient. The splint should immobilize the fractured limb in its functional position. For the knee there should be a slight bend at the knee. The ankle and elbow with the joints flexed at a 90-degree angle. The wrist should be splinted straight or slightly bent dorsally (extended) The fingers should be bent in a position similar to that as if holding a can of soda. General Guidelines for Splinting Remove all jewelry and accessories such as watches, bracelets, and rings before applying the splint. Pad the splint with soft material, such as clothing. Use plenty of padding over bony protrusions such as elbows, knees, and ankles. Splints should be made from rigid, sturdy material. The SAM Splint is a fine commercial product for a field splint. In the wilderness you may also use sticks, boards, skis, paddles, heavy cardboard, and rolled up magazines or newspapers. The splint should immobilize at least one joint above and one joint below the fracture site. Secure the splint in place with straps, tape, belts, strips of cloth, webbing, or rope. Tie firmly, but not tight enough to cause discomfort. Secure the splint in several places, both above and below the fracture. Do not tie directly over the injured area. Fashion the splint on the uninjured body part first and then transfer it to the injured area to minimize discomfort. After splinting, elevate the injured body part to minimize swelling. Check circulation often. Swelling within the confines of a splint can cut off circulation to the limb. If this occurs, loosen or reposition the splint to allow blood flow. Spinal Fractures Life-Threatening Fractures The spinal column is composed of vertebrae, which surround the spinal cord. When vertebrae are fractured or dislocated, the spinal cord may be injured. Damage to the spinal cord can cause permanent paralysis and even death. Any accident that places excessive pressure or force on the head, neck, or back can result in fractured or dislocated vertebrae. Extreme care must be taken in the wilderness when treating back and neck injuries. Any further twisting or jolting of the spinal column can further damage the spinal cord. Although it is always better to assume a spinal injury when in doubt, everyone with a bump or cut on their head does not need to have his or her spine immobilized. Signs and Symptoms The victim has pain in the neck or back. The victim is unconscious or has an altered level of consciousness in association with trauma. 28
There are significant cuts and bruises along the spine. There is weakness, numbness or tingling in the victim s arms, legs, fingers, or toes. There is another extremely painful injury, such as a fractured femur or dislocated shoulder, which might distract him or her from noticing the spinal pain. The victim is under the influence of alcohol and/or drugs that may alter his or her perception of pain. Immobilize the victim s head, neck and back. If the victim is not breathing or is having trouble breathing, straighten the injured area only enough to open an airway. If the neck is bent at an angle, it should be straightened with gentle in-line traction. Place rolled-up clothing, life jackets, blankets, or plastic bags filled with sand or dirt around the victim s head, the sides of the neck, the shoulders, and from the armpits down alongside the trunk to prevent movement. Secure the head to these supports with tape or straps. Secure the rest of the body to a flat board. Treat for shock and evacuate the victim as soon as possible. Ruling Out Cervical Spine Fractures You may use clinical criteria to rule out potential cervical spine fractures using the NEXUS Criteria The following areas must be evaluated and if all are negative then you may clinically clear the patient No posterior midline spinal tenderness to palpation No altered level of consciousness No drug or alcohol intoxication No painful distracting injury No neurological deficits Pelvis Fractures Pelvis fractures are often associated with significant life-threatening hemorrhage due to the numerous vessels that course through it. There is also a risk of injuries to the intestines, bladder, uterus, and the sacral spinal nerve roots. An open pelvic fracture with associated GI and/or GU injuries carries a 50% mortality rate. Signs and Symptoms Suspect a pelvis fracture if there is pain in the pelvis, hip, or lower back. The victim will be unable to bear weight and will be very sensitive with pain around his waistline or hips. Pain and tenderness with palpation and compression of the pelvis. Abnormal motion or crepitus on palpation and compression of the pelvis. Bruising over the pelvic area to include the perineum. Neurologic deficit over one or both of the legs. There may be blood in the urine or the victim may be unable to urinate if the bladder or urethra is damaged. Bleeding from the urethra, rectum or unexpected vaginal bleeding. Pelvic splinting is important to minimize motion of the fractured bone, bleeding, and pain. There are numerous commercial products available to splint and immobilize the pelvis. One may use a wide belt, sheet, or piece of clothing that is wrapped around the pelvis and tied tightly to immobilize the pelvis and to hold the pelvic ring together. If you do not have anything available to wrap around the pelvis, you may place padding between the legs and then strap the legs together. Treat for shock, but do not elevate the legs. Femoral Fractures 29
The femur is the longest bone in the body. A fractured femur can produce severe blood loss, possibly leading to shock. When the bone breaks, the powerful thigh muscles contract and pull the broken bone ends into the muscle causing extreme pain and possible blood loss. A femur fracture is best splinted by using a traction splint. The traction splint will pull the overlapped bone ends into alignment, which may minimize bleeding and relieve pain and muscle spasm. Before placing your improvised traction splint on the victim, test it on the victim s uninjured leg. Once tested, place the splint on the injured side. Treat for shock, checking the victim s circulation by palpating distal pulses and observing capillary refill periodically. Improvising a traction splint: There are many ways to improvise a traction splint in the wilderness but you need to ensure you have the following components Ankle attachment (use webbing or a band of cloth). Upper thigh (crotch) attachment Strong support that is one foot longer than the leg Method to fix the two attachments to the support Method to pull traction Padding If you are unable to fashion a traction splint, then you should secure the two legs together with straps after padding between the two legs. Dislocations A dislocation occurs when so much force is placed across a joint that a bone is pulled out of its articulation. Dislocations are most common in the fingers, shoulder, elbow, and kneecap. Dislocations can damage blood vessels, nerves, muscle, and ligaments. Splint the joint with plenty of padding. Ice the joint to minimize swelling. Check for circulation. Depending on your education, comfort level and the ability of the patient to tolerate the procedure you may be able to relocate dislocations of the fingers, shoulder, and patella in the wilderness. Dislocations of the elbow and ankle are usually too painful to relocate in the wilderness. Hip dislocations usually require a great deal of sedation to relocate and are not amenable to relocation in the wilderness. Sprains A sprain is the stretching or tearing of a ligament caused by twisting, wrenching, or stretching movements beyond the ligament s normal range of motion. Sprains are most common in the finger, ankle, wrist and knee. Slight sprains cause only mild discomfort, but in serious cases you could be temporarily disabled. Symptoms include pain, swelling, and discoloration. General treatment for sprains is summarized by the acronym RICES Rest the joint from activity and stress Ice: apply ice at least 3 times per day for 20 minutes 30
Compression: follow the ice with a compression wrap. Cover the sprained joint with a sock, cloth, or other light material and then wrap tightly. The wrap should compress the joint, but not so tightly that it restricts circulation or causes pain. Elevation: elevate the injured area above the level of the victim s heart to minimize swelling. Stabilization: tape or splint the injured joint for transport. Follow the RICES treatment protocol for the first 72 hours after the injury. 31
Questions 1) Which one of the following is the most commonly sprained major joint? a) Ankle b) Elbow c) Hip d) Knee e) Shoulder 2) Which one of the following dislocations is unlikely to be relocated in the wilderness setting? a) Ankle b) Finger c) Hip d) Patella e) Shoulder 3) Which one of the following is important to perform when splinting a potential fractured forearm? a) The splint should flex the wrist into a 30 degree position b) The splint should immobilize the elbow and the wrist c) The splint should immobilize the elbow, wrist and the shoulder d) The splint should immobilize the wrist only e) The splint should place the elbow at approximately 60 degrees of flexion 4) Which one of the following is a concern when managing a patient with a potential pelvic fracture in the wilderness setting? a) Fracture fragments tearing the femoral artery at the time of fracture b) Internal hemorrhage due to bleeding vessels in the pelvis c) Splinting it will cause movement of the pelvic bones which will cause more damage d) Spinal fracture as an associated injury is very common 5) Which one of the following is not part of the acute therapy for the management of a patient who has a sprain? a) Active motion with full weight bearing b) Elevation above the heart c) Ice three times daily d) Rest when possible e) Stabilization with a splint or tape Answers: 1a 2c 3b 4b 5a 32