Lesson 9: Bone & Joint Injuries

Objectives Define strain, sprain, fracture and dislocation List Signs & Symptoms of strain, sprain, fracture & dislocation Demonstrate field assessment Define RICE (Rest, Immobilization, Cold, Elevation) Describe use of RICE

Objectives (cont’d.) Demonstrate & describe the emergency treatment for: Strains & sprains Fractures Dislocations, including re-alignment Describe treatment for: Angulated fractures Open fractures Describe long term care for injuries to bones & joints Describe when to evacuate

Bone & Joint Injury Overview Injuries to musculoskeletal system are among most common wilderness injuries Care is same, regardless of exact diagnosis Strains are overstretched muscles or tendons Sprains are injuries to ligaments (e.g. holding bones to bones)

Bone & Joint Injury Overview (cont’d.) A fracture is a bone break, chip or crack Open fracture: open wound in skin over fracture Closed fracture: no break in the skin Closed fractures more common…open ones more dangerous Dislocation: movement of bone or joint away from normal position, often includes tearing of ligaments.

Guidelines for Preventing Bone & Joint Injuries Pay attention to safety Wear adequate footwear Engage in pre-trip physical conditioning Set up camp or home so there are few trip hazards

Checking for Strains, Sprains & Fractures Signs & Symptoms: Deformity, Open injuries, Tenderness and Swelling (DOTS) Moderate to severe pain or discomfort Bruising (may take hours to appear) Inability to move or use affected area Broken bone or fragments sticking out Bones grating or sounds of grating Feeling or hearing snap or pop Loss of Circulation, Sensation, Motion MOI such as fall, suggests injury may be severe

Checking for Possible Bone or Joint Injury Have patient rest in comfortable position Remove clothing as necessary to check injured area Ask how injury happened & what areas hurt (MOI) Visually inspect entire body. Compare both sides of body to look for differences. Feel for DOTS

Checking for Possible Strain or Sprain Have patient actively move joint & evaluate pain involved Manipulate joint with your hands & evaluate pain If joint appears usable, have patient test it with his/her weight

Checking for Possible Fracture Determine whether injured part looks broken (deformed). Compare to uninjured side Ask patient whether he/she thinks it is broken Gently touch injured area look for: Patients reaction to touch Muscles appear to be in spasm Injured area seems unstable One spot hurts noticeably more than the rest Check CSM beyond site of injury

Caring for Strains, Sprains & Fractures Whether usable or not, general care is RICE Rest: don’t allow injured area to be used for at least ½ hour Immobilization: prevent further injury by keeping injured area still Cold: ice works best, avoid direct contact with the skin Elevation: Keep injury higher than patient’s heart 20-30 min of cold followed by 10-15 min of warming Repeat RICE cycle 3-4 times a day, if possible

Splinting In remote areas, patients will likely need to be moved The splint should restrict movement to prevent further injury & increase comfort The splint must be made of something to pad injury & rigid enough to provide support Padding should fill in all spaces to help prevent movement Possible splint materials include branches, hiking poles, SAM splints, magazines, etc. Use triangular bandages, tape, elastic wraps, etc. to secure splints

Improvised Splinting Material What items can be used for splinting? Sticks Tent poles Oars/paddles Ski/trekking poles SAM Splints Internal Pack frames

Improvised Splinting Material (cont’d.) Padding: Sleeping bags Foamlite pads Extra clothing Soft debris from forest floor Rolls of sterile dressing

Splinting Prepare splinting material before starting trip Splints must be able to hold injury in natural, neutral position: Spine inline, pad the small of the back Legs almost straight, pad behind knees Feet 90 degrees to legs Arms flexed to cross the heart Hands in functional curve with padding on palms Leave shoe on foot, it can act as splint. Remove, if circulation is an issue Remove rings, bracelets, watches…may restrict flow

Splinting Types Hard Splint: splinting material is rigid (i.e. poles, sticks, etc) Soft Splints: splinting material is soft & bulky (i.e. newspaper, sleeping pad, sweatshirt, etc) Anatomical: splint material is another body part (i.e. fingers taped together, legs splinted & tied together)

Splinting Skills Session Form pairs or groups of 3: Splint lower leg with rigid material Splint legs anatomically Splint Forearm with soft material (using a sling & swath)

Applying a Sling & Swathe Support injured arm above & below site of injury Place triangular bandage under arm & over uninjured shoulder. Wrap outside of bandage around other side of neck. Tie on side of neck add padding Bind arm to torso with folded bandage Check CSM below in hand

Splinting Specific Fractures Jaw: hold jaw in place, wide wrap around head. Make sure can be removed (in case of vomiting) Collarbone: Secure collarbone with sling & swathe Fingers and toes: Bind to adjacent finger/toe Ribs: support arm on injured side with sling & swathe. Make sure patient breathes deeply Hip/pelvis: secure legs together. Watch for shock/internal bleeding

Caring for Complicated Fractures Angulated fractures leave bones distorted, open fractures expose body to infection Irrigate open fracture, dress appropriately If bone ends stick out & help is more than 4 hours away: Control bleeding Clean wound & bones ends (do not touch) Apply gentle inline traction Dress wound

Caring for Complicated Fractures Splint the fracture, infection likely, but bones survive better in body With angulated fracture, bones must be straightened with in line traction: Pull in direction in which bones are pointed Slowly & gently move broken bone back to place Do not force Do not continue, if increasing pain Splint limb once aligned

Checking and Caring for Dislocations Dislocation will produce pain in joint & loss of normal motion Joint “Looks wrong” Many dislocations can only be splinted in the field Some can be put back by realignment through process called “reduction”

Dislocation Reduction Work quickly, but calmly. The sooner reduction is done, the better Encourage patient to relax, particularly when a joint is injured Stop, if pain increases dramatically Splint joint after it is back in place

Shoulder Reduction Anterior Shoulder dislocations most common: Position patient face down on rock/log, injured arm dangling down Tie something 10-15 lbs in weight to dangling wrist. Patient does not hold weight Wait. Process takes 20-30 min. to work Key is for patient to be relaxed & allow gentle pull to ease joint back in place

Shoulder Reduction Injured patients can do this on themselves, as well The sooner the better, waiting may cause chest muscles to tighten & spasm As soon as process completed, put arm in sling & swathe to secure it

Toe/Finger Relocation Keep injured finger partially bent Pull on end with one hand, press gently back in place with other Place gauze pad between injured finger & the finger next to it Tape in place Do not tape over injured joint

Kneecap Dislocation Apply gentle traction to the leg to straighten it Kneecap may pop in place with just traction Massage thigh & use hand to push kneecap gently back in place Apply a splint that does not put pressure on the kneecap. Patient may be able to walk

Guidelines for Evacuation If injured body part is usable, level of pain determines whether evacuation is needed Evacuate anyone with un-usable body part & first time dislocations GO FAST with angulated fractures, open fractures, fractures of pelvis, hip, femur (thigh), more than one long bone, or decrease in CSM below injury

Scenario During trail restoration, an adult leader falls on downed branch & down 5 foot embankment. You can call the ranger station, but help is at least 1 hour away