1. Lesson 9: Bone & Joint Injuries

2. 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

3. 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

4. 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)

5. 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.

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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 min of warming
Repeat RICE cycle 3-4 times a day, if possible

12. 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

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

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

15. 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

16. 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)

17. 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)

18. 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

19. 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

20. 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

21. 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

22. 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”

23. 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

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

25. 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

26. 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

27. 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

28. 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

29. 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