1. Lesson 9: Bone and Joint Injuries

2. Objectives Define strain, sprain, fracture and dislocation
List Signs and Symptoms of strain, sprain, fracture, and dislocation
Demonstrate field assessment
Define RICE (rest, immobilization, cold, elevation)
Describe use of RICE

3. Objectives Demonstrate and describe the emergency treatment for
Strains and sprains
Fractures
Dislocations including re-alignment
Describe treatment for
Angulated fractures
Open fractures
Describe long term care for injuries to bones and joints
Describe when to evacuate

4. Bone and Joint Injury Overview
Injuries to musculoskeletal system are amongst most common Wilderness injuries
Care is same regardless of exact diagnosis
Strains are overstretched muscles or tendons
Sprains are injuries to ligaments (hold bones to bones

5. Bone and Joint Injury Overview
Fractures 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. Fracture Types

7. Guidelines for Preventing Bone and Joint Injuries
Pay attention to safety
War adequate footwear
Engage in pre-trip physical conditioning
Set up camp/home so there are few trip hazards

8. Checking for Strains, Sprains, and Fractures
Signs and Symptoms
Deformity, open injuries, tenderness and swelling (DOTS)
Moderate or server 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
MOI such as fall, suggests injury may be severe

9. Checking for a Possible Bone or Joint Injury
Have patient rest in comfortable position
Remove clothing as necessary to check area
Ask how injury happened and what areas hurt
Visually inspect entire body. Compare 2 sides of body to look for differences. Feel for DOTS

10. Checking for Possible Strain or Sprain
Have patient actively move joint and evaluate pain involved
Manipulate joint with your hands and evaluate pain
If joint appears usable, have patient test it with their weight

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

12. Caring for Strains, Sprains, and 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, min of warming
Repeat RICE cycle 3-4 times a day if possible

13. RICE

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

15. Splinting

16. Splinting

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

18. Improvised Splinting Material
Padding:
Sleeping bags
Foamlite pads
Extra clothing
Soft debris from forest floor
Rolls of sterile dressing

19. Splinting Prepare splinting material before starting
Plan splints to hold injury in natural, neutral position
Spine inline, padding in the small of the back
Legs almost straight, padding behind knees
Feet 90 degrees to legs
Arms flexed to cross heart
Hands in functional curve with padding on palms
Shoe left on foot, can act as splint. Remove if circulation issue
Remove rings, bracelets, watches if could restrict flow

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

21. Splinting Skills Session
In Pairs or 3’s:
Splint lower leg with rigid material
Anatomically splint legs
Splint Forearm with soft material (provide sling and swath)

22. Applying a Sling and Swathe
Support injured arm above and below site of injury
Place triangular bandage under arm and 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

23. 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 and swathe
Fingers and toes: Bind to adjacent finger/toe
Rib: support arm on injured side with sling and swathe. Make sure patient breathes deeply
Hip/pelvis: secure legs together. Watch for shock/internal bleeding

24. Caring for Complicated Fractures
Angulated fractures leave bone distorted, open fractures expose body to infection
Irrigate open fracture, dress appropriately
If bone ends stick out, and help is more than 4 hrs away,
Control bleeding
Clean wound and bones ends (don’t touch)
Apply gentle inline traction
Dress wound

25. 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 point
Slowly and gently move broken bone back to place
Do not force
Do not continure if increasing pain
Splint once aligned

26. Checking and Caring for Dislocations
Dislocation will produce pain in joint and 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”

27. Dislocations

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

29. 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 and allow gentle pull to put joint back in place

30. Shoulder Reduction Injured patient can do this on themselves as well
The sooner the better, waiting may cause chest muscles to tighten and spasm
As soon as complete, put arm in sling and swathe to secure it

31. 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 and next finger
Tape in place
Do not tape over injured joint

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

33. Guidelines for Evacuation
If injured body part is usable, level of pain determines if evac is needed
Evacuate anyone with un-usable body part and 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.

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

35. f