How to treat fractures in the wilderness
By Randy Gerke ©
Preparation and prevention are the first line of defense against illness and injury, but accidents can occur regardless of your best efforts. You cannot always avoid injuries and illnesses, but you can learn how to recognize and treat them.
Evaluating injuries can be overwhelming if you do not know where to begin. An organized approach divides the task into a scene survey, a primary survey, and a secondary survey. When you have corrected all life-threatening problems, you have completed the primary survey and can begin the secondary survey, which consists of three parts, including the head-to-toe exam, the person’s history, and vital signs. When you complete your surveys of the injured person, you can use that information to begin treating the injuries. Always be alert for changes in the person that may indicate a worsening condition or additional injuries that you may have missed. Think ahead and try to anticipate problems before they happen.
Assessment of fractures and dislocations is a straightforward process that involves evaluating the mechanism of injury along with signs and symptoms. If the forces involved in the mechanism of injury were sufficient to cause a fracture and if during the exam you find positive signs and symptoms indicating a fracture, then you treat the injury as a fracture. If the injured person is complaining of pain to a limb or joint but no mechanism of injury for a fracture is present, you should continue to look for other causes. The signs and symptoms of fractures include the inability to bear weight on or use the body part; significant pain, tenderness, and swelling; an observable deformity or angulation; or a bone protruding through the skin or visible in the wound. Additionally, people may describe hearing a crack.
Treat all suspected skeletal injuries, including fractures (broken bones), strains (stretched or torn muscles), sprains (stretched or torn ligaments), and dislocations (joints that are or were out of place), as if they are fractures until proved otherwise. The correct treatment for fractures is splinting. A properly applied splint stabilizes the bone in its normal anatomical position. The splint prevents the movement of the fractured bone ends, which left unsplinted can cause further damage to bone, blood vessels, muscle, and nerve. Considerable pain and additional bleeding and swelling will result.
Traditional methods of first aid teach that fractures should be splinted in the position found. In a backcountry situation that is hours or even days from a medical facility, this method is neither practical nor advisable. Bones and their underlying structures of muscles, connective tissue, nerves, and vessels will function better and be less painful when placed in their anatomically correct position. Gentle manipulation of the fracture is required, as described here.
- Use traction in position. This task is accomplished by gently grasping the proximal (closest to the center of the body) part of a limb above the fracture site and holding it in the position found. Apply steady traction to the distal (farthest from the point of attachment) part of the fracture by using your free hand to grasp the limb firmly below the fracture site and gently apply downward pressure on the limb. While maintaining this downward pressure, slowly and gently bring the limb into its normal anatomical position. Traction in position (TIP) is safe and usually relieves pain when done properly. Discontinue TIP if it causes considerable pain or if the movement of the distal part of the fracture is met by resistance. In this case splint the fracture in the position found.
- Make the injury hands stable. Hold the fracture in a stable position until you can apply the splint.
- Make the injury splint stable. Apply the splint to provide stability to the fractured bone.
Before applying a splint, check the CSM (circulation, sensation, and movement) below the fracture site. Can you feel pulses below the fracture site? Is the skin color normal below the fracture? Does the person have normal sensation below the fracture, or does it feel numb? Is the person able to wiggle fingers or toes? If the person does not have normal CSM, attempt to ascertain why. Adjust or remove tight or constrictive clothing, or reposition the injured limb.
If you are working alone, gather all the splinting materials needed and have them nearby before you begin the process. If the person is conscious, willing, and able, the person can use his or her hands as an extra aid under your direction. You can improvise splints from almost any material strong enough to serve the purpose. Some materials to consider are skis, poles, backpacks and frames, aluminum stays from frameless backpacks, snowshoes, paddles, life jackets, insulated sleeping pads, belts, boot laces, climbing rope, sticks and boughs, duct tape, compressed clothing, webbing, cargo and accessory straps, parachute cord, tent poles, cardboard, fence posts, scrap metal and wood, and bicycle pumps. The basic principles of splinting for several types of injuries follow:
Fractures of Long Bones
- Splint in the anatomically correct (or inline) position.
- Immobilize the joint above and the joint below the fracture. For example, to splint a forearm fracture, immobilize the wrist and elbow.
Fractures of Joints
- Splint in the position found or in the midrange position.
- Immobilize the bone above and the bone or bones below the fracture. For example, to splint a knee, include the femur (thighbone) and the tibia and fibula (bones in the lower leg) in the splint.
- Fractured joints are generally already in a position to be splinted. Exceptions to this include extremely deformed joint fractures or a loss of sensation or circulation below the joint. In these cases, use gentle traction to move the joint into normal anatomical midrange position.
- Fractures with protruding bone ends should be gently cleansed but left uncovered before applying traction or splinting.
- Use traction in position as with other long-bone fractures. The exposed bone ends may pull below the skin surface when traction is applied. This occurrence is normal.
Splints should be snug but not so tight that they restrict circulation or cause pain. The best splints are multidimensional—splint material is applied to two or more sides of the fractured part. Use enough padding to prevent discomfort where the splint comes in contact with the fractured part. Compact or compressed padding works best. Loose fluffy padding will cause a splint to be sloppy and ineffective. Swelling near the fracture site may increase for the first 24 hours. Increased swelling can cause decreased circulation to extremities below the fracture site because the swelling causes the splint to become too tight. Check the splint often to ensure that it does not become too tight or loose. Check the CSM below the fracture frequently. If the person complains of pain, adjust the splint.