Article from April, 2013


Traumatic events in the field are dramatic and emotional.  In cases where there are orthopedic injuries, proper assessment, stabilization and initial treatment of the victim are very important to limit the damage and salvage function of limbs.  Although some fractures and dislocations are obvious, the lack of imaging (x-rays, ultrasound) on site prevents knowing if a fracture exists and its extent.  Diagnostic limitations and lack of training about treatment make it very important for explorers to know the basics of field management of these problems.

Sophisticated management of orthopedic injuries (skeletal system and associated muscles, joints, and ligaments) is beyond the scope of this column but we should all be aware of some basic critical actions and care.  So let’s break this down into different components.

Evaluation.  The first consideration is to make sure the scene is safe for rescue.  Do not assume the site is safe.  It is a natural tendency to rush to the victim but an unstable debris field, electrical lines that are down, potential combustion of fuel at a crash site and other hazards must be recognized.  You must assure your safety and that of other rescuers before approaching the victim.

Once you are with the victim, first assess the ABCs – airway, breathing, circulation.  If the patient can talk to you relatively normally, it is likely that the airway and breathing are adequate at the time.  If not, you must assess those functions.  Next, look for any active signs of bleeding or shock.  Remember that pelvic and thigh crush injuries can harbor a great deal of blood loss.  Lastly, remember to evaluate neurologic damage by checking for level of consciousness, movement and sensation in all limbs, and pupil response to light.

If the patient is stable, evaluation of orthopedic injuries should proceed with particular attention to the skull, spine, and pelvis.  Layers of clothing and a harsh environment may make evaluation more difficult.  Do not move the victim except in a life threatening situation until it is determined that movement will not worsen the injuries.  Head injury was the subject of a previous column and the important points include determining if the victim lost consciousness, examining the scalp for lacerations and deformities, and determining that the pupils react equally to a light source.  Without rotating the neck, the cervical (neck) spine should be felt for point tenderness, swelling, or a deformity.  Any suspected neck injury requires immobilization before movement.  Next, while maintaining spinal alignment, the back should be inspected for point tenderness or deformity.   A pelvic fracture or dislocation can be determined by visual inspection and placing gentle pressure on the hips.

Extremities are then assessed for circulatory, nerve, bone, and joint function.  It is important to note if the injury to the extremity is open or closed.  Another important aspect is whether a joint is involved.  If you can feel pulses beyond the site of injury and the skin color is normal, there is likely adequate circulation.  Normal movement and sensation beyond the injury site suggests normal nerve function.  However joint involvement and open injuries are very serious and rapid evacuation is advised.  In the case of suspected fracture, gentle traction and repositioning of the limb with splinting offers the best chance for recovery.

Treatment.  The specific treatment for many significant orthopedic injuries is beyond the scope of this column.  Furthermore, various maneuvers to reduce dislocations and fractures require knowledge about diagnosis and practice of technique and should not be undertaken by the inexperienced.  However, there are general treatment principles that you can undertake to aid the victim while awaiting more sophisticated assistance and evacuation.

Pain management.  One of the mainstays of a medical kit for an expedition to a remote area is pain medication.  Orthopedic injuries can cause very severe pain with control an important part of management.  It is uncommon to have injectable opioid analgesics available such as morphine, but oral opioids can and should be used.  However patients with head injuries may not be able to swallow and the risk of aspiration from vomiting must be considered.  In addition, opioids may alter consciousness and mask deteriorating mental function that signifies a worsening injury.

Wound management.  Cleansing an open wound greatly reduces the risk of infection.  High pressure irrigation using a syringe with tap water helps remove bacteria, foreign substances, and contaminants.  Washing the wound with soap and water is effective in the field.  Avoid using peroxide, betadyne, or chlorhexidine on the wound because these damage tissues and impair wound healing.

RICE.  RICE is the acronym for Rest, Ice, Compression, and Elevation and is the rule for initial treatment of soft tissue injuries of the extremities.  Rest and protect the injured area, apply ice or cold to reduce swelling and pain.  Gentle compression and elevation reduce swelling.  Make sure the compression does not compromise circulation.

Antibiotics.  Broad spectrum antibiotics are indicated for any open wound associated with an orthopedic or joint injury.

Splinting.  Immobilize the fracture or dislocation as well as the joints above and below the injury.  Elevate the extremity if possible.

Evacuation.  Rapid evacuation is advised for any significant orthopedic injuries particularly those with open wounds, joint involvement, head or spine trauma.


This article was published in The Explorers Journal


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