UPPER EXTREMITIES TRAUMA:

Dislocated Shoulder:
The shoulder was forced past the normal range of motion.
The shoulder is locked in position and painful to motion.

Techniques of reduction:
Depends upon the position of the humerus.
If the humerus is abducted past 60 degrees then use the Mosher Technique.

Mosher Technique is a gentle passive technique using position and gravity.
1. Have them place the hand of the affected arm on top of their head.
2. Have them place their other hand on top of their head also and interlock their fingers.
3. Lay them flat on their back, and then allow the elbows slowly relax, under the tug of gravity, towards the ground. The dislocated shoulder will spontaneously reduce back into proper anatomical position over then next 5 - 15 minutes.

If the humerus is hanging down next to the body then use the Traction at the Elbow Technique.
Traction Sling at the Elbow:
1. Have them sit up in a chair or on a rock, whatever is comfortable.
2. Have someone else stand behind them and place their hands on the patient’s shoulders to support them sitting up straight.
3. With the affected arm beside the body and with the elbow flexed at 90 degrees, place a wide sling at elbow.
4. The sling needs to be in a loop to support your foot.
5. Place one foot in the loop and apply gently in-line traction to the upper arm. Do not move the arm, keep the forearm bent at 90 degrees and maintain gentle traction.
6. After about 5 minutes of gentle traction, without straightening the forearm, externally rotate the arm, if there is sufficient traction the shoulder will reduce and pop back into place.
7. If not then continue to maintain traction, if necessary slowly increase the traction-in-line.
8. After about 5 minutes again externally rotate the forearm to about 90 degrees or until the shoulder reduces.
9. Once the shoulder has reduced back into proper anatomical position, place in a sling and swathe and monitor circulation.
10. Transport, may walk if comfortable.

Fractured Humerus: 
May be angulated, if angulate straighten out with traction-in-line.
Treatment:
Apply a sling and swathe to support the humerus and forearm.

Fracture/Dislocation of the Elbow: 
Fractures and dislocations very painful.
Treatment is to support with sling & swathe.
May have to straighten if circulation impaired distal to injury.
Straighten with traction-in-line, initially maintain elbow at 90 degrees,
Once under traction, and the elbow has slid into proper anatomical position, you may slowly extend the forearm until circulation restored (pulse at wrist).

Fractured Radius/Ulna:
Fractures with deformity arm common (Colles’ and Smith’s deformities)
May need to straighten if circulation is impaired, but this is unusual.
Splint with wrist at 30degrees of extension, and the fingers at the MCP joints relaxed at about 60 degrees of flexion.

Fractured Wrist:
Most common carpal fracture is of the scaphoid,
Pain in the anatomical snuffbox can indicate a fracture scaphoid.
Splint with wrist at 30 degrees extension & fingers at 60 degrees of flexion.

Fracture/Dislocation of the Hands/Fingers:
Reduce dislocated fingers with TIL, may require ant/post pressure.
Buddy tape fractured fingers.
Splint fingers in position of function, flexed as if holding a soda can.

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Musculoskeletal Trauma - Fractured Pelvis:

EXAMINATION & EVALUATION of the Pelvis and Sacrum:

Principles of Management:
The Pelvic bowl is a very vascular area.
A fractured pelvis can be a source of severe internal bleeding.
Can only shift a fractured pelvis once.
MOI: The pelvis is injured by direct impact and/or compression.

Level Of Consciousness:
To properly evaluate the pelvis the patient needs to be awake & alert with no other distracting injuries.

Signs and Symptoms:
Typically in severe pain and unable to walk.
They will have guarding, in that they will not be willing to move their legs or try to sit up.

Physical Exam:
Place your hands on the sides of the pelvis, over the iliac wings, and gently lean on the pelvis pushing it towards the floor or ground and then with you hands in the same position compress the pelvis by pushing your hands towards each other, lateral compression, as if trying to close and open book.
Any motion and/or pain indicates a fractured pelvis.

Treatment:
You can only move a fractured pelvis once, due to the risk of internal bleeding.
The pelvis is lined with a great many of blood vessels, it is very vascular and can therefore be the source of a major internal bleed and hypovolemic shock.
During exam if the pelvis shifts, like closing a book, do not let go, hold the pelvis closed until a pelvic binder can be applied or improvised.
A pelvic binder is a 6″ - 8″ wide piece of fabric that is wrapped around the pelvis and then secured to prevent the pelvis from falling open. This can be improvised from any 6″ - 8″ wide piece of cloth and secure it with cravats or belts to hold the pelvis still and prevent it from falling open.
There are also commercially available pelvic binders.
In the long-term care setting you should also wrap the abdomen with two 6″ wide ACE bandages to shrink the potential space for blood to collect in the abdomen if internal bleeding were to occur.
MAST or Pneumatic Anti Shock Garments also work very well to stabilize a fractured pelvis and control internal bleeding.
Treat for shock:
 Keep flat on their back.
 Adminster O2
 IV fluid for shock if indicated.
Monitor vital signs.
Transport ASAP.

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CHEST TRAUMA

Fractured Clavicle:
The clavicle tends to break in center to distal 1/3, the fracture is tender and palpable.
Treatment:
Sling & swathe on the affected side.
Concerns: Monitor for shortness of breath, possible pneumothorax.

Fractured Scapula:
Is a very uncommon injury, requires a direct blow to the scapula.
Treatment:
Sling & swathe on the affected side.
Concerns: Monitor for signs of respiratory distress.

Fractured Ribs:
Point tenderness over the ribs, may have crepitation with deep breathing.
Increasing pain with deep breathing.
Monitor for increasing shortness of breath.
If, on physical exam there are decreased breath sounds on one side = pneumothorax.
Treatment:
Sling & swathe to support injured side, and monitor for tension pneumothorax.

Flail Chest:
Two or more ribs are broken in two or more places that causes a free floating section.
This is a true life-threatening injury, evacuate ASAP.
Treatment:
Positive pressure ventilation, with 100% O2 if possible.
Position of comfort to support respirations.
Beware of taping bulky dressings that can depress the flail section making it more difficult to breath.

Sucking Chest Wound:
Hole in the chest wall that extends into the pleural space allowing are to move in and out of the pleural space interfering with breathing.
Treatment:
Airproof dressing that is taped down on 3 sides over the wound effectively creating a one-way valve.
This allows the air to vent from the pleural space helping to prevent a tension pneumothorax.
Monitor for signs of respiratory distress and a tension pneumothorax.

Pneumothorax & Tension Pneumothorax:
A pneumothorax is air escaping into the pleural space causing the lung to collapse.
A tension pneumothorax occurs when the pressure on the side of the collapsed lungs builds up to the point where it compresses the heart and compromises circulation.
Treatment:
Monitor for respiratory distress.
If tension occurs with tracheal deviation, JVD, and 1 -2 word dyspnea they may need a needle thoracostomy or place a chest tube to decompress the tension and restoring circulation and improving air exchange.

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MUSCULOSKELETAL TRAUMA: Head, Skull, and Face:

Skull Fractures:          

May be obvious = dented, depressed, open.
The skull is thick in front, top, back, and thin on the sides.
The most dangerous are temporal area fractures, because the middle meningeal artery may be severed causing bleeding into the skull.
There can be dramatic superficial swelling = hematoma, usually harmless.
May have “Battle’s sign” (ecchymosis behind & below the ears), which indicates basal skull fracture, very dangerous. 

The severity of the injury is deteremined by the level of consciousness.

AVPU Scale                or         Glascow Coma Scale (GCS)
A-awake                                  Eye Opening (1-4)
V-verbal                                  Motor Response (1-6)
P-pain                                      Verbal Response (1-5)
U-unresonsive             (GCS < 8 = severe head injury) 

The danger is bleeding/swelling inside the cranium that can cause increasing ICP. 

Signs of increasing ICP:
Change in Level of Consciousness:
They become irritable, angry as their LOC decreases down the AVPU scale.
Respiration rate and depth will increase, hyperventilation.
Heart Rate will slow, bradycardia, as the systolic blood pressure increases.
Blood Pressure: The systolic blood pressure will increase faster than the diastolic causing a widening of the pulse pressure (systolic – diastolic pressures).
Vomiting can occur as the ICP increases.
In severe head injuries cerebrospinal fluid (CSF) may leak out of the nose, ears, or wounds. 

Evacuate at first signs of increasing ICP.
Cover wounds with dressings, being careful not to depress fragments.
Examine spine carefully for possible injury associated with the head trauma.  

Facial Fractures:
Orbit injuries - check for “Blowout fx”, one eye cannot look up.
“Le Fort fxs” of the face will have a loose hard palate or maxilla.
Fractured nose, may bleed, easy to control, cosmetic injury.
Monitor for runny nose that will not stop, can indicate leaking CSF.
Fractured jaw, teeth will not fit properly, cannot easily open/close, check TMJs.                 
Avulsed teeth, replace into socket or transport in patient’s own spit.
Greatest concern with facial injuries is the airway.

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Musculoskeletal Trauma: Spinal Cord Injury Mangement:

Pre-hospital personnel are trained to treat all possible spinal cord injuries based on the Mechanism Of Injury (MOI) as well as symptoms and complaints.

It is important in the wild environment for rescuers to recognize a possible back injury based on MOI, but, it is equally important that they be able to rule out a spine injury or “clear the spine” by a proper history and physical exam in order to avoid an unnecessary litter evacuations.

SPINE EXAMINATION & EVALUATION:

1.  Mechanism of injury (MOI):
The neck, cervical vertebra, is broken by flexion and axial loading (C4/5)
The upper back, thoracic vertebra, by direct force.
The lower back, lumbar vertebra, by compression or rotation (T12/L1)

2.  Level of Consciousness (LOC):
AVPU scale: Awake, Verbal, Pain, Unconscious
Are the conscious, coherent, sober, or in any way obtunded.
Monitor every 15 minutes until stable, every 1 hour x 24 hours.
If unconscious or obtunded, treat as if injured until AWAKE & ALERT.

3.  Pain & Guarding:
Is there a “distracting” pain.
Are they complaining of pain anywhere in the vertebral column.
Is there radiating pain, numbness, paresthesias into the hands/arms.
Are they guarding or is there paravertebral muscle spasm.

4.  Tenderness (tenderness = pain on palpation):
Is there pain on palpation over the vertebra or in the vertebral muscles.

5.   Circulation, Sensation, & Motion (CSM):
Can they feel and move all four extremeties.
Can they move their neck and back,
With movement, is the back pain free,
With movement, is there any locking sensation or impairment.

TO CLEAR THE SPINE & BACK, they must be:
Awake, alert, oriented x 3, completely sober, have no distracting pain.
Be pain free and no palpable tenderness on physical exam.
No palpable step-offs or malalignments.
Have full C/S/M in all 4 extremeties (not caused by another injury).
Active range of motion without pain or locking.

Spinal Cord Injury Management:
Move patient into proper anatomical position = supine.
Maintain alignment = move as a unit when lifting or rolling.
Keep supine, unless an airway problem that requires the “Recovery position”
The most dangerous cervical motion is flexion.
The most dangerous thoracic & lumbar motion is rotation out of alignment.
Provide cervical immobilization with bulky, conforming, comfortable materials.
Keep supine on ensolite pad in bivouac.
If unconscious, monitor airway, if unable to monitor place in recovery position.
Transport on well-padded but rigid/stiff back supporting materials.

Cervical Collars:
Long-term cervical collars can become very uncomfortable.
You can improvise a very comfortable and immobilizing collar with a soft blanket or
clothing such has a pile jacket.  They provide support, comfort, and warmth.

Backboards:
Backboards or litters are only necessary for the carry-out. 
They will become very painful over time so they require extra padding especially behind the knees and in the small of the back.
Backboards are not required in litters.
 
While waiting for help to arrive simply keep the patient still and comfortable.
Remember not to flex the neck and keep the spine straight by log rolling the patient.

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Wilderness Orthopedics - Sprains and Strains

Sprains & Strains:Sprains and strains are by far the most common backcountry injuries.
Sprains and strains are injuries to muscles, tendons, ligaments, and the supporting structures of joints.

Signs & Symptoms of a Sprain/Strain:
Think of how a sprained ankle appears.
There is generalized pain and tenderness around the affected joint.
Unlike a fracture that is no point tenderness, if there is then suspect a fracture.
There is pain with movement of the affected joint.
There is pain with weight-bearing or use of the affected joint.
Swelling can be rapid and dramatic because of bleeding from the damaged blood vessels.
The area may become discolored over several hours, “black and blue” = ecchymosis.

Evaluation of a sprain/strain:
Consider the mechanism of injury.
Expose the injured area to look at the injury and the skin.
That includes removing boots and socks.
You cannot properly evaluate an injury that is hidden by clothing.
Gently palpate the area for pain, tenderness, and crepitation.
Put the injured joint through passive range of motion, that is, you gently move the joint and monitor for pain, loss of motion, or crepitation.
Loss of motion, a locked joint, indicates a dislocation.
Crepitation indicates a fracture.

Treatment: 
The goal is to minimize swelling. The less the sprain swells the faster it will heal. We use the acronym RICE to remind us of the principles to control swelling:
REST, ICE, COMPRESSION, & ELEVATION  
Rest, put the affected joint at rest. This will minimize blood flow and chance of further injury.
Ice, keep the area cool, this causes vasoconstriction thus reducing bleeding into the damaged tissues.
Compression, with a wide ACE wrap applies counter pressure to damaged tissues, again helping to control bleeding.
Elevation, raise the affected area above the level of the heart to decrease blood pressure and aid in the control of bleeding.
Immobilize & support affected joint. Splinting the affected area puts the injury at rest allowing the healing process to begin and continue.

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Wilderness Medicine by Paul S. Auerbach, MD, MS

Once again, Paul Auerbach has managed to provide us with a tome that holds an absolute wealth of information. He has not only updated all the information contained in the previous edition, but he has also called upon more experts in the field who have added a wide variety of new topics. The list of contributing authors reads like a Who’s Who in Wilderness Medicine and Rescue. This text is a true accomplishment and a marvelous contribution to the wild side of medicine.

The Fifth Edition, 2007, consisting of 2316 pages is divided into 97 chapters, written by 157 contributing authors. A myriad of charts, tables, and spectacular photography complement the well-written text.

Needless to say, I have not had the time to read the entire book, but the several chapters I have read were packed with valuable information for all of us who are interested in or participate in wilderness medicine and rescue work.

Paul, a personal thanks. Great job! What a tremendous contribution this text will make to emergency medicine that is practiced in the extended care environment.

Wilderness Medicine, Fifth Edition, by Paul S. Auerbach, MD, MS is published by Mosby, ISBN 978-0-323-03228-5 and available through www.elsevier.com and probably amazon.com.

The Principles of Managing Musculoskeletal Trauma in the Backcountry

Assessment:  Look, Listen, and Feel

Look: 
Look at possible fracture sites.
Remove clothing, remove boots, and socks.  
Do you see any wounds, deformity, angulation, discoloration, or swelling?
Look around: 
What was the Mechanism of Injury (MOI)?
If the MOI indicates a possible fracture, treat as such. 
Listen: 
Talk to the victim. 
Did they feel anything break, snap, crack, or pop? 
Is there decrease in normal function? 
Is there guarding?
Feel: 
Check Circulation, Sensation, and Motion (CSM)?
Is there any point tenderness or crepitus?
WHEN IN DOUBT, SPLINT!

The Principles of Splinting:

Circulation, Circulation, Circulation
Is there good circulation distal to the site of the injury?
Can the injury be immobilized in the position found?
If not, pull traction-in-line to slowly and gently move the extremity into proper anatomical alignment. This is to establish and maintain good circulation distal to the site of the injury.
Create a rigid but very well padded splint.
Splints should be BUFF; Big, Ugly, Fat, and Fluffy.
It is more important for a splint to be well padded than rigid.
Immobilize the entire extremity, the joint above and below the site of the injury.
Monitor all splints, check C/S/M distal to the site of the injury every fifteen minutes for the duration of the evacuation.
In the cold winter environment beware of the risk of frostbite in immobilized extremities, may have to apply chemical heat packs to the hands and feet. 

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MUSCULOSKELETAL TRAUMA

The next series of blogs will be an in-depth review of the recognition and management of musculoskeletal trauma in the wilderness, marine, disaster, and military environments.  This body of knowledge is the best example of the difference between urban, or street medicine, and the extended care environment. 

In the urban realm, typically, the ER is just minutes away and the primary concern is to stabilize the fracture or dislocation in the position found, and transport. Once outside the golden hour, the primary concern becomes circulation distal to the site of the injury. This may require straightening out angulated fractures, reducing dislocations, proper long-term splinting with big, ugly, fat, fluffy splints, and monitoring the circulation every 15 minutes for the duration of the evacuation.

ANATOMY AND PHYSIOLOGY OF THE MUSCULOSKELETAL SYSTEM

ANATOMY:

Bones:
Consist of a dense cortex surrounding an inner, soft marrow and they provide the rigid framework to which everything attaches. Bones also store calcium, an essential electrolyte, and produce the blood cells in the bone marrow.
Cartilage:
Acts as a lubricated durable cap on the ends of the bones so that your joints can
flex and rotate smoothly and without friction. Cartilage also provides support for muscle in areas where more flexibility than bone offers is needed.
Periosteum:
Is the tough fibrous layer that covers the bones and which contains the nerves that produce the pain associated with injuries.
Synovial fluid:
Is the lubricant in the joint space produced by the synovial lining of the joint capsule that surrounds the joint, allowing for friction-free movement.
Muscles:
Are like bundles of bungee cords. In response to signals sent from your brain through your central nervous system, they contract and relax, which flexes your joints and allows you to move. All muscles work by contracting, 
Tendons:
Are the ties connecting muscles to bone. They span joints and allow for movement.
Ligaments:
Are like nylon cords and attach bones to other bones. They span joints, maintaining proper alignment and setting the limits of range of motion.

PHYSIOLOGY:  Musculoskeletal system functions:

Movement: 
The contraction of muscles provides us with purposeful movement.
Heat Production:
The contraction of muscles produces heat.
Protection: 
The strength and flexibility of  muscle protects many internal structures including the bundles of nerves, arteries, and veins beneath the muscles.
Calcium storage: 
The bones act as a large calcium store.  Calcium is an electrolyte that allows for the contraction of muscle, including the heart muscle, and the conduction of nerves impulses.
Hematopoiesis: 
The process by which the various blood cells (red blood cell, white blood cell, and platelets), are produced in the bone marrow.
Cosmesis: 
The muscular and skeletal structures contribute greatly to how we look.

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Book Review:

Hypothermia, Frostbite, and other Cold Injuries
Prevention, Survival, Rescue, and Treatment
By Gordon Giesbrecth, Ph.D., and James A. Wilkerson, M.D.

The book is published by The Mountaineers Books, 
They describe themselves as “Outdoor books by the experts” and in this case it is certainly true. The authors of this text are recognized experts in the field of cold-related injuries.

The authors have done an excellent job of describing and reviewing the various cold-related injuries. The text is up-to-date, comprehensive, well written, and applicable. This is a very useful body of knowledge for both the outdoor enthusiast as well as mountain rescue personnel. The authors have taken the time to provide information on the fundamentals of thermoregulation and clothing design as well as the recognition and management of cold-related injuries. I had the opportunity and honor of writing the chapter on non-freezing cold injuries.

If you enjoy the outdoors, or if you are a provider wilderness emergency medicine and rescue, this is a must read book. I think you will enjoy it.

This blog is powered by the Wilderness Medicine Newsletter, now celebrating 20 years of publication. The WMN is published and distributed online six times each year by TMC Books, and subscriptions cost as little as $10 per year. To find out more, or to subscribe online, click here.