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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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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SOLO Adventures Blog goes live today.

SOLO has been offering various wilderness medicine training programs since 1976. To date, we have trained over 100,000 people around the world.  As a result, we have a very large group of friends and alumni with whom we want to stay in touch with. This blog site will give the SOLO community the opportunity to share out memories, experiences, and adventures.

As our staff travels around the world they will be loading pictures and events from various courses and on-site staff will update their activities. If you aren’t familiar with SOLO, this site will give you the opportunity to see who we are and what we’re up to.

SOLO is also working on a new website and we expect to have that up and running within a month.

Click here to check out the SOLO BLOG