What is the most common type of outdoor injury, aside from minor skin wounds? According to the people who quantify such things, damage to the “musculoskeletal system” accounts for 70 to 80 percent of the injuries suffered in wilderness settings. Translated into ordinary language, this means strains, strains, bone fractures, and joint dislocations. Most of us have experienced some or all of these maladies firsthand–or first wrist, foot, knee, elbow, etc. These “extremity” (arm or leg) injuries are not only painful, they often raise some worrisome questions. What’s actually happened here? Is this just a strain or bruise that will pass, or did I rupture something? Is it a bad sprain, or is it broken?
Generally, the signs of an extremity fracture can include: immediate and continuing pain; inability or limited ability to use or move the injured area; quick onset of swelling and discoloration; tenderness to a pressured touch; an audible crack, snap, or pop at the time of injury; the feel or sound of grating bones (crepitus) when the site is moved or palpated, and in some cases, obvious deformity–such as a bone “angulating” out of normal alignment.
Unfortunately for diagnostic purposes, many of those symptoms can also accompany a bad sprain and certain types of dislocation. Nor are these different injuries mutually exclusive. Sometimes a bad sprain can also involve a bone fracture. For that matter, a severe strain, which occurs when a tendon is pulled or torn, can cause what’s known as an “avulsion fracture,” where a fragment of bone is broken or torn away along with the adhering tendon. The fact is, even experienced doctors can’t always tell the exact nature of a musculoskeletal (MSK) injury until or unless they get an X-ray view. So how can hunters, especially those with little or no first-aid training, do the right thing when confronted with this type of injury in the field?
Mainly by simplifying things to a practical level that’s easy to remember and always errs on the safe side, an approach taught in some of the better Wilderness First Responder programs. Here we examine the injury and try to determine what it is–a fracture, a sprain, etc.–but if we can’t tell for sure, it doesn’t really matter because we’re really concerned with a broader either/or question: Is the injury stable or unstable?
Is the Injury Stable or Unstable?
In the simplest terms, stable means: unlikely to worsen and/or cause further internal damage if properly treated; no need to evacuate the victim out for medical help. Unstable means: The injury will not improve without medical intervention and must be immobilized against further and possibly serious internal aggravation; the victim should then be evaluated for proper treatment.
The usual signs and symptoms of an unstable MSK injury can include: the quick onset of pain, tenderness, and swelling; the inability to move or use the affected area immediately or soon after the injury; the feel or sound of a snap, cracking, or pop at the time of injury; obvious deformity of the bone or joint; and crepitus–the sound or feeling of grating bones when the injury is moved or finger-probed.
Note the emphasis on the rapid onset of pain and swelling, and the victim’s inability to use the extremity soon after the injury. This is important because some stable MSK ailments can lead to high pain levels, swelling, and temporary crippling, but these occur over a longer period of time. A minor sprain, for instance, can worsen with use and lack of proper treatment, and can eventually feel and even look like an unstable injury. But the telling fact is the slow, gradual worsening of the problem, possibly over a period of hours or even days. Even at this worsened point, the injury could be considered “stable” if given proper treatment.
Stable injuries usually improve when the sufferer does some or all of the following: Ceases all aggravating activity (rest); applies a compression wrap, using tape or bandage, and elevates the injury to decrease swelling; applies an ice pack or other cold source to the site in twenty- to forty-minute intervals; and takes ongoing recommended doses of an anti-inflammatory such as ibuprofen to reduce both pain and swelling.
One factor in the stable/unstable determination is the level of first-aid care available at the scene. Once, for instance, a hunter in deer camp fell while descending a tree stand, jamming a finger on the way down. He returned in severe pain, clutching his hand, saying he had broken the finger, which was bent back and kicked off to one side at the middle knuckle. Another hunter, who had First Responder training, recognized the injury as a knuckle dislocation, not a broken bone.
By using slow, firm traction (pulling straight and steadily on the finger from either side of the injury) he soon got the knuckle to pop back into place, to the immediate and immense pain-relief of the victim. The finger was then buddy-taped to its neighbor for support, the knuckle was iced and Sibu pro-feed, and the hunter was able to return to the field the next day. However, if no one in camp had known how to diagnose and properly treat a dislocated knuckle, the hunter would have remained in severe pain and any movement or attempted use would have risked further damage. The injury would have then been considered “unstable,” and the hunter would have had to leave camp to seek medical help.
What else, aside from evacuation, should be done for someone with an unstable injury? As always, the primary first-aid directive is “do no harm.” Without training you might only be able to do the absolute (but still very important) minimum, which is to carefully immobilize the injury, usually by splitting, to minimize pain and prevent increased damage.
Before applying a splint, first check the CSM (circulation, sensation, movement) below the injury. If, for instance, the victim has an unstable knee–possibly broken, possibly sprained–test circulation by feeling for an ankle pulse and/or by noticing any discoloration (paling or bluing) of the skin. “Sensation” is present if the victim can feel a touch or pinprick on the foot; and “movement” is demonstrated by wiggled toes.
If the CSM is impaired, you have a more serious emergency, because the injury is causing nerve damage and/or is restricting blood flow to extremity tissue. The victim might also be suffering excruciating pain that could be relieved to a substantial degree if the fractured bone or dislocated joint is properly realigned. Now you have a tough judgment call: should you attempt to traction (or with dislocation, “reduce”) the injury back into alignment, or should you simply split it as is and get professional help as quickly as possible?
As a General Guideline
If professional help is less than two hours away, and if you have no appropriate first-aid training, it’s usually best to err on the side of doing no harm. Simply immobilize the injury and either get the victim to help, or get help to the victim. But if help is more than two hours away, and/or if you have the know-how, you might decide that realignment is worth the risk. If so, the sooner it’s done, the better, before swelling and muscle spasms add increasing resistance.
Remember that traction is a steady, firm pulling below the injury (preferably while someone else pulls in the opposite direction above the injury), and never involves jerking or snapping. Generally, traction or reducing begins by steadily pulling first in the direction of the deformity and then easing back toward proper, natural alignment. It’s normal for the victim to feel some increased pain at first, followed by a significant pain reduction. However, if tractioning causes a severe pain elevation, it should be stopped at once.
Fortunately, most unstable MSK injuries are not this complicated, and in those cases the general, rule is to “splint ’em as they lie,” without any manipulation that could cause further internal damage. Immobilizing the limb and getting medical aid is all that you should do.
If possible, try to splint an extremity in the position of function, meaning in its normal resting position. Don’t, for instance, force an arm or leg rigidly straight before splitting. When in doubt, check the opposite, uninjured limb to see how it naturally lies.
Next, wrap or surround the injury with padding–anything soft and pliable that you can find or devise. Then support the site on either side with something rigid–sturdy sticks or branches, for instance–and tape or tie them firmly into place. For leg splints, an alternative approach is to use an inflatable air mattress, which is wrapped around the limb and then inflated to provide firm (never an over-tight), padded support. Make sure any splint extends well above and below the injury and includes the adjacent joints or bones.
Finally, check the CSM after the splint is in place to make sure it isn’t impairing circulation. A splinted arm should be further immobilized with a sling, using a triangular bandage (cravat) or other suitable piece of doth or clothing. Be sure to tie the injured hand/arm high against the chest, since it will automatically lower when the sling is completed. Bring the sling ends up and around behind the victim’s neck, but not them at the side of the neck rather than directly in back, where a knot could become uncomfortable if the person needs to lie down while being evacuated.