Neck

If a fracture of the cervical spine is suspected because of neck pain, weakness or loss of feeling in an arm or leg, tingling in an arm or leg, or mechanism of injury (for instance, a victim who has fallen, is unconscious, and has a face or head injury), you must immediately immobilize the head and neck. This can be done by taping the head to a backboard or stretcher, by applying a rigid collar (which may be fashioned from a SAM Splint, as in Figure 22), or by placing sandbags or their equivalent on either side of the head (see Figure 21). Never move the neck to reposition it.

For the ambulatory, cooperative victim with minor neck discomfort, a thick pad (rolled towel, jacket) can be placed posteriorly at the base of the neck. Secure this by wrapping tape or cloth around the forehead, and then cross it over the pad and bring it back out under the armpits to be tied across the chest (see Figure 23). Alternatively, use a thick removable waistband from a backpack or a rolled Ensolite pad in a horse-collar configuration. Soft-collar techniques should not be relied on to hold the neck immobile; they merely offer gentle support.

If the victim is uncooperative or agitated, hold his head until you can firmly immobilize it and restrain the victim from motion (see Figure 24). All of this is necessary to avoid injury to the spinal cord. If the victim must be moved or turned on his side (most commonly to allow vomiting or to place insulation beneath him), hold his head fixed between your forearms while you hold his shoulders with your hands. In this way the victim can be “logrolled,” using as many rescuers as possible to avoid unnecessary head, neck, and spine motion.

Skull and Face

See page 61. If there is a fracture of the skull, the victim may demonstrate black eyes (“raccoon eyes”), bruising behind the ears (“Battle’s sign”), or cerebrospinal (clear or watery blood-tinged) fluid leaking from the nose or ears. If there are fractures of bones in the face, there will usually be swelling and pain of the overlying soft tissues. If the swelling is severe around the nose, breathing may be impaired. If the bones around the eye socket are broken, there may be double vision or inability of the affected eye (or eyes) to traverse its full range of motion.

Nose

See page 194.

Jaw

A fractured jaw is usually caused by a fall or a blow from a closed fist. The lower bone (mandible) may be broken in one or more places. The victim will complain of pain, swelling, inability to close his mouth, improper fit of the teeth, perhaps missing or broken teeth, and difficulty talking. If the fracture extends into the oral cavity, there may be bleeding from the mouth. Treatment is to wrap a bandage over the top of the head and under the jaw for support (Figure 42). It should be easily removable in case the victim needs to vomit. A liquid diet should be maintained until the victim can reach the hospital.

Figure 42 Bandage for a fractured or dislocated jaw. The bandage must be easy to remove, in case the victim needs to vomit.

A dislocated jaw can occur from a blow, from a widemouthed yawn, or even during sleep. The mandible slips loose from its two bony sockets below the ears and slides forward (Figure 43). To reposition the mandible, grasp the jaw by placing your thumbs (with cloth or gauze padding for traction) inside the mouth against the lower molars (rear teeth), holding the bone firmly with your remaining fingers. Exert steady pressure straight down until you feel the mandible “pop” back into place, and the victim says his teeth fit properly (Figure 43, B). After the jaw is repositioned, tie a bandage under the chin and over the top of the head to keep the jaw from easily dislocating again (see Figure 42). The bandage should be easily removable in case the victim needs to vomit.

Figure 43 Dislocated jaw. A, The condyle of the mandible slips forward out of the joint. The teeth do not fit together properly. B, The rescuer applies firm downward pressure to relocate the jaw. C, Normal position is restored, and the teeth fit properly.

Wrist, Hand, and Finger

A fracture or dislocation of the hand, wrist, or finger should be positioned and splinted in the normal resting position (position of function; see Figure 39, A). For a wrist or hand injury, this may be accomplished by allowing the victim’s fingers to rest around a padded object in his palm (such as a rolled pair of socks, rolled elastic bandage, or wadded cloth; Figure 44), with a circumferential wrap to maintain position (Figure 45). Every attempt should be made to allow the fingertips to remain uncovered, to assess circulation. If the wrist is involved, place a rigid splint on the underside of the hand, wrist, and forearm to prevent motion (Figure 46). Fingers may be splinted independently or taped together (with padding in between) for support (Figures 47 and 48).

Figure 44 A rolled elastic bandage is gripped gently to maintain the hand in the “position of function.”

Figure 45 Hand dressing in the “position of function.” A, The fingers hold a pad of cloth in the palm. B, A circumferential wrap is applied, taking care to pad between the fingers. C, The completed wrap leaves the fingertips exposed, so that they can be checked for adequate circulation.

Figure 46 A SAM Splint fashioned to stabilize the wrist and forearm. A, In this method, the elbow is free to bend. B, The splint can be extended to immobilize the elbow.

Figure 47 Buddy-taping method to immobilize a finger.

Figure 48 A variation of the buddy-taping method to immobilize a finger. If the fingers are taped together tightly, cotton or cloth should be placed between them for padding.

A sling can be applied to the forearm for support and pain relief. A swathe may be added for further immobilization. To make a classic arm sling out of a triangular bandage, lay the bandage under the arm as shown in Figure 49. Tie two corners together with a square knot at the opposite shoulder—which creates the arm cradle—and then pin the remaining elbow corner up onto the body of the sling. A rolled or folded triangular bandage becomes a cravat (see page 277), which is wrapped around the sling-encased arm and chest (as a swathe) to hold the arm snug against the body wall (see Figure 49, C). If materials to fashion a sling are not available, the victim’s shirt can be pulled up and pinned to create a crude hammock for the arm (Figure 50), or you can pin the shirt sleeve to the body of the shirt after the elbow is flexed to the proper position (Figure 51).

Figure 49 Sling and swathe. A, A triangular bandage is draped under the arm and over the opposite shoulder. B, Two corners are tied behind the neck, and the third is pinned at the elbow. C, A cravat swathe holds the arm against the chest.

Figure 50 Pinning the shirt to make a hammock sling for the arm.

Figure 51 Pinning a shirt sleeve to the chest.

If a finger is dislocated at the middle or distal joint (Figure 52, A), make a gentle attempt at relocation by applying steady, firm traction to the fingertip (Figure 52, B). Do not try to reposition the joint with a sudden forceful snap. It is often easiest to relocate a finger if you hold the joint slightly bent and push the distal (overriding) bone back into position with your thumb(s) while you are pulling the bones back into their proper position. It is nearly impossible to reduce a dislocation at the knuckle of the index finger without an operation. After a finger is realigned, it should be taped to one or two adjacent fingers for splinting (see Figures 47 and 48).

Figure 52 A, Dislocation of a finger joint. B, Relocation of the bones with firm, steady traction.

A “mallet finger” (Figure 53, A) results from disruption of the extensor tendon, which normally pulls the tip of the finger into a straight position. The finger should be splinted with a slight amount of hyperextension (Figure 53, B).

Figure 53 A, Mallet finger. B, Splinting a mallet finger.

If the thumb is dislocated or fractured, it can be taped to prevent further injury, by fixing it with an anchor to the index finger (Figure 54, A) or directly against the hand (Figure 54, B). You can use the anchor technique to hold any two fingers together.

Figure 54 Taping the thumb for immobilization. A, The buddy-taping method. B, A thumb-lock. If possible, padding should be placed between the thumb and the forefinger.

Forearm

A fracture of the forearm should be splinted to immobilize the wrist and bent elbow (see Figure 46, B). This may also be done in a “sugar tong” fashion (Figure 55). Fashion a sling and attach it to the trunk with a swathe (see Figure 49).

Figure 55 SAM Splint used to splint the wrist and elbow.

Elbow

A fracture of the elbow should be splinted to include the wrist and shoulder, if possible, and at an angle of 60 to 90 degrees. However, if it is painful for the victim to move his elbow, splint it in the position in which you found it. A sling should be fashioned and attached to the trunk with a swathe. A dislocated elbow should be realigned if necessary to restore circulation to the hand. Hold the arm bent 45 to 90 degrees at the elbow and use a lever motion to pull the bones of the forearm back into position, while holding the upper arm fixed in countertraction (Figure 56). This may require a fair amount of force to accomplish and is usually difficult if the victim cannot relax.

Figure 56 Repositioning a dislocated elbow.

“Nursemaid’s Elbow.” The radius and ulna are the long bones of the forearm, and join with the humerus (the long bone of the upper arm) at the elbow joint. In young children, if a sudden straight pulling force is applied to the arm, such as when a child’s hand is tugged to pull him along, or he is swung in a circle vigorously by the arms, the ligament that holds the radius in place may slip off the head of the radius within the elbow. There may be an audible snapping sound and immediate pain, but the pain may subside rapidly, after which the child will not use the arm. If this occurs and you are close to medical care, splint the arm as for a fracture. However, if you are far from care and wish to see if you can remedy the situation (that is, return the ligament to its proper position), take the child’s arm and do the following. First, bend the elbow to 90 degrees and rotate the hand and forearm such that the thumb moves away from the body (accentuated hitchhiker’s gesture) (Figure 57). If no “pop” is felt or heard, keep the thumb pointed away from the body and move the forearm toward the upper arm (that is, “flex” the arm) until you have moved it as far as you can (Figure 58). If the ligament moves back to its proper position, the child will begin to use his arm again within 10 minutes. After that, there is no need for a sling or splint. If the child still will not use his arm, seek medical attention.

Figure 57 To reduce a nursemaid’s elbow, rotate the hand and forearm as shown, and then flex the forearm up toward the shoulder.

Figure 58 If no pop is felt after rotating the elbow and flexing the forearm toward the shoulder, maintain the rotation and flexion and push the hand more firmly toward the upper arm.

Upper Arm

The entire length of the bone of the upper arm (humerus) can be palpated for tenderness or deformity from the arm’s inner aspect. A fracture of the humerus can be differentiated from a dislocated shoulder by observing how the victim holds his arm. With a humeral fracture, the arm is often held close to the chest, whereas a dislocation of the head of the humerus from the shoulder socket (shoulder dislocation—see page 89) prevents the victim from pulling his arm into his body.

A fracture of the upper arm, particularly if it is close to the shoulder, is often quite difficult to splint. A “sugar tong” splint can be fashioned using a SAM Splint, by laying the splint along the inner and outer surfaces of the arm, with the U of the “tong” at the elbow (Figure 59). If possible, the elbow should be kept bent at 90 degrees and the arm placed in a sling. Attach the sling to the body by using a circumferential (around the chest) swathe fashioned from a belt, rope, or long piece of cloth to prevent motion of the arm at the shoulder (see Figure 49).

Figure 59 The SAM Splint can be conformed in a “sugar tong” to immobilize the upper arm.

Two padded board splints can be used to stabilize an arm fracture above the elbow (Figure 60). The splints cross the upper part of the arm and the midforearm to create a triangle with the elbow. A sling is added for support.

Figure 60 Padded boards to splint the upper arm.

Collarbone

A fracture of the collarbone is best managed with a sling and swathe (see Figure 49) or a modified figure-of-eight bandage (or both). The latter is created by draping a rope, cloth, or cravat behind the neck across the shoulders, then forward over the shoulders and under the arms (pad the armpits, if possible), to be tied in the back (Figure 61). This will pull the shoulders back into the military position. To provide a tighter fit, tie the cross-shoulder section to the lower knot (giving a figure-of-eight appearance). After the figure-of-eight bandage is pulled snug, the affected arm may be fixed to the chest using a sling and swathe. Another technique is to weave a figure-of-eight bandage with a long, rolled elastic bandage (Figure 62). If any figure-of-eight bandage increases the victim’s discomfort, you can use a sling and swathe alone. A collarbone fracture appears to heal equally well with either technique, so the major issue is immobilization for comfort.

Figure 61 Modified figure-of-eight bandage for a broken collarbone.

Figure 62 Woven figure-of-eight bandage for a broken collarbone.

Another alternative is to have the victim wear a properly fitted backpack with shoulder straps and carry approximately 15 pounds of weight in the pack.

Shoulder Dislocation

The long bone (humerus) of the upper arm fits into the shoulder joint with a ball-and-socket mechanism, held in place by muscles and tendons (Figure 63, A). When a person falls onto his shoulder or an outstretched arm, or has his arm twisted or pulled forcefully, the head of the humerus can dislocate out of the shoulder joint (Figure 63, B). This is usually quite painful and may be associated with a fracture of the humerus or the lip of the shoulder socket. The diagnosis of shoulder dislocation is made by observing and feeling a depression in the shoulder where the upper arm bone should be (see Figure 63, B), noting that the victim holds the arm up and away from the body (Figure 64), and feeling the head of the humerus as a firm ball 2 to 3 in (5 to 7.5 cm) below its normal location. There is reduced range of motion of the joint and absence of a “grating sensation” (indicating absence of a broken bone). Those who have previously suffered shoulder dislocations are often prone to recurrent episodes with lesser forces applied to the joint.

Figure 63 Dislocated shoulder. A, Normal anatomy. B, With dislocation, the head of the humerus slips out of the glenoid (socket), and a depression (arrow) is noted in the external appearance of the shoulder.

Figure 64 The victim with a dislocated shoulder carries the arm up and away from the body.

If the injured victim can be transported to a medical facility within 3 hours, there is no need to attempt relocation of the arm unless he is in extreme pain. Place the arm in a sling, position some padding underneath the arm and against the chest, and secure the sling to the victim’s chest with a swathe to minimize motion and discomfort (see Figure 49).

If more than 3 hours will elapse before medical help is obtained, if the dislocation is recurrent (has happened to the same shoulder before), or if the victim is suffering intolerable pain, you can make an attempt to reposition the arm bone in its socket. Do not attempt relocation if the upper arm or elbow is deformed (indicating a broken bone). The safest and simplest technique for relocation is to pull with steady, forceful traction on the injured arm, directed at a 45- to 90-degree angle away from the body. At the same time, someone should provide countertraction by holding a sheet or blanket that is wrapped across the victim’s chest and under the affected armpit (Figure 65). The easiest technique is to tie a sheet, belt, webbed strapping, or avalanche cord around the rescuer’s waist and the victim’s bent forearm, so that the rescuer (standing or kneeling) can lean back to apply traction, keeping his hands free to guide the head of the humerus back into position (Figure 66). In all cases, place padding in the armpit and bend of the elbow to prevent a pressure injury to sensitive nerves beneath the skin. A single rescuer can provide countertraction by placing his foot against the victim’s chest just below the armpit, or fixing the countertraction sheet or rope to a tree or ice ax buried in the ground; he can also use a life jacket as a foot brace (Figure 67). Do not jerk the arm, attempt to twist or lever it into position, or pull with a tugging motion.

Figure 65 Technique for relocating a shoulder dislocation. One rescuer applies traction at the forearm while another applies countertraction at the chest.

Figure 66 Repositioning a dislocated shoulder. Attached to the victim’s forearm with a strap, rope, or sheet, the rescuer uses his body weight to apply traction, leaving his hands free to manipulate the victim’s arm. A second rescuer applies countertraction, or the victim can be held motionless by fixing the chest sheet to a tree or ground stake.

Figure 67 Life jacket brace to assist in the relocation of a dislocated humerus.

Another technique is to have the victim lie prone so that his injured arm can dangle free. Place a thick pad under the injured shoulder. Attach a 10 to 20 lb (4.5 to 9 kg) weight to the wrist or forearm (do not have the victim attempt to hold the weight) and allow it to exert steady traction on the arm, using gravity to relocate the humeral head (Figure 68). Alternatively, have the standing victim bend forward at the waist as you pull steadily downward on his arm to simulate the gravity effect, with gentle side-to-side (at the wrist) rotation (Figure 69).

Figure 68 A fanny pack filled with rocks can be used for a weight in the “dangle” method of shoulder relocation.

Figure 69 Pulling on the hanging arm to relocate a dislocated humerus.

In the scapular manipulation technique, the victim is placed in a prone position so that his injured arm can dangle free. Apply traction for 5 to 10 minutes. Then, while maintaining traction, push the tip (lower edge) of the scapula (“wingbone”) in toward the spine while pulling the upper portion (toward the shoulder) of the scapula away from the midline. This can also be done with the victim in a standing position (Figure 70, A). If the victim is standing, it may help to pull the arm forward as well as down (Figure 70, B).

Figure 70 A, Pushing the lower edge of the scapula toward the spine while an assistant pulls downward on the hanging arm to assist in the relocation of a dislocated humerus. B, The downward pull on the arm may be slightly forward to help put the arm bone back in the shoulder socket.

In the Milch technique, the victim attempts self-reduction of the dislocation. He should sit, stand, or lie on his back and slowly reach, using the hand of the injured shoulder, behind the head in order to touch the opposite shoulder. Another way to describe this technique is to have the victim reach up and backward with the injured arm as if going into a windup to throw a baseball. If the technique works, the victim will feel a “pop” as the dislocation is corrected. If you wish to assist the victim, use one hand to gently cup his elbow and assist him with this procedure, while using your other hand to steady the affected shoulder.

If pain medicine is available, the victim should be medicated before relocation is attempted, to allow the greatest possible shoulder and chest muscle relaxation. As the arm bone moves back into proper position (this may require 15 minutes of steady traction), it will sometimes “give” in little movements, with a final “pop” back into the socket. Once the bone is back in place, the victim will be able to bring his arm across the chest. If the victim cannot relax his muscles sufficiently to allow relocation, if your attempts cause excruciating pain, or if you are otherwise unsuccessful after 30 minutes, leave well enough alone (no one ever died of a dislocated shoulder). Place padding in the armpit and fix the arm near the body in as comfortable a position as possible with swathe bandages, and then head for help. A shoulder harness (Figure 71) may be useful. The victim who cannot walk should be transported in a sitting (for comfort) position, if possible. If the shoulder relocates, it should be placed in a sling and swathe, to prevent a repeat dislocation (see Figure 49). A first-time shoulder dislocation that is relocated should be immobilized for 3 weeks. A recurrent dislocation that is relocated can be exercised gently after 3 to 5 days.

Figure 71 Shoulder harness.

Shoulder Separation

A shoulder separation, as contrasted with a dislocation, occurs when the collarbone’s ligamentous attachments to the acromion and coracoid structures of the triangular scapula (“wingbone”) are weakened or disrupted (Figure 72). This can range from small tears in the ligaments, which do not result in a visible deformity, to full disruption of the ligaments, leading to a “free-floating” collarbone. The injury usually follows a direct blow to the shoulder, such as occurs when you fall onto your side and cannot break the fall with an outstretched arm.

Figure 72 A, Ligamentous attachments of the collarbone at the shoulder. B, Second-degree shoulder separation. C, Third-degree shoulder separation.

If tenderness is elicited when pressing directly over the acromioclavicular joint (AC joint), particularly with swelling and a spongy sensation over the end of the collarbone, suspect a shoulder separation. Treat as for a broken collarbone (see page 87).

Rib

A broken rib can be very painful, but there is little that the rescuer can do to improve the situation. Pad the chest wall with blankets or clothing (if the victim needs to be carried out on a stretcher) to restrict unnecessary motion and contact. Never bind the chest tightly; this inhibits deep breathing and prevents full expansion of the lungs, which predisposes the victim to partial lung collapse and pneumonia. Encourage the victim to breathe deeply (sigh) or cough a few times an hour. If there is a segment of detached (flail) ribs (see page 41), attempt to stabilize its position with padding (see Figures 26 and 29). Because of the force necessary to break a rib, anticipate internal bleeding (lungs, liver, and spleen) (see page 59). A rib will sometimes break during forceful coughing. In this case, internal injury is not a concern.

Spine (Chest and Lower Back)

A victim who falls a great distance and lands on his feet frequently fractures his heel(s), ankle(s), and lumbar vertebrae (lower bones of the spine—see Figure 41). Symptoms of spinal cord injury include back pain, weakness, numbness or tingling below the injury, loss of bladder or bowel control, and low blood pressure (“spinal shock”). If a fractured spine is suspected, the victim must be completely immobilized to avoid damage to the spinal cord. Position him on a firm litter or backboard, and secure him so that no motion of the back is possible (see page 37). If a scoop stretcher or backboard is not available and the victim must be moved, he should be logrolled (see page 39).

Pelvis

If pressing inward on the victim’s hips or downward on the pubic bone causes pain, suspect a fracture of the pelvis, and immobilize the victim from his waist down. A pelvic fracture is frequently associated with severe internal injuries and bleeding, so rapid evacuation is a high priority. Be prepared to treat the victim for shock (see page 60). Do not allow a victim with a suspected pelvic fracture to walk. A SAM Pelvic Sling is a force-controlled circumferential pelvic sling belt for effective reduction and stabilization of pelvic fractures. Another device is the pelvicbinder (www.pelvicbinder.com). If one of these devices is not available, the pelvis can be wrapped tightly with a sheet, sleeping pad (held in place with tape), blanket, or jacket to attempt to keep the bone fragments from moving, which hopefully diminishes instability, internal bleeding, and pain (Figure 73). Before applying any pelvic sling, be sure to empty the patient’s pockets and remove his belt so that the external pressure doesn’t press any items against the pelvis. For transport, place padding between the victim’s legs and gently tie his legs together to minimize motion and improve comfort.

Figure 73 Pelvic sling improvised with a jacket provides compression to the pelvis to control bleeding.

(Redrawn from Auerbach PS [ed]: Wilderness medicine [ed 5]. St. Louis: Mosby, 2007, p 515.)

Femur

A fracture of the femur (the large bone of the upper leg—the longest and strongest bone in the body) can be diagnosed by severe pain, inability to bear weight, deformity, and rapid swelling (from bleeding). Often, the affected leg is shortened and the foot is rotated away from the other leg. Sometimes a fracture of the neck of the femur can be subtle, as the victim complains only of minor pain on the inside of the groin or knee, and may continue to walk. On close inspection, the affected leg may be seen to be slightly shortened, and there may be some swelling and pain in the anterior hip area. Any disabling femur fracture requires splinting from the hip to the ankle. Because the muscles of the thigh are quite powerful and will tend to force the broken bone ends to overlap (Figure 74, A), traction is often necessary to control bleeding, maintain position, decrease pain, and prevent further internal muscle and blood vessel damage (Figure 74, B). If sufficient rescuers are available, one person should maintain firm traction on the leg at the ankle to oppose the strong muscle contractions of the thigh (Figure 75). A broken femur can bleed 2 quarts (liters) of blood into the thigh rapidly, so evacuation is a high priority. Be prepared to treat the victim for shock (see page 60).

Figure 74 Fracture of the femur. A, Without traction, strong muscles of the thigh pull the broken bone ends together, causing pain and deformity. B, Traction straightens the leg and helps control bleeding and pain.

Figure 75 Technique for applying traction to the lower leg.

The standard Thomas (“half ring”) splint allows traction to be applied to the femur. A Hare splint has a ratchet mechanism at the end to provide mechanical traction. A Sager splint allows traction by facilitating lengthening of its long, rigid axis rod. The Kendrick Traction Device is a lightweight, portable field traction apparatus that operates on the same principle and can easily be carried and applied in a wilderness setting. The Slishman Splint, now available in a shortened version, is an excellent, lightweight device.

You can also prepare an improvised traction splint that replicates the features of a Thomas splint: a half ring to anchor up against the pelvic bone (ischial tuberosity) underneath the lower crease of the buttock, two longitudinal rigid rods to run the length of the leg, a fixed spacer at the lower (foot) end between the two rods, and a traction mechanism to pull on the leg to align the fracture.

The ankle should be padded with foam or cloth pads, or a boot should be worn. If the latter is done, you can cut away the toe section to assess the circulation (skin color, sensation) (Figure 76).

Figure 76 The toe section of a boot can be cut away to allow inspection for adequate circulation. A cravat or piece of webbing can be passed through a boot as the first step in creating a traction harness.

A traction harness must be created to pull the leg straight down away from the head. One method is to cut two slits through the victim’s sturdy boot, above the sole just in front of the heel and directly below the leg bones. Pass a cravat or nylon webbing (such as a pack strap) through the opening (see Figure 76); the ends of the strap will be secured to the rigid object that will form the spacer at the foot end of the leg splint. The paired-loop (“double runner”) method of creating an ankle hitch uses paired lengths of cravat, nylon webbing, or rope (Figure 77, A). Fold each in half, creating a single turn at one end. Lay one cravat over the top of the ankle and one behind the ankle (behind the Achilles tendon), with the curved ends pointed in opposite directions. Pass the free ends of each cravat through the loop in the other cravat, and tighten the cravats so that they fit snugly and flat against the ankle. The free ends should now hang down (Figure 77, B) and will be secured to the spacer, directly or with an interposed pulley system, that connects the long, rigid rods of the splint. Another method to apply traction is “Buck’s traction,” in which a pad is secured firmly around the lower leg in such a way that the pad can get enough purchase to allow it to anchor tape stirrups (Figure 78).

Figure 77 Paired-looped webbing to create an ankle hitch. A, Position the webbing around the ankle. B, Pull the harness tight with the ends pointed down for fixation to the splint.

Figure 78 Buck’s traction.

The traction splint rods can be fashioned from two ski poles, rigid tree limbs or saplings, tent poles, or anything else that is approximately a foot (30 cm) longer than the distance from the top of the thigh to the bottom of the foot. To measure the proper length, lay the rods next to the victim on either side of the thigh, with the top of the inner rod tucked up against the groin crease and the top of the outer at the top of the thigh. Cut the lengths to be even at a distance of approximately 8 to 12 in (20 to 30 cm) below the foot (Figure 79).

Figure 79 Proper length of traction splint rods.

Construct the splint away from the victim. Using a cravat, ski pole straps, webbing, or rope, attach the tops of the two poles with a length that approximates half the circumference of the thigh at this point, to create the “half ring” that will be snugged up underneath the victim into the lower buttock crease (Figure 80). At the lower (foot) ends of the rods, attach a perpendicular rigid spacer about 8 in (20 cm) in length (Figure 81). This could be a piece of ski pole, a wrench, a piece of tree limb, or the like. Then lay four cravats (two for above the knee, two for below) or straps (that can be fastened) over the rods and wind them to be configured as cradle hitches (Figure 82). These will fix the rods to the leg after traction has been applied. Velcro straps are nice, if you have them.

Figure 80 Creation of the half ring, which snugs up into the buttock crease.

Figure 81 Attachment of the spacer at the foot end between the splint rods.

Figure 82 Configuration of cravats for cradle hitches.

Holding traction on the leg, lift it enough to slide the splint underneath. Snug the half ring up into the buttock crease, remembering to keep the shorter rod on the inside of the leg. Attach the splint firmly to the leg with tape or a cravat around the front of the thigh (over thick padding, if available) at the top of the splint above the suspected point of the fracture (Figure 83).

Figure 83 Attaching the splint to the leg above the suspected point of the fracture.

Tie the free ends from the traction harness (which you created through the boot or around the ankle) to the spacer at the end of the long splint. Create a “Spanish windlass” by inserting a short, rigid stick or rod between the tied-down free ends and twisting to produce the desired amount of traction (Figure 84). Fix the twister rod in place by tying it to the adjacent long splint rods (Figure 85).

Figure 84 Tie the free ends of the foot harness to the spacer. Then, twist the Spanish windlass to create downward traction on the leg.

Figure 85 After the windlass is twisted to achieve the desired traction, tie the windlass rod to the long struts of the splint to maintain the traction.

Finally, secure the splint to the leg with the cradle hitches, two above the knee and two below (Figure 86). Pad everything. The victim may be more comfortable if you apply traction while his knee is slightly bent.

Figure 86 Secure the splint in place by tying off the cradle hitches.

With a broken femur, the rescuer would ideally remove the victim’s shoe or boot to be able to assess whether or not the circulation is intact, by checking the dorsalis pedis artery pulse on the top of the foot (see page 33) and observing for normal skin color and sensation. This should only be done if it will not interfere with splinting and if the foot can be protected from the elements (e.g., to avoid frostbite). If the footwear is removed, tent up the sock and cut a hole just large enough to allow a finger to enter to find the pulse and to get a peek at the skin color.

Hip

If a person (usually elderly) falls with great force directly onto his knee, the large leg bone may be forced backward out of the hip socket and create a posterior hip dislocation. In such a case, the affected leg appears shorter and is bent at the knee; the foot and knee are also turned inward (toward the other leg) (Figure 87). With an anterior hip dislocation, the ball of the femur slips forward out of the hip socket, and the leg is shorter and externally rotated (knee and foot face outward) (Figure 88). Either dislocation is a serious condition, because the blood supply to the head of the femur (the “ball” of this ball-and-socket joint) is disrupted. If medical attention cannot be reached within 1 hour, make an attempt at relocation—unless there is a deformity of the upper leg or knee (indicating a fracture). Hold the leg and knee of the victim firmly, and exert forceful traction pulling on the thigh directly down toward the victim’s feet, in an attempt to slide the head of the femur back into the hip socket. If this is successful, you will feel a “give,” and the leg, knee, and foot will regain proper alignment.

Figure 87 Position of the leg with posterior hip dislocation.

Figure 88 Position of the leg with anterior hip dislocation.

Because of the force required to perform this maneuver, it is generally necessary to have a second rescuer provide countertraction to the victim’s upper body. The two-rescuer method involves the first rescuer straddling the supine victim directly over his hips, facing toward the victim’s head and holding the victim’s bent leg between his knees. The second rescuer holds the victim’s pelvis to the ground while the first lifts upward on the dislocated femur (Figure 89). If relocation is successful, firmly splint the hip by securing the victim’s legs together, slightly bent at the hips and knees with padding in between; he should be promptly evacuated, and should not attempt to walk.

Figure 89 Two-rescuer method for repositioning a dislocated hip.

Knee and Kneecap

A suspected fracture of the knee or kneecap should be splinted from hip to ankle. If there is such great deformity that the foot becomes numb and turns blue or pale and cold (usually with severe dislocation of the knee joint), and pulses cannot be felt, then dislocation of the knee joint should be suspected and the rescuer should use traction to attempt to realign the leg in a position of function (with the knee bent at a 15- to 30-degree angle; see Figure 39, B) to reestablish circulation. If pulses do not return after the knee is repositioned, the major artery that traverses the knee joint may have been torn or crushed and occluded. This is a surgical emergency. If the relocation attempt is successful, the victim still must be evacuated promptly for a full evaluation.

If the kneecap becomes dislocated, gently straighten the leg while pushing the kneecap from the lateral side back into place. Occasionally, the kneecap will not pop back into position. If the maneuver is painful or not easily accomplished, do not apply force. After the kneecap is repositioned, splint the leg straight or at a 15-degree bend (knee) using an Ensolite or foam pad and elastic bandage(s). If the splint slips, duct tape can be used to fashion suspenders (Figure 90). To prevent the kneecap from becoming dislocated, a person with a history of frequent (patellar) dislocation may choose to wear an Aircast patellar brace or similar support. This stabilizes the kneecap and compresses the surrounding soft tissue with a circular cushion of air.

Figure 90 Duct tape suspenders support an improvised knee splint.

If the knee has been dislocated or fractured, the victim must be carried. If a kneecap dislocation is the only injury, however, successful treatment will allow the victim to walk, using an ice ax, ski pole, or other object as a crutch.

The knee can be sprained (or strained) when it twists or withstands impact. The supporting ligaments that bind the joint on the outside and inside (lateral and medial collateral ligaments) and those that cross front to back through the interior of the knee joint (cruciate ligaments) can be stretched, slightly torn, or completely disrupted. This causes immediate pain with weight bearing (walking), motion (trying to bend the knee or extend the leg), or touch (pressing against the injured side of the knee). Often, there is swelling and a spongy feel to the knee. As swelling increases, the knee becomes less flexible and more difficult to bend. If you suspect more than a minor sprain, immobilize the knee as if for a fracture; the victim should avoid weight bearing. Sometimes the mechanism of injury can suggest what has been damaged:

Lower Leg

A fracture of the lower leg should be splinted from knee to ankle. If necessary, the legs can be attached side by side with padding in between. If the knee is not involved, keep it bent at 15 to 30 degrees.

Ankle

A fracture of the ankle can be stirrup-splinted or wrapped to prevent movement. This can be accomplished using a SAM Splint, parka, or piece of rolled foam taped or wrapped into place (Figures 91 and 92). Remove or loosen the boot or shoe to avoid entrapment due to swelling, which could impair circulation. However, if the victim must walk out under his own power, replace footwear as soon as possible, before swelling makes this impossible.

Figure 91 Methods of foot and ankle immobilization. A, A piece of rolled foam can be used as a “stirrup” to hold the foot and ankle motionless. B, The SAM Splint is easily configured in a similar fashion.

Figure 92 Ankle fixation with the SAM Splint. A, The splint is wrapped in a figure-of-eight over the top of the ankle. B, The aluminum is molded to fit snugly against the foot and lower leg. C, Rear view of completed splint.

Toe

A fractured toe may be splinted by buddy-taping. This is performed by placing some padding (cloth or cotton) between the toes and taping the injured toe to a healthy adjacent toe for support.