Chapter 27 Wilderness Orthopedics
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Problem Scope
Musculoskeletal injuries account for 70% to 80% of injuries that occur in a wilderness setting.11,18 Presumably as a result of the use of flak jackets and core protective gear that shield axial and central anatomic structures, bone and soft tissue injuries have also accounted for 70% of injuries in the Iraq and Afghanistan wars.16 In the initial management of a musculoskeletal injury that occurs in a wilderness or nondeveloped setting, the following must be considered: etiology and time of the injury, direction of the causative force in relation to the individual or limb, and environment where the accident occurred. These factors may indicate the severity of the injury and help determine examination and treatment priorities that can affect outcome.
Physical Examination
Respiratory Function
Basic resuscitation efforts in any setting begin with evaluation of an individual’s airway and breathing. This prioritization is no different in the wilderness. Once a victim’s airway is secured and his or her breathing is deemed adequate, evaluation of obvious musculoskeletal injuries can commence. Small portable pulse oximeters, comparable in size with a 35-mm film canister, are now available for less than $100 (Figure 27-2, online). These can be especially helpful if one is engaging in outdoor activities at high altitudes. These devices provide pulse rate and arterial oxygen saturation (SaO2), vital measures in any hypoxic or hemodynamically unstable patient.
Potentially Life-Threatening Musculoskeletal Injuries
Spinal Injuries
Cervical Spine
In the wilderness, cervical spine fractures or dislocations can be the result of a fall from a height, a high-velocity ski crash, in a combat setting, or a diving accident. Because head and cervical spine injuries are highly associated, a victim with a significant head injury should be considered to have a cervical spine injury, especially if the individual is unconscious. Ideally, a person with a suspected cervical spine injury is placed on a backboard with neck immobilization to prevent further injury and promptly evacuated. Approximately 28% of persons with cervical spine fractures also have other spinal fractures.3 Therefore the person providing care must protect the entire spine.
Neurologic deficit often results from cervical spine fracture. Complete neurologic injury from the occiput to the C4 level is usually fatal because of paralysis of the phrenic nerve, diaphragm, and respiratory muscles. The corollary to this is that surviving victims generally have partial deficits or are neurologically intact. Axial cervical spine fractures may result from flexion forces (most common), extension forces, rotational forces, or a combination of these. Cervical spine fractures most commonly occur at C5-6.3 Fracture of the C1-2 complex results from axial loading (a C1 ring fracture, or Jefferson’s fracture) (Figure 27-4) or from an acute flexion injury (a C2 posterior element fracture, or hangman’s fracture) (Figure 27-5). A pure flexion event may dislocate one or both posterior facets, producing neck pain and limitation of motion. Because the interspinous ligament is ruptured and this fracture dislocation is highly unstable, victim transport must be done with the neck rigidly immobilized to reduce the risk for posterior motion.
Thoracolumbar Spine
Thoracolumbar spine fractures occur most frequently at the T12-L1 junction. Because the thoracic spine is well splinted by the thoracic cage, when an axial or flexion load is applied, the ribs diminish forces on the thoracic vertebral bodies and transmit the force to the upper lumbar levels. In the wilderness, falls from significant heights or a high-velocity sporting vehicle crash may produce these fractures (Figure 27-6). Thoracolumbar spine fracture may also be associated with other fractures that occur with axial loading, such as femoral neck fractures (Figure 27-7) and calcaneus fractures (Figure 27-8). These injuries commonly occur when there is an axial force, such as a fall onto the lower limbs from a height. Therefore an individual who sustains a presumed hip fracture or calcaneus fracture as the result of a fall from a height generally should be transported under spinal precautions.
Pelvic Injuries
A study of mortality in the wilderness setting in Pima County, Arizona, between 1980 and 1992 demonstrated that most deaths occurred as a result of falling or drowning.12 Pelvic fractures generally occur with a fall from significant height, high-velocity ski accident, or vehicle crash. The Young and Burgess classification of pelvic fractures is based on the mechanism of injury. Pelvic fractures are categorized as anteroposterior compression injuries, lateral compression injuries, and vertical shear injuries.5 These fracture patterns have been shown to correlate with blood loss, associated injuries, multisystem morbidities, and mortality.5,7,31 Anteroposterior compression injuries can result in rotational instability if there is greater than 2.5 cm (1 inch) of pubis symphysis separation (Figure 27-9). Furthermore, if the posterior pelvic ring is disrupted, this can lead to both rotational and vertical instability. These fractures, which may include acetabular fractures, are often accompanied by hemorrhagic, neurologic, urologic, gynecologic, and gastrointestinal injuries (Figures 27-10 and 27-11).
Hemodynamic instability may occur with pelvic fractures, especially if the injury is the result of translational or shear forces or if the posterior pelvic structures are primarily involved. Bleeding associated with a pelvis injury is usually from cancellous bone at fracture sites, a retroperitoneal lumbar venous plexus injury, or, rarely, pelvic arterial injuries. Medical antishock trousers, the portable SAM sling, or even a bedsheet wrapped around the pelvis of an individual with a suspected unstable pelvic fracture may provide stability and accomplish adequate tamponade of bleeding from the fracture22 (Figure 27-12). Other similar devices are available or may be improvised. The applied sling belt (pelvic binder) or similar contrivance should be left in place until definitive care is available (Figure 27-13). Degloving injuries can also be seen in high-energy pelvis injuries (Figure 27-14).

FIGURE 27-14 Prone patient with an unstable pelvic fracture and a large degloving (Morel-Lavallée) flank lesion.
Extremity Injuries—General Considerations
Splinting Techniques
Splinting in the wilderness is performed so that alignment is maintained and further soft tissue injury is minimized. A victim with suspected cervical or thoracolumbar spine trauma should be transported on a hard surface. Backboards or scoop stretchers (see Chapter 19) are most effective, but improvisation with hard pieces of wood, fiberglass, or straight tree limbs lashed together may be needed. If cervical spine injury is suspected, a roll of clothes or a water bottle can be placed as high as the victim’s midface on either side of the head to prevent rotational movement. Tape applied from the supporting stretcher across the objects and the victim’s forehead adds stability. A child with a suspected spine injury should be transported on a backboard with the child’s body slightly elevated relative to his or her head (Figure 27-15). Any victim with a suspected major pelvic injury is transported in a similar fashion, stabilizing the pelvis with a circumferential sheet or piece of clothing or special belt and holding the lower extremities as immobile as possible, with the knees slightly flexed (see Figure 27-12).
Upper extremity splints may also be made from plaster or fiberglass, which can be applied over a soft cotton roll. Lightweight fiberglass splints, such as Ortho-Glass and FareTec, are easy to use and effective in the initial management of these injuries (Figure 27-17). These splints are prepadded and can be applied with either cold or warm water. The warmer the water, the faster the fiberglass sets and the greater the exothermic reaction. Hot water should be avoided because it may generate an excessively exothermic reaction and possibly burn the skin. The fiberglass is immersed in water, excess water is gently squeezed out, and the splint is applied. An elasticized bandage helps hold the splint where desired until the fiberglass is hard. Air splints, when inflated, can adequately splint the upper extremity in a stable position. Wooden or metal splints, custom made or improvised, also can be used to stabilize an injured extremity. New thermoplastic casts and braces may be used in a wet outdoor environment and immersed in water without compromising function or stability (Figure 27-18).

FIGURE 27-17 Water-activated FareTec splint for distal radius fracture, with wrist and hand in position of function.
For the lower leg, air splints provide adequate immobilization of tibia or fibula fractures and of ankle fractures and dislocations. Splints made from plaster or fiberglass may be applied over cotton padding and held in position with elasticized bandages. The SAM Splint, an excellent first-aid item that may be molded to immobilize a wide variety of injuries, provides stability and strength through its aluminum and foam core (Figures 27-20 and 27-21). The aluminum structure can be bent into three configurations to provide different degrees of stability, flexibility, and immobilization. The ankle is held in neutral position and the splint applied firmly. For transport, the lower extremity is positioned with the hip and knee extended and the ankle in neutral position. Victims with unstable lower extremity fractures or dislocations are transported in the recumbent position with the afflicted limb elevated.
For hip or femur fractures or dislocations, traction is applied whenever possible, improvising as necessary. For suspected hip, femur, or knee injury, one of multiple splints can be used. The basic principle guiding application of these is to provide traction of the lower extremity using a lightweight device (Figures 27-22 and 27-23). The ischium and/or pubis are proximal structures against which the splint is set. The ankle is usually the structure through which traction is applied (Figure 27-24). Lightweight splints that may be of use in the wilderness setting include those known either by their manufacturer or developer, such as Donway, Thomas, Kendrick, Slishman, Reel, FareTec, Sager, CT-6, and Hare (see Chapter 19). It behooves a backcountry health care provider to be familiar with whichever splinting device he is carrying. If commercial splints are unavailable, the injured leg is strapped to the noninjured leg, with a tree limb or walking stick placed between them. If possible, the victim is transported on a backboard.

FIGURE 27-22 Slishman splint applied for femur fracture following the 2010 earthquake in Haiti.
(Courtesy Sam Slishman.)
Reduction and Relocation Maneuvers
Even in the wilderness, the four principles of fracture reduction should be followed:
Steady traction and patience are the mainstays of fracture and dislocation reduction maneuvers.4
For distal radius fractures, the usual dorsiflexion deformity is reproduced and a flexion force is applied through the fracture. Steady traction can also assist with reduction of these fractures (Figures 27-25 to 27-27 ).

FIGURE 27-25 Reduction maneuver for the most common distal radius fracture (dorsally angulated).
(Netter illustration from www.netterimages.com. Copyright Elsevier Inc. All rights reserved.)

FIGURE 27-26 Distal radius fracture with distal radioulnar joint dislocation sustained after a fall on an outstretched hand.
Open Fractures
Recognizing an open fracture is imperative; without prompt surgical treatment, the incidence of osteomyelitis in this setting is high.14 In an open fracture, the fractured bone communicates with a break in the skin. With subcutaneous bones (e.g., tibia), open fractures are easily identified, but with other bones that have more surrounding soft tissue (e.g., humerus, femur, pelvis), identification is more difficult because the fractured bone end usually retracts once it punctures the skin and is then covered by soft tissue. A laceration near a fracture may be an indication of an open fracture. Most open fractures persistently ooze blood or fat globules from the laceration, which may facilitate diagnosis (Figure 27-31). Clothes should be split and skin examined.

FIGURE 27-31 Type IIIB open tibia-fibula fracture that occurred as a result of a fall while the individual was holding a chainsaw.
Subtype IIIC
Subtype IIIC is a fracture in which there is a major arterial injury requiring repair for limb salvage. Mangled Extremity Severity Score can provide prognostic considerations for limb salvage versus amputation.15
Tourniquets
Although the use of tourniquets outside of a medical facility historically has been anathema, there has been a resurgence in their use in the field by the military. In fact, in the Iraq and Afghan theaters, soldiers are trained in the application of tourniquets on themselves and others, and tourniquet use in the setting of a mangled or badly injured extremity is high. Evacuation as soon as possible after tourniquet application is crucial. Exsanguination remains a major cause of death in military conflicts. Reduction of blood loss volume is seen as an important way to reduce mortality in war casualties. Sacrificing a limb to save the soldier is a difficult but clear decision.19
Amputation
In the wilderness, the amputation victim requires immediate evacuation. Control hemorrhage using direct pressure, or employ a tourniquet. Without cooling, an amputated part remains viable for only 4 to 6 hours. Cleanse the amputated part with saline or water, wrap it in a moistened sterile gauze or towel, place it in a plastic bag, and transport the bag in an ice-water mixture. Do not use dry ice. Keep the amputated part with the victim throughout the evacuation (Figures 27-32 and 27-33).
Compartment Syndrome

FIGURE 27-34 Developing compartment syndrome in the setting of a tibia-fibula fracture, 6 hours following a crush injury.
Fasciotomies for compartment syndrome that cannot be done within 12 hours of the syndrome’s development should not be undertaken. A retrospective analysis of individuals who underwent late release for compartment syndrome (more than 35 hours after the injury) demonstrated significant complication and amputation rates. Therefore, even in an urban trauma hospital, delayed compartment release for compartment syndrome is not recommended.10