Chapter 27 Wilderness Orthopedics
The textbook discussion of orthopedic trauma in wilderness medicine has traditionally focused on discrete musculoskeletal injury to individuals or small groups in the mountain, sea, or desert setting. The scope of wilderness medicine today has widened significantly to include terrorism, military engagement, and the forces of nature. Recent disasters, such as the Great Indian Ocean tsunami of 2004, Hurricane Katrina in August 2005, and the Haitian and Chilean earthquakes of 2010, serve as powerful examples of situations in which orthopedic injuries were myriad and the provision of care limited in significant part by the remoteness of setting or inaccessibility of resources.
The wilderness practitioner needs to approach trauma outside the normal clinic or hospital setting with a sense of anticipation and improvisation. One needs to be prepared for a scenario of chaos, inadequate medical supplies or support, sepsis, and limited or delayed evacuation potential. The tidy fractures of individual sport injury or accidental trauma in civilized society share little in common with massive crush injuries, limb mangling with segmental loss, and severed limbs of natural or terroristic disasters. Issues of triage and prioritization become paramount. The successful organization of resources and effective mobilization of personnel skills often determine the outcome of the operation. Improvisation in splinting to stabilize or immobilize shattered limbs can minimize neurovascular compromise and reduce morbidity and mortality (Figure 27-1). Although most of us will hopefully not experience such large-scale tragedy, readiness and focus are required of the modern wilderness caregiver!
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.
Stabilization of a victim’s cardiovascular and pulmonary status is critical. Once this has been accomplished, examination of the musculoskeletal system should be undertaken in a systematic manner. Careful initial attention should be devoted to the spine. After the cervical, thoracic, and lumbar spine are evaluated and stabilized, the focus is brought to bear on the pelvis and extremities.
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.
Penetrating or blunt trauma can injure major vessels that supply the limbs. Fractures can produce vessel injury by stretching, which can produce intimal flap tears, or by direct laceration. Intimal injuries can occlude distal flow or lead to platelet aggregation and delayed occlusion. Thus, examination of vascular function should be performed and repeated at regular intervals before the victim’s arrival at the definitive care center. Color and warmth of the skin or distal extremity should be assessed; pallor and asymmetric regional hypothermia may indicate vascular injury. In the upper extremity, the brachial, radial, and ulnar arteries should be palpated. In the lower extremity, the femoral, popliteal, posterior tibial, and deep peroneal arteries should be palpated. If blood loss, hypothermia, or obesity makes these pulses difficult to assess, temperature and color must be relied on to determine vascular integrity. Any suspected major arterial injury mandates immediate evacuation after appropriate splinting.
Nerve function may be impossible to assess in an unconscious or uncooperative person. In the conscious person, the results of light touch and pinprick tests should be carefully documented. For spinal and pelvic injuries, dermatomal distribution of spinal nerves is assessed, and muscle function is evaluated by observing active function and by grading the strength of each muscle group against resistance (Figure 27-3). If possible, once the victim’s condition has been stabilized, nerve function to the distal extremities is established. These initial findings should be compared periodically with repeat examinations during transport. Any change and, in particular, any deterioration in condition should be noted.
The long bones of the lower extremity serve as the major structural supports for locomotion, whereas those of the upper extremity stabilize the soft tissues and allow functional use of the arm and hand for manual dexterity. A visible angular deformity suggests a fracture; palpable crepitus confirms the diagnosis. The health care provider in the field should perform appropriate splinting after aligning the limb using gentle axial traction. After noting the degree and orientation of the limb’s position when the victim is found, there should be no delay in aligning and splinting fractures. The risk-benefit of fracture reduction and realignment in the wilderness to protect neurovascular status and reduce pain typically outweighs the medical center imperative to image before manipulation. Distinguishing joint injuries and intra-articular or very proximal or distal fractures must wait for the definitive care facility, where radiologic studies can be done. Similarly, distinguishing a wrist or ankle ligamentous injury from a fracture is not required for initial treatment.
Muscle forces act across joints to optimize the positions of the lower limbs for ambulation and the upper extremities and hands for manual dexterity. Each joint has a normal range of motion and limits to ensure stability. Making the diagnosis of a joint injury in the field allows appropriate splinting and prevents further damage during transport. Diagnosis is usually made by palpation of the limb and fracture. If a tuning fork is available, it can be used in the following manner: the tuning fork is struck and then placed on one end of a limb in question. If the vibration cannot be auscultated at the other end of the bone, or if the vibration is significantly diminished when compared with the other limb, a discontinuity (fracture) may exist. Portable ultrasound can also be employed if it is available and if doubt remains regarding the existence and location of a fracture.
The palpation of long bones begins distally and proceeds across all joints. A splint should be applied if there is palpable crepitus, swelling, deformity, or a block to motion. If the victim can cooperate, each joint is taken through an active range of motion to quickly locate any injury. When this is not possible, passive motion of each joint is evaluated after palpation for crepitus and swelling.
Any dislocations are carefully reduced after completing the neurovascular examination. This generally relieves the victim’s discomfort considerably. Once relocation has occurred, stability is evaluated by careful, controlled motion. Joints with associated fractures or interposed soft tissues may still be unstable after reduction. Great care is required in applying splints to prevent redislocation or further soft tissue injury. A report of details of the reduction or relocation maneuver, including orientation of the pull, amount of force involved, amount of sedation, and residual instability of the joint, should be provided to the definitive care physician (see Reduction and Relocation Maneuvers, later).
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.
When a cervical spine injury is suspected, the field examination involves grading motor strength, documenting sensory response to light touch and pinprick, and noting the presence or absence of the Babinski reflex (see Figure 27-3). When appropriate supplies are available, a rectal examination should be done. Complete lack of tone and failure of the sphincter muscles to contract when pulling on the penis or clitoris (the bulbocavernosus reflex) indicates spinal cord injury.
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.
Fractures and dislocations may result in neurologic insult distal to the bony injury. Because flexion injuries are the most common cervical spine injuries, the neurologic deficit is generally an anterior cord syndrome. In this setting, the victim suffers complete motor loss and partial sensory loss but retains proprioception.
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.
When a thoracolumbar spine fracture is suspected, a careful neurologic examination should be performed as part of the secondary survey, and close attention should be paid to the dermatomal response to light touch and pinprick, motor function, and the presence or absence of cord level reflexes. Because significant fluctuations in sympathetic tone may occur, the rescuer should monitor blood pressure and body temperature, taking appropriate steps to cool or warm the victim. If evacuation cannot be performed immediately, hemodynamic and neurologic function should continue to be noted and documented. The victim should be logrolled, maintaining perfect spinal alignment, and carefully placed on a backboard. The scoop stretcher may be used in this situation (see Chapter 19).
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).
Because the posterior pelvic ring accounts for about 60% of pelvic stability, in a suspected pelvic fracture, it should be determined whether there is an injury to the posterior pelvis. Posterior pelvic fractures are identified by instability of the pelvis associated with posterior pain, swelling, and ecchymosis. This victim should be immediately evacuated on a backboard, taking care to minimize leg and torso motion.
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).
In addition to these high-energy injuries, simple, nondisplaced inferior or superior ramus fractures and avulsion fractures can occur. On clinical examination, these pelvic fractures are generally appreciated as areas of tenderness without instability. Lateral compression injuries are usually stable, with impaction of the posterior structures.
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).
Many different extremity splints are available for use in the wilderness setting. These splints are lightweight, compact, and easy to use. They are, of course, more elaborate than a hiking pole or branch that is more readily available. These more intricate devices have considerable advantages for larger-scale evacuations in the setting of natural disasters. They are designed to provide traction through the injured extremity while using the intrinsic properties of the splint and the injured limb to apply the traction. With proper splint application, the injured limb can be immobilized securely in a functional position until definitive care is reached (Figure 27-16).
Air splints may be of some benefit, but they are generally manufactured in one shape. Especially in the setting of injured tissues and in environments that might include wide temperature variability, these splints can cause compressive damage to an already injured extremity. Therefore, in more extreme conditions, an air splint is used only if it has an automatic adjustment valve to account for atmospheric variability. Also, these splints should be stored in a minimally inflated state when the temperature is below freezing, to prevent ice from causing splint dysfunction. Beaded vacuum splints can also be used. However, temperature and altitude considerations can make adequate and consistent inflation less reliable. When beaded vacuum splints and air splints are used, vigilance is required to ensure that no excessive pressure is applied to already injured soft tissues.
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).
Hand splints are applied with the metacarpophalangeal (MCP) joints flexed to 70 to 90 degrees and the interphalangeal (IP) joints extended. This position places the collateral ligaments at maximal length and prevents joint contracture (Figure 27-19). Wrist or forearm splints are applied with the wrist in a neutral position; excessive wrist flexion or extension might detrimentally affect median or ulnar nerve function in an already compromised limb. The elbow is positioned in a splint or sling at 90 degrees, if possible.
For shoulder fractures or dislocations, a commercially available sling or improvised triangular bandage should be used to take the weight of the arm off the injured structures. Although it may be difficult to place an injured elbow in 90 degrees of flexion and neutral rotation, the upper extremity should be splinted in the position of comfort and function whenever possible.
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.
(Courtesy Sam Slishman.)
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 ).
(Netter illustration from http://www.netterimages.com. Copyright Elsevier Inc. All rights reserved.)
For ankle fractures, traction is applied. Most fractures are the result of an eversion, external rotation force. Therefore reduction is undertaken and a splint applied so that the ankle is in inversion and internal rotation, known as the Quigley maneuver. Care must be taken in the absence of diagnostic imaging so that excessive force on a limb, which has already sustained significant vascular or nerve injury, is not exerted (Figure 27-28).
Skeletal traction is applied in the setting of pelvis or acetabular fracture or lower extremity fractures, such as femur or tibia fracture. This mode of stabilization can be used for temporary or more definitive treatment. This technique can be used in a setting such as a natural disaster (see Figure 27-1).
Distal femoral traction pins are inserted from medial to lateral. The knee is flexed during insertion to facilitate access to the medial aspect of the distal femur and to allow for flexion of the knee once the pin has been placed; if the pin is placed with the knee in extension, the iliotibial band might be tethered and thereby prevent knee flexion. The pin is placed approximately two finger breadths proximal to the adductor tubercle. If the pin is placed too distally, it can enter the intercondylar notch of the knee. If the pin is placed too proximally, it can injure the superficial femoral artery near its exit from the adductor hiatus, or one of the branches of the superficial femoral artery, near the knee.
Proximal tibial traction pins are inserted from lateral to medial. The pin is placed approximately two finger breadths distal to the tibial tubercle and two finger breadths posterior to the anterior tibial crest. These pins should not be placed in children, if possible; proximity of the tibial tubercle physis puts this important structure at risk during insertion of a proximal tibial traction pin (Figure 27-29).
A calcaneal pin can also be used for applying lower extremity traction. This type of traction pin may be of particular benefit in the setting of ipsilateral femur and tibia injuries. It is usually placed medial to lateral, with care taken to avoid the posterior tibial neurovascular bundle. The pin is driven through the calcaneus and exits laterally (Figure 27-30).
If possible, balanced traction should be maintained. This helps to counteract deforming forces and to allow for relatively comfortable movement in bed. There are no hard-and-fast rules for the amount of weight to apply. If balanced traction is employed, the rule of thumb is for enough traction to be applied that the ipsilateral buttock is elevated just barely off the bed. When radiography is available, traction is applied until the fracture fragments are well aligned and nearly out to length. For an average-sized adult, this likely will be between 6.8 and 13.6 kg (15 and 30 lb).
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.
Familiarity with the Gustilo-Anderson open fracture classification system is useful. This open fracture classification assigns musculoskeletal trauma to one of three major categories (types I to III) depending on the mechanism of injury, extent of soft tissue damage, and degree of skeletal involvement.
Type III fractures involve extensive damage to the soft tissues, including muscle, skin, and neurovascular structures. They are often the result of a high-velocity injury or a severe crushing component. The following special patterns are classified as type III:
The wound is less than 10 cm (3.9 inches) with crushed tissue and contamination, or it is the result of high-energy trauma, irrespective of the size of the wound. This includes segmental fractures or severely comminuted fractures. Adequate soft tissue coverage is usually possible despite soft tissue laceration or flaps.
There is extensive soft tissue loss (greater than 10 cm [3.9 inches]) with periosteal stripping and bony exposure. This is usually associated with massive contamination and typically will require regional or free-flap reconstruction.
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
General care of an open fracture outdoors depends on evacuation time. Open fractures require prompt operative irrigation, debridement, and stabilization. If evacuation can be completed within 8 hours, realign the fracture, administer a broad-spectrum antibiotic, and splint the extremity. If bone ends extrude through the skin, cover the exposed bone with a dilute povidone-iodine solution–soaked gauze sponge, splint the extremity, and arrange for prompt evacuation. If evacuation time exceeds 8 hours, in addition to antibiotic administration and splinting, irrigation and debridement in the field may be attempted. If available, and tetanus vaccine is not known to have been given in the past 7 years, this should also be provided. Antibiotic options are listed in Box 27-1.
Ciprofloxacin 400 mg IV or 750 mg PO bid; or a sulfonamide and trimethoprim combination (Bactrim DS: 800 mg sulfamethoxazole and 160 mg trimethoprim) with either cefazolin (Ancef) 1 g IV q 8 hr or cephalexin (Keflex) 500 mg PO q 6 hr
Bid, Twice a day; IV, intravenously; PO, orally; qid, 4 times a day.
Degloving injuries (sometimes referred to as Morel-Lavallée lesions) and/or crush injuries can occur in the wilderness (see Figure 27-14). Although they are seen more commonly in high-energy, urban accidents, they can also occur as the result of a significant fall or crush beneath a boulder, for example. Natural disasters and warfare can also result in a mangled or crushed limb. Splinting, monitoring for compartment syndrome, and expeditious evacuation are imperative.
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
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).
A compartment syndrome begins when locally increased tissue pressure reduces capillary blood flow to a muscle compartment. When local blood flow is unable to meet metabolic demands of the tissue, ischemia ensues. In the wilderness, a compartment syndrome most frequently occurs in association with a fracture, crush injury, or severe contusion. It can also occur when the victim has been lying for some time across an extremity so that the body weight occludes the arterial supply. Elevated local tissue pressure (compartment pressure within 10 to 20 mm Hg of diastolic arterial blood pressure) can also occur with acute hemorrhage or after revascularization of an ischemic extremity. Because perfusion pressure is the most important variable in development of compartment syndrome, hypotension can increase the risk for a compartment syndrome.
Compartment syndrome can occur in the thigh, hand, foot, and gluteal regions. It is more common, however, in the lower leg and forearm, because of the tight fascia in these regions. The conscious victim complains of severe pain out of proportion to the injury. The muscle compartment feels extremely tight, and applied pressure increases the pain. There may be deceased sensation to light touch and pinprick stimuli in the areas supplied by the nerves traversing the compartment. Stretching muscles within the compartment produces severe pain. The most reliable signs of a compartment syndrome are pain, tight compartments, hypesthesia, and pain on passive stretch. Pulselessness, pallor, and slow capillary refill may not be observed, even with a severe compartment syndrome (Figure 27-34).
Emergency evacuation is required when compartment syndrome is suspected. The victim must be definitively treated in the first 6 to 8 hours after onset to optimize return of function to the involved limb. Emergency fasciotomy, the treatment of choice, relieves the pressure. If a compartment syndrome develops and evacuation cannot occur within 8 hours, it must be decided whether the treating individual possesses the skill to perform a fasciotomy and whether it can be performed in an aseptic manner. Fasciotomies can convert a closed fracture into an open fracture and can provide a conduit for limb- or life-threatening infection: the function of a limb with nonfunctioning nerves and muscles as a result of compartment syndrome months after the compartment syndrome can be salvaged with tendon transfers, whereas a limb that becomes infected after providing fasciotomies in the wilderness could easily result in an amputation.
If a fasciotomy is to be done, antibiotics should be administered. In the forearm, the procedure usually involves making volar and dorsal incisions and splitting the underlying fascia. In the lower leg, the procedure usually involves making two long incisions, one on the medial aspect and the other on the lateral aspect of the leg, and splitting, in a vertical fashion, the compartmental fascia in each of the four lower leg compartments.
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
The general principle in the acute management of extremity injuries is rest, ice, compression, and elevation (RICE). For unstable fractures, immobilization is also indicated. Avoid heat for the first 72 hours after injury. Chemical cold packs work well, but cold packs made from ice or snow will suffice. If cold packs are unavailable, the extremity can be immersed intermittently in a cold mountain stream. If ice is used, mix some water in a bag with the ice to more evenly distribute the cold. The cold pack to the injured area may be held in place with an elasticized bandage. A piece of fabric is placed between the cold pack and the victim’s skin to prevent frostbite. The ice is applied to the elevated extremity (above the level of the heart) for 30 to 45 minutes every 2 hours. A compressive dressing also helps decrease swelling but should not be used if development of a compartment syndrome is possible. In this situation, keep the limb at the level of the heart and avoid compressive dressings.
In the wilderness, without benefit of radiographic images and high-dose analgesics, determination of the exact anatomic structures affected by an injury can be a challenge. The following sections have therefore been divided in a manner that is based on the location of general pathology.
Fracture of the clavicle usually occurs in the middle or lateral one-third of the bone and is associated with a direct blow or with a fall onto the lateral shoulder (Figure 27-35). Clavicle fractures are common in snow skiing and mountain biking accidents. The victim complains of shoulder pain, which may be poorly localized. Arm or shoulder motion exacerbates the pain. To localize the problem, gently palpate the clavicle to identify the area of maximal tenderness. The presence of crepitus at the clavicle confirms the diagnosis. Although rare, a pneumothorax can be associated with a clavicle fracture if the cupola of the lung is punctured; therefore auscultate the chest for breath sounds. Shortness of breath and deep pain on inspiration increase suspicion for a pneumothorax.
FIGURE 27-35 Midshaft clavicle fracture sustained by a 13-year-old snowboarder, riding in the backcountry with his friends. Proximal humerus demonstrates physis normal growth plate, often mistaken for a fracture. Comparison view of the opposite shoulder may be obtained if proximal humerus fracture is suspected.
Clavicle fracture may also be accompanied by injury to the brachial plexus, axillary artery, or subclavian vessels. In an individual with a fractured clavicle, a thorough neurovascular examination of the affected extremity is performed, and the skin is examined carefully. Approximately 3% to 5% of clavicle fractures may be open because of the bone’s subcutaneous location. The victim should be evacuated if there is a significant open wound, suspected pneumothorax, or nerve or vascular injury. Field treatment for a clavicle fracture consists of a sling or figure-8 bandage and judicious use of analgesics.
These injuries to the “wing-bone” are uncommon in the wilderness but may result from a fall on the back or a direct blow. Confirmation of the exact injury often requires radiographic or computed tomography evaluation (Figure 27-36). Scapula fractures can be seen in isolation or, in higher-energy injuries, in conjunction with thorax injuries, such as rib fracture or pneumothorax. Palpation and auscultation for breath sounds assist in making these associated diagnoses. Symptomatic, nonoperative treatment for a scapula fracture is usually indicated.
Traumatic dislocation of the sternoclavicular joint generally requires tremendous force, either direct or indirect, applied to the shoulder. Consequently, it is rare. Anterior dislocation is most common, with the medial head of the clavicle going anterior to the manubrium of the sternum (Figure 27-37). The victim complains of pain around the sternum and frequently has difficulty taking a deep breath. When the dislocation is posterior, significant pressure may be placed on the esophagus and superior vena cava. The victim may complain of difficulty swallowing and have engorgement of the veins of the face and upper extremities, representing superior vena cava obstruction syndrome. A step-off between the sternum and the medial head of the clavicle (compared with the uninjured side) confirms this diagnosis.
Unreduced anterior dislocation does not produce neurocirculatory compromise and is treated with a sling. Reduction of a posterior sternoclavicular dislocation should be attempted as soon as possible if any neurocirculatory compromise is present. The victim is placed supine with a large roll of clothing or other firm object between the scapulae. Traction is applied to the arm against countertraction in an abducted and slightly extended position. The medial end of the clavicle may need to be manually manipulated to dislodge the clavicle from behind the manubrium (Figure 27-38). If this fails, sharp, firm pressure is applied posteriorly to both shoulders. This maneuver is repeated several times, with a larger object placed between the scapulae if reduction attempts are initially unsuccessful. Alternatively, with the victim seated and the caregiver’s knee against the back between the shoulders, both shoulders are pulled back. Although it might seem macabre, if the victim remains in extremis, the medial end of the clavicle is grasped with a towel clip or pliers and forcefully pulled out of the thoracic cavity. Once reduced, the injury is usually stable. The posterior sternoclavicular dislocation requires evacuation.
FIGURE 27-38 Technique for closed reduction of the sternoclavicular joint. A, The patient is positioned supine with a sandbag placed between the shoulders. Traction is then applied to the arm against countertraction in an abducted and slightly extended position. For anterior dislocation, direct pressure over the medial end of the clavicle may reduce the joint. B, For posterior dislocation, in addition to the traction, it may be necessary to manipulate the medial end of the clavicle with the fingers to dislodge the clavicle from behind the manubrium. C, For a stubborn posterior dislocation, it may be necessary to sterilely prepare the medial end of the clavicle and use a towel clip to grasp around the medial clavicle and lift it back into position.
(From Rockwood CA Jr, Green DP, Bucholz RW, editors: Rockwood and Green’s fractures in adults, ed 3, Philadelphia, 1991, JB Lippincott.)