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Wilderness Medical Society - snowmass 2005 (Page 200)

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Wilderness Medical Society - snowmass 2005
Chapter 8

Recommendations are considered Category 1B, unless where indicated 1A, by the WMS
Panel of Expert Reviewers

Sprains, strains, and fractures, especially injuries to lower extremities, are among the
most common accidents in wilderness settings. The treatment of these injuries may vary,
depending upon the expertise and experience of those in the party and the distance from
definitive medical help. In remote settings, making the patient as functional as possible is
often the overriding concern, thereby facilitating self-rescue and eliminating the need for
outside assistance. Remember, the safety of the group takes precedence over optimal
treatment of any individual injury.
Managing fractures in remote environments requires common sense, good
diagnostic skills, and sensitivity to the needs of the patient and the group. For example, in
a severe ankle injury where a fracture is suspected, one would normally immobilize the
part and put the patient on crutches with instructions for elevation, ice, and rest from
weight bearing. In the wilderness, however, one must weigh other factors: the desire of
the patient to ambulate on a suspicious ankle injury, the availability of people to transport
the patient, the type of terrain involved in transport, the severity of the environment,
distance involved, and the patient's need or desire as well as ability to continue carrying a
load. Thus, whereas the best medical judgment precludes weight-bearing, the best
decision in a remote environment might be to immobilize the ankle in a splint, or tape the
ankle securely as for an athletic event, and allow the patient to hobble along on his or her
good ankle using an ice axe, ski pole or wooden stick for balance. This could be the
safest and most reasonable decision based on the situation.
In the wilderness, without a radiographic picture of the involved bones, assessment of a
fracture includes the following questions:
Are there obvious signs of a fracture, such as angulations, swelling, or
Can the patient move the injury or does she/he guard it carefully?
Is there crepitation with movement?
Is there point tenderness with palpation of the site, or pain at the
suspected injury site with axial compression along the long bone or
with torque on the bone?
Is there discoloration and swelling?
How does the injured side compare to the uninjured side?
Does the injury feel rigid with spasm of the surrounding muscles?
Did the patient feel or hear anything break?
What was the mechanism of injury? (High-speed impacts cause more
fractures than low-speed impacts).

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