Wilderness Medical Society snowmass 2005 Page 202
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D. Hand: Fractures of the hand are often associated with dislocations of the proximal or
distal interphalangeal joints. Reduce phalangeal fractures and splint in a position of
function as indicated above, not in an extended position. Immediately after injury, these
fractures can be reduced with only minimal discomfort. Hours after the injury, swelling
and pain make realignment more difficult. Use of an ice compress and very gentle
traction can realign fractures of the hand without significant discomfort. Immobilize the
digits in a position of function whenever possible, and use adjacent digits for splinting
(the "buddy system"). Place gauze between the buddy-taped fingers to absorb moisture
and prevent skin ulceration. A suitable hand splint may be made by placing the entire
hand in a functional position with a soft roll of material in the palm, and then wrapping
the whole with an elastic wrap or roller gauze. Torn strips of clothing can be used for an
improvised hand splint.
E. Hip: In fractures of the hip, the typical position of external rotation and shortening of
the leg may or may not be present. The fracture may be an impacted femoral neck type or
an acetabular fracture. Diagnosis might be difficult. As a general guideline, if a patient
has sustained significant trauma and has very painful motion in the region of the hip, plus
pain with weight-bearing, carry him or her out on a litter or sled. Do not place suspected
fractures of the hip in traction. Secure the leg on the affected side to the uninjured leg for
splinting.
F. Pelvis: In suspected fractures of the pelvis, treat for shock due to the massive blood
loss often associated with this injury. Because of possible bladder trauma, check for
hematuria. Gentle constricting wraps placed around the pelvic region may provide
temporary comfort and more stability to the fracture. A ThermaRest pad, secured around
the pelvis then inflated, offers excellent improvised pelvic stability. The patient requires
stabilization on a rigid backboard, litter, or sled and urgent evacuation.
G. Femur: While pain is relieved with initial manual traction, placing a person in a
traction splint is technically difficult and can result in complications from tissue necrosis
due to pressure points, compromised circulation, and complications of extraction due to
the length of the traction device. Closely observing the compression of the traction
system is mandatory and causes heat loss during cold weather, due to the temporary
opening of the thermal wrap.
A traction splint is no more efficacious than a good packaging technique.
Immobilize the fractured extremity to the uninjured leg with adequate padding. When
long transport is anticipated, place padding behind the knee to create 5 to 10% knee
flexion. This position is much more comfortable than if the knee is fully extended.
H. Knee: Patellar fractures from a fall directly on the knee may be difficult to
differentiate from a severe contusion unless there is an obvious deformity. A person with
a comminuted fracture of the patella will be unable to extend the knee. Immobilize a
patient with severe knee pain in a cylinder splint that stabilizes the knee, and allows
walking with assistance. Improvise a cane or crutch, if terrain and other factors dictate
that this is the best course of action.
