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Wilderness Medical Society - snowmass 2005 (Page 203)

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Wilderness Medical Society - snowmass 2005
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I. Lower Leg: Splint tibia and both bone fractures to incorporate the knee and ankle.
Many isolated fibula fractures require only an ankle splint and the victim can ambulate
with a cane or crutch. Traction splinting is unnecessary. Gently correct angular
deformities (see Lower Arm above).

J. Ankle: Fractures of the ankle may be difficult to assess. The Ottowa Ankle Rules
indicate a fracture might exist (literally that an x-ray was indicated) if there was
tenderness over the inferior or posterior pole of either malleolus, including the distal
malleolus (Recommendation 1A) Ref: Dunlop MG, Beattie TF, White GK, Raab GM,
Doull RI. Guidelines for selective radiographic assessment of inversion ankle injuries.
BMJ (Clin Res Ed) 1986;293:603-605. Early examination and treatment are important.
Immobilize adequately, then elevate and apply cold to the injured extremity. A well-
wrapped compression dressing is also quite helpful. Ankle fractures may be splinted very
well with parkas, foam sleeping pads, or other comparable gear arranged in a "U" shape
around the foot and lower leg.

K. Specific indication of a midfoot fracture are tenderness along the base of the 5
th
metatarsal or navicular bone and the inability to bear weight (4 steps) at the time of the
injury and at the time of examination (Recommendation 1A, Ref: as indicated under
ankle, above). Splinting is similar as for ankle fractures. Ambulation may be possible for
self-evacuation, especially when aided by a cane or crutch.

III. GUIDELINES FOR ASSESSMENT AND TREATMENT: DISLOCATIONS
It is important to diagnose and reduce a dislocation quickly after it occurs. Discretion
must obviously be used in deciding to reduce the dislocation when evacuation to a nearby
medical facility can be easily accomplished. Always examine and document motor,
sensory, and circulatory status distal to the dislocation both before and after attempted
reductions.
The major advantages of early reduction are:
1) Reduction is easier immediately after the injury, before swelling and muscle
spasm have developed;
2) Transport of the patient is easier after reduction;
3) Reduction usually results in dramatic relief of pain;
4) Immobilization of the injured joint is easier to accomplish and more stable after
reduction;
5) The safety of the entire party may be jeopardized during the evacuation of a
patient with a major joint dislocation;
6) Early reduction reduces the circulatory and neurological risks to the extremity.
Signs helpful in identifying a dislocation include:
1)
Restriction of motion through the joint's normal range;
2)
Obvious deformity in comparison with the uninvolved side,
3)
Crepitus or grating of bone fragments is absent;
4)
Often a typical, identifiable posture of the dislocated joint, which the patient
will maintain to minimize pain.

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