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July, 2006
Mountain Medic- Stable or Unstable?
Assessment and Care of a Backcountry Extremity Injury
Jon Tierney
You are several hours into the day and enjoying a long hike above tree line with friends in the Presidential Range. While descending a boulder field your partner slips on a large boulder and disappears. You hear a loud shriek followed by some well known expletives and arrive a few seconds later to hear your friend utter "I am in a world of hurt!"
Your friend tells you they "slipped and twisted their leg between the rocks". They report that it "really hurts" and that "it may be broken." You notice a bit of blood soaking into their sock.
After checking your friend over, you find that the injuries are limited to the left lower leg and ankle. There is a large laceration along the left lower leg which is bleeding briskly. There is pain and tenderness in the ankle. They can feel you squeezing their toes and are able to wiggle them. Now you need to decide what to.
First control the bleeding. Try to find some gloves to wear (you have them in your first aid kit, right?). If you don't have any, consider a plastic baggie or ask your friend if they can put pressure over the wound using their own hand. A quick pressure dressing around the leg should control the bleeding and protect the wound for now. As you wrap the dressing around the leg you notice some whitish-colored tissue in visible deep in the wound.
Now what to do about the ankle? The primary objective is to determine stability rather than the specific type of bone or joint injury. Essentially, is it stable or unstable?
Unstable bone injuries are characterized by significant pain, relatively quick swelling, and inability to bear weight. Obvious deformity is a clear sign of an unstable injury. You note some tenderness on the outside of the ankle just in front of the ankle bone and your friend demonstrates reasonable range of motion and can apply gas pedal like pressure against your hand with their foot. You assist them to their feet and find that they are able to bear some weight on the injured leg.
Your conclusion is that they have a stable ankle joint injury and a leg laceration that is considered a high risk for infection.
The primary factor here is the weight bearing ability of the injury - this determines whether you may be able to self evacuate by assisting your friend or will need help to carry them out.
Treatment for a stable injury follows the RICE principles - Rest, Ice (about 30 minutes of cool application every 3 - 4 hours), Compression (an Ace like bandage wrap to limit swelling) and Elevation (try to elevate the extremity when possible). Taping or splinting may be advisable to improve comfort and stability during evacuation. You are able to soak a t-shirt in cold water from a nearby stream and apply an Ace wrap to the ankle in figure eight fashion.
An unstable joint injury is treated by splinting it in position unless there is evidence of nerve or blood vessel impairment below the injury in which case you would try to manipulate the injured area to improve circulation. An unstable long bone injury such as a boot top fracture is best treated by first bringing it into position of alignment (aka, its normal anatomic position). Any manipulation of an injury is done with gentle traction. Grasp the extremity above and below the injury and gently apply traction by pulling them apart from each other and into alignment. With long bone injuries, this typically results in a more comfortable situation along with improved circulation and nerve function below the injury. Next a splint is applied to maintain this position. A good splint should extend well beyond the injury immobilizing the adjacent joints or long bones above and below. It should be rigid, well-padded, and three-dimensional if possible. Snug it down well but always remember to continually check the area below the injury for on-going circulation, sensation and movement. If necessary, loosen the splint.
Now back to the wound. The bleeding has been controlled through application of well-aimed direct pressure and some elevation while splinting was going on. You remove the bandage and observe a three-inch jagged laceration that is gaping wide open and appears quite deep. Given the time it will take to evacuate, this is best treated as a high risk wound to minimize the potential for infection and promote the healing process. A high risk wound is indicated by the visual evidence of underlying muscle, ligament, bone, etc. A bite, puncture, or extremely dirty wound is also considered high risk.
Backcountry treatment for a high risk wound
Visualize the wound
Control the bleeding through direct pressure/elevation
Wash your hands with soap and water
Put on protective gloves
Briskly wash the area around the wound and the wound
Pick out any debris with clean tweezers
Flush the wound vigorously with water (try to make a squirt gun out of plastic baggie or soda bottle). The pressure will help you flush hard to reach spots.
Rinse thoroughly with a very diluted iodine solution in water (check for allergies). You can forego this step if the wound is not high risk.
Redress and bandage the wound
Check for on-going circulation and movement
Excellent work. Your friend is able to stand and walk with some assistance. In a few hours you will be back at the road. A quick trip to the emergency room is always a good idea for further evaluation and follow-up care. Now you have another epic adventure to share with your friends!
DISCLAIMER: The above guidelines are not a substitute for professional instruction.
Jon Tierney is an internationally licensed IFMGA guide, paramedic and owner of Acadia Mountain Guides and Alpenglow Adventure Sports located year round in Orono and in Bar Harbor during the summer season. He has been guiding and instructing mountain skills, wilderness medicine and outdoor leadership since the early 1980s. He is also a lead instructor for Wilderness Medical Associates.
Email nick [at] noumbrella [dot] com with your questions, comments and concerns.
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