14 Treatment: limbs and back

Limb injuries may be life-threatening and an initial ABC evaluation should be performed, with respiratory and circulation status regularly re-evaluated (see Initial response to an incident, p. 180; Assessment of a casualty, p. 185). Consider the possibility of associated head, spine, chest, abdominal, or pelvic injuries, particularly if the patient is unconscious.

When applying splints, remember that they must be well padded and must immobilize the joints above and below the injury (Fig. 14.1). Where possible, splint with the limb in the anatomical position.

A fracture is a soft tissue injury with an underlying break in the bone. Fractures are either open if the skin is broken or closed. They are comminuted if there are more than two fragments. Children’s bones may bend, leading to greenstick fractures. Complicated fractures involve damage to blood vessels, nerves, tendons, or organs.

A dislocation is an injury in which the normal relationships of a joint are disrupted. In some dislocations the bone end may be forced out of a socket (shoulder, hip, and elbow dislocations); in others the joint surfaces may simply be displaced (finger dislocations). Fractures, nerve, and blood vessel injuries may also be present with a dislocation.

Correction of dislocations can be technically difficult. Attempts to correct the deformity are justified in certain circumstances, particularly in remote areas. If the blood supply to the distal part of the limb is obstructed by a dislocation, reduction must be attempted. Steady, firm traction along the limb’s long axis may correct the deformity or at least relieve the obstruction temporarily. Reduction should be attempted as soon as possible because of increasing muscle spasm. After reduction, splint the limb as for a fracture.

(See Fig. 14.2.)

In the wilderness this may be improvised by passing a long sock around the patient’s neck and wrist of the affected side. This can then be secured using a cable tie or piece of cord. This uses the weight of the arm to apply slight traction to the upper arm and should be used for fractures of the humerus.

(See Fig. 14.3.)

This is mainly used to reduce hand swelling with hand injuries. Avoid excessive flexion of the elbow as this reduces venous drainage of the forearm.

(See Fig. 14.4.)

This is commonly used to support the weight of the arm and reduce movement in shoulder and clavicle injuries, dislocations/fractures of the elbow, forearm, and wrist. If used during evacuation of a walking casualty, a swathe around the chest placed on top of the broad arm sling further reduces movement. A broad arm sling may be improvised by pulling the lower edge of a jacket over the arm and then securing with a safety pin.

Arm slings and splints should be worn inside clothing to keep the hand and arm warm.

This is a common injury following a fall onto the outstretched arm. The clavicle is palpable along its length and there is often obvious deformity and localized tenderness. If the skin over the fracture is tented, then gentle traction with the arm out to the side will reduce the risk of developing an open fracture. Check movement, circulation, and sensation carefully. Treat with analgesia and a broad arm sling.

Injury to the acromio-clavicular joint commonly follows a fall onto the point of the shoulder. There is usually a characteristic step together with point tenderness at the joint. Treat with analgesia and a broad arm sling. X-rays will show the grade of injury, and the most severe may require surgical treatment.

The shoulder joint may be dislocated after violent injury (particularly forced abduction/external rotation) or after minimal injury in those with previous shoulder dislocations.

Most dislocations are anterior and are straightforward to diagnose as there is ‘squaring’ of the shoulder on the affected side and reduced movement, particularly abduction and forward flexion. The humeral head may be palpated antero-inferiorly to the glenoid fossa.

After any shoulder injury examine the area carefully for complications such as damage to the axillary nerve (loss of sensation over the insertion of deltoid—the ‘regimental badge area’). Axillary nerve damage merits expert assessment.

On an expedition it is reasonable to attempt reduction in the field, preferably with strong analgesia (± sedation such as midazolam). Reduce using the external rotation method or Spaso method. A clunk is often seen, felt or heard, and the shoulder’s normal contour is restored.

Sit the patient as upright as possible. Hold the patient’s elbow next to the trunk and, with the forearm mid-prone, slowly externally rotate the shoulder to 90°. The shoulder usually reduces at this point; if it does not, forward flex the upper arm slowly. An assistant may help to manipulate the humeral head into position.

Spaso Miljesic and Anne-Maree Kelly first reported the Spaso technique in 1998.¹ This method is simple, needs minimal force, can be performed by a single operator, and is highly effective even in inexperienced hands. The Spaso technique is relatively atraumatic and countertraction is not required.

Lay the patient on their back and give sedation/analgesia as available. Grasp the affected arm around the wrist and slowly lift vertically to 90° shoulder flexion, applying gentle vertical traction as well as external rotation of the shoulder at the elbow. If difficulty is experienced, it may be helpful to use one hand to palpate the head of the humerus and gently push it to assist reduction, while maintaining traction with the other hand.

Lie the patient prone with the arm hanging down with a 5-kg weight attached to the wrist/hand. This method may take half an hour or more to achieve reduction.

Re-examine for axillary and radial nerve movement/sensation. Check pulses. Rest in a broad arm sling or collar and cuff. Evacuate for X-rays and orthopaedic follow-up/physiotherapy. Recurrent dislocations of the shoulder may not require an X-ray and can be managed with a broad arm sling and early mobilization.

This injury is rare and may follow electric shock or convulsions. It is easy to miss. It results from force applied to the anterior shoulder. The shoulder is internally rotated and there is marked loss of movement. Attempt reduction by applying traction and external rotation with the arm at 90° to the body. Manipulation under anaesthesia may be required.

The patient presents with the arm held above the head. Examine carefully for neurovascular deficits. Attempt reduction by applying traction along the abducted arm, then adduction. If it is not possible to reduce in the field, give strong analgesia, support the arm using padding with sleeping bags or similar, and evacuate for reduction under anaesthesia.

All conditions are caused by acute injury or soft tissue degenerative changes and may be provoked by unaccustomed activity as may occur on wilderness trips. The main symptom is of pain, often following lifting or a fall and onset may be sudden or gradual. Abduction and forward flexion in particular are restricted (unable to upturn a drinks can with arms outstretched in front of patient). There may be a painful arc of movement. Treatment with rest, NSAIDs, and a broad arm sling will usually reduce symptoms. Further assessment will be required if pain and restricted movements persist. Significant loss of ROM in the absence of pain may indicate a complete rotator cuff tear. Avoid prolonged periods of immobilization in a sling.

If crepitus is felt during manipulation of a shoulder dislocation, suspect an associated fracture and desist from further attempts at reduction in the field until the fracture has been identified or excluded by an X-ray. Support in a broad arm sling, give analgesia, and evacuate.

These are caused by a fall onto the outstretched arm or onto the elbow. Midshaft fractures can involve the radial nerve as it runs through the spiral groove and result in a wrist-drop.

Treatment for proximal injuries is with a collar and cuff sling. Midshaft injuries may benefit from a splint or broad arm sling and strapping arm against the body. Any involvement of neurovascular structures, particularly the radial nerve or brachial artery, should prompt urgent evacuation for definitive care.

This can be torn during lifting and may not require large forces. It is seen more commonly in elderly males. There is a characteristic bulge of biceps muscle above the elbow but often little pain; bruising may, however, be extensive. Surgical repair may be considered if the arm is not fully functional.

The elbow may be injured by a direct blow or transmitted forces such as a fall onto the outstretched hand. Full extension without pain makes the presence of fracture or serious injury very unlikely.

This requires considerable force and may be associated with fractures. The radius and ulna are usually dislocated posteriorly. Damage to the brachial artery or radial/ulnar/median nerves may occur. Attempted reduction is justified in a wilderness environment, particularly if evacuation to definitive care will take more than a few hours.

After suitable analgesia, apply steady traction to the limb by pulling at the wrist. The elbow is usually flexed at around 30°. Countertraction above the elbow with concurrent pushing of the protruding olecranon forwards is essential. Rest in a broad arm sling and evacuate for X-ray and further assessment/rehabilitation. If reduction proves impossible, place in a broad arm sling and give analgesia. Monitor radial pulse and assess for nerve damage.

Golfer’s elbow refers to inflammation around the common flexor origin at the elbow; tennis elbow involves the same process at the common extensor origin. Both conditions are caused by repetitive hand and wrist movements, particularly rowing and paddling on expeditions. On examination there is tenderness at the medial (golfer’s) or lateral (tennis) epicondyles of the humerus and pain on gripping.

Rest, anti-inflammatory drugs and, where possible, avoidance of the provoking activity and gentle stretching after 3–4 days.

The olecranon bursa may become inflamed and painful, sometimes after minor trauma. The lump over the elbow is fluctuant and may be very tender if it becomes infected.

This condition may take weeks to resolve but usually only requires rest in a broad arm sling and anti-inflammatory drugs. If there is evidence of spreading infection or fever then give antibiotics. Avoid aspiration in the field because of the danger of introducing infection.

Displaced fractures around the elbow may be associated with neurovascular injury, particularly the brachial artery. Check distal pulses and seek evidence of neurological deficit. Such fractures usually require orthopaedic assessment and often need internal fixation. With the forearm midprone, splint either in the position found, or with the elbow at 90°. Evacuate for X-rays and further management.

This injury can only be diagnosed with the help of radiographs but clinically is suggested by a history of a fall onto the outstretched hand and then pain and tenderness on palpating the radial head. Pronation/supination is often very painful. Support the forearm in a broad arm sling and evacuate for assessment.

These tend to be unstable fractures and may affect the radius and ulna at the same level, at different levels with spiral fractures, or involve a fracture of one bone with associated dislocation at one of the radio-ulnar joints. Check carefully for neurovascular compromise. Treat with analgesia, splinting, and evacuate for definitive care. If there is evidence of an open fracture, clean and dress the wound and give antibiotics.

These fractures are commonly caused by a fall onto the outstretched hand. There is often obvious deformity together with pain and swelling. Dorsal displacement of the distal fragment is most common—Colles’ fracture. For those familiar with a haematoma block, 6–8 mL lidocaine 2% can be injected into the fracture site before reduction—a haematoma block. All potential wrist fractures on an expedition should be supported in a suitably padded splint and rested in a broad arm sling. Imaging and definitive treatment will be required after evacuation from the field.

A fall onto the outstretched hand may lead to pain and swelling, together with difficulty gripping. If there is tenderness in the anatomical snuffbox, pain when ‘telescoping’ the thumb (pushing the straight thumb towards the wrist) or palpating over the scaphoid tubercle, a scaphoid injury must be considered. Avascular necrosis, non-union, and osteoarthritis may complicate scaphoid fractures. On an expedition, immobilize in a below-elbow splint, and evacuate for X-rays and follow up as long-term disability may result from undiagnosed scaphoid injury.

If the mechanism of injury makes a fracture unlikely and if findings on examination are non-specific, it is reasonable on an expedition to treat a tender wrist as for a sprain using a support bandage, anti-inflammatories, and early mobilization. If there is any uncertainty or if symptoms are not settling, it is safer to assume that there is a fracture and arrangements should be made to image the wrist in a suitable facility.

Inflammation of tendon sheaths may follow repetitive strain injuries. Characteristically there is pain on moving the wrist or thumb and a ‘creaking’ or ‘buzzing’ sensation may be felt over the affected tendons, usually on the dorsum of the wrist. Treatment consists of rest in a suitable splint for up to 3 weeks and anti-inflammatories.

Fractures may be suggested by the mechanism of injury, swelling, bruising, deformity, and loss of normal function. In all cases, check for neurovascular deficit. If suspected, immobilize the hand in a boxing glove dressing (Fig. 14.5) and broad arm sling. Evacuate for imaging and further treatment.

Dislocations can occur at the MCPJs or IPJs. After assessing for obvious fractures (small avulsion fractures cannot be diagnosed without imaging), check for any neurovascular damage. It is worth attempting reduction with in-line traction under LA (ring block). If successful, apply buddy strapping or use a boxing glove dressing (Fig. 14.5).

Attempt reduction, then immobilize in a suitable splint or ‘boxing glove’ (Fig. 14.5). Evacuate for definitive care as internal fixation may be required if there is an associated fracture.

These can occur at the metacarpophalangeal or interphalangeal joints. If the joint is grossly unstable when gently stressing the collateral ligaments, surgical treatment may be required. For most ligament injuries, rest with neighbour strapping will allow healing to occur. Warn patients that swelling may take weeks to settle. This occurs in particular with injuries to the volar plate at the PIPJs. If the mechanism of injury involves a forced abduction at the thumb MCPJ (gamekeeper's/skier's thumb), ensure that laxity of the ulnar collateral ligament is tested for. If there is no end point on stressing, surgical repair will be required.

Small cuts or lacerations may damage tendons and these injuries may easily be missed unless hand injuries are carefully assessed. (Beware of any injuries caused by broken glass—evacuation for X-ray is recommended.)

Loss of function is the only reliable sign that a tendon has been damaged, but pain out of proportion to the injury should suggest damage to underlying structures. Ensure that you examine the wound with the fingers moving through their range of movement as tendons move with the finger so the injury may not initially be visible.

This injury is usually obvious. Partial tendon ruptures are easily overlooked—explore wounds under LA or evacuate for full assessment in a bloodless field.

Flexor digitorum superficialis flexes the PIPJ. Flexor digitorum profundus flexes the distal interphalangeal joint (DIPJ).

To test these tendons see Examination of the hand, p. 430.

Tendon injuries should be repaired in a suitably equipped hospital, not in the field, because of the danger of infection of the flexor sheath that can cause long-term disability.

On an expedition, fingers can be injured in many ways; they may be crushed in vehicle doors or under heavy weights or during the use of tools/machinery. After release, the digits should be carefully examined (under LA if possible), cleaned, and elevated. Open fractures should be given an antibiotic such as co-amoxiclav and evacuated for X-ray and further management. Always remember to remove rings.

Rupture of the central slip of the extensor tendon to the distal phalanx results in loss of extension at the DIPJ. This may be associated with an avulsion fracture of the base of the distal phalanx. On an expedition, splint the DIPJ in extension for 6 weeks and arrange for orthopaedic review on return. Do not remove the splint as movement will disrupt the healing tendon.

Provided the bone is not exposed and the area of skin loss is <1 cm² it may be possible to treat these injuries in the field. After assessment, clean and dress (using Vaseline^® gauze or similar). Re-examine every 2 days. If the wound is not healing, evacuate for imaging and possible terminalization of bone or skin grafting.

Finger entrapment or crushing injuries may result in partial or complete avulsion of a nail. The finger should be anaesthetized (Fig. 14.6) and cleaned. The patient may be able to help to clean the finger by immersing in warm, clean water. If the nail is displaced it should be removed under LA, any defect should be repaired, the nail should be replaced for protection and the finger dressed and splinted.

Crush injuries to the nail may result in bleeding under the finger nail. The pressure results in throbbing pain which may be relieved by heating a paper clip to red heat and burning a hole in the centre of the nail, using minimal pressure. On an expedition a Leatherman^® multi-tool can be used to hold the heated wire paper clip. It may be necessary to reheat the wire on several occasions. Alternatively, a 21 G hypodermic needle can be used to drill a hole in the nail by gentle twisting motion. Once the blood has drained the pain is significantly reduced.

Splinters of metal or wood under the finger nail are common. A ring block may allow removal with splinter forceps or trimming of part of the nail to allow removal.

See Paronychia, p. 297; Fig. 9.6.

Many fractures to the lower limbs are high-energy injuries and are associated with other injuries:

Bony injuries to this part of the body are always serious and usually associated with major blood loss. Blood loss for closed lower limb fractures as a proportion of the total circulatory volume are shown in Box 14.1. Blood loss following open fractures may be much greater.

These follow high-energy trauma such as falls and RTC. Considerable force is required to disrupt the pelvis, therefore these fractures are frequently associated with other major thoracic/spinal/abdominal or skeletal injury. Major vessels and pelvic organs lie adjacent to pelvic bones, and these may also be damaged. Mortality rates are ~10–20%.

If a pelvic injury is suspected by mechanism, pain, or hypovolaemic shock (see Hypovolaemic shock, p. 234), treat as a fracture. Do not perform unnecessary examination that will exacerbate bleeding and do not log roll the patient unless absolutely necessary.

Treatment is aimed at stabilizing the pelvis and reducing further haemorrhage/visceral damage during onward transfer of the patient.

The elderly and those with osteoporotic bones may fracture the neck of the femur with relatively minor trauma; however, the same fracture in younger patients indicates high-energy trauma such as a climbing fall.

Often there is a history of a fall onto the lateral aspect of the hip. Pain may radiate to the knee and the affected leg may be shortened and externally rotated. Give analgesia; look for and treat shock. A traction splint may improve comfort during evacuation (see Femoral fracture, p. 437). If experienced, consider a fascia iliaca nerve block (see Fascia iliaca block, p. 594).

These usually follow a fall from a height or dashboard injury in RTCs. The hip joint usually dislocates posteriorly with or without fracture of the acetabulum. Travellers with hip replacements are at greater risk of dislocation with minimal trauma.

There is pain and deformity of the leg, which is shortened and rotated (internally if posterior dislocation). Assess neurological status and distal pulses—hip dislocations may be associated with injury to the femoral or sciatic nerve. If immediate evacuation is possible then splint legs in position and give strong analgesia. If >6 h before evacuation to hospital, then blood supply to the femoral head may become compromised and an attempt at reduction is justified but will require adequate analgesia ± sedation.

In posterior dislocation, the assistant places hands as countertraction on the pelvis (anterior superior iliac spine). Flex the hip to 90° with the knee bent and then apply vertical traction with internal rotation. As the hip relocates externally rotate, extend the hip, and continue longitudinal traction to the lower leg. Wrapping a bandage around the lower leg and foot may allow application of 2.5–5 kg skin traction to be maintained. Check neurovascular status post reduction—relocation may be prevented by entrapment of the sciatic nerve around the femoral neck. The hip may re-dislocate owing to an unstable acetabular fracture. Repeated attempts at reduction are not justified—evacuation is required ASAP for operative intervention.

A great deal of force is required to fracture the femur—usually following a fall from a height or RTC. It can be associated with other head, spinal, chest, or abdominal/pelvic trauma.

There is pain and deformity of the thigh, together with swelling and fracture crepitus. Assess neurological status and distal pulses. Anticipate and whenever possible treat hypovolaemia (the patient may lose 20% of blood volume rapidly even in closed injury). Splint legs in position (splint to un-injured leg); apply traction through a splint if available to maintain alignment and to reduce bleeding into the thigh compartment. Cover any open wounds with sterile dressings, e.g. saline-soaked gauze.

Strongly consider a fascia iliaca block if suitably experienced (see Fascia iliaca block, p. 594).

Knee injuries on expeditions are relatively common. In all cases take a careful history which may give clues to the diagnosis. Ask about previous knee problems such as swelling, clicking, locking, or ‘giving way’.

Examination of the injured knee:

This is relatively common and refers to bleeding into a joint. Rapid tense swelling develops in 1–2 h. Haemarthrosis may be spontaneous (coagulation disorders and rare vascular tumours) or traumatic (80% after anterior cruciate ligament injury, 10% patella dislocation, 10% meniscal injuries/capsular injuries).

RICE, analgesia, and evacuate for further assessment.

There will be good range of movement at the knee. Inflammation of the fluid-filled bursa in front of or below the patella may result from unaccustomed, frequent minor trauma such as kneeling. Rest and NSAIDs usually relieve symptoms. If there are features of spreading cellulitis and a fever, antibiotics should be given (e.g. co-amoxiclav).

Sudden knee flexion or a direct blow may result in a fracture of the patella. There is usually pain, swelling (sometimes from a haemarthrosis), and inability to straight leg raise. If suspected, splint the leg almost straight (with 5° of flexion at the knee) and evacuate for imaging and definitive treatment.

Suspected fractures around the knee should be treated with adequate analgesia and splint, as for patellar fracture. Avoid traction splints if there is a possible fracture in the supracondylar region of the distal femur. Traction may displace the distal part of the fracture posteriorly and damage the popliteal artery.

This is not uncommon and may be a recurrent problem (more common in females). The patella dislocates laterally and, typically, the patient’s knee is held flexed with obvious displacement of the patella. Give analgesia and reduce the patella by pressing with the thumbs on the lateral aspect of the patella as the knee is straightened. Once reduced it may be possible to rehabilitate this injury in the field without evacuation.

This is a rare injury and huge forces are required to produce disruption of the knee ligaments. There is a high likelihood of nerve and blood vessel damage—check distal pulses and sensation carefully. Treat with strong analgesia and immobilize as for patellar fracture before evacuation. Keep monitoring foot pulses, as popliteal artery injury may not be apparent initially. If there are signs of vascular compromise, evacuate urgently for vascular surgery.

The medial collateral ligament runs from the medial epicondyle of the femur to 4 cm distal to the knee joint on the medial aspect of the tibia. An isolated rupture usually results from a direct blow to the lateral aspect of the knee in slight flexion. If there is a rotational component, such as a fall when skiing, there may also be injury to the cruciate ligament.

The lateral collateral ligament runs from the lateral epicondyle of the femur to the head of the fibula. Isolated injuries are rare but are more usually associated with injury to all the lateral capsular ligamentous structures. This may result in marked instability.

Anterior cruciate ligament injuries account for 50% of documented knee ligament injuries. Posterior cruciate ligament injury is rare (10% knee ligament injuries). Usually, injuries are caused by non-contact twisting injury, occasionally following hyper-extension. There is pain and difficulty weight-bearing. Swelling usually develops immediately with an ACL rupture. A PCL rupture will have no swelling and a dull posterior knee ache.

The menisci act as stabilizers for the knee and distribute forces across the articular surfaces. There is usually a history of an axial load with a twisting injury to the knee. ‘Degenerative’ tears may occur in patients >35 years with very little history of injury.

Disruption to any one of these may prevent straight leg raising or active extension of the knee. (NB Tense knee effusion and pain may also prevent straight leg raise without disruption of extensor mechanism.)

This can occur as a result of a fall, RTC, or twisting injury (particularly when skiing). There is often an associated fibula fracture. Because there is little soft tissue cover, tibial fractures are commonly open.

There is a significant risk of compartment syndrome whether an open or closed injury (see Crush injuries, p. 277; Compartment syndrome, p. 443).

Splint legs in position (splint to the other uninjured leg); apply traction through a splint, if available, to maintain alignment. Cover open wounds with a sterile dressing (take a photo first) and give antibiotics during evacuation, e.g. co-amoxiclav.

This refers to increased soft tissue pressure within an enclosed soft tissue compartment which can lead to devastating muscle necrosis and nerve damage.

The soft tissues swell but the surrounding envelope does not allow expansion, causing pressure to rise above the capillary pressure. It usually follows fractures or crush injuries (particularly to the lower leg, thigh, forearm, and foot/hand), and is most common following closed fractures to the tibial shaft. Occasionally it occurs as a chronic exercise-induced condition (‘shin splints’).

Try to prevent occurrence in the field with elevation of the affected limb above the level of the heart. The soft tissue compartment looks swollen and tense. The most reliable sign is pain on passive stretching of a muscle group within the compartment, e.g. great toe or fingers. Remember the 5Ps—Pain, Pallor, Paraesthesia, Paralysis, and Pulseless, reflecting tissue ischaemia. Pain ‘out of proportion to the injury’ and local tenderness are the earliest features and are difficult to control with even opiate analgesics. Loss of pulse is a very late sign.

Acute compartment syndrome is an emergency requiring urgent evacuation and surgical decompression.

This refers to micro-tears in the Achilles tendon. It usually affects those aged 35–55 years and follows unaccustomed activity such as running, trekking, jumping or direct trauma to the tendon.

This occurs in two areas:

Conservative measures improve symptoms in 90%. In the acute stage, RICE and regular NSAIDs are required. Modify activity to reduce strain on heels.

After the acute phase has settled consider Achilles stretching exercises (eccentric loading) and removal of heel tabs in training shoes. A heel-raise to reduce stretching of the tendons can also be considered. There is a small risk of complete rupture.

There is a relatively poor vascular supply and high tension ~4–8 cm proximal to the insertion into the calcaneum. Age is usually 35–55 years. The injury occurs during sudden contraction during ‘push-off’ or an injury with forced dorsiflexion of the ankle.

The patient complains of sudden pain and weakness of plantar flexion at the ankle. A ‘gun shot’ may be heard as the tendon ruptures. On examination there is tenderness and a palpable boggy gap in the tendon.

Simmonds’ test-positive—lay the patient prone with foot over end of bed. Gently squeezing the calf causes plantar flexion at ankle in the unaffected side but no or minimal plantar flexion with rupture of Achilles tendon.

Initial management is RICE and splint ankle in equinus position (foot plantar flexed), non-weight-bearing. Evacuate for expert assessment and management. Currently there is considerable debate regarding non-operative treatment in equinus cast for 9 weeks (slow recovery and possibly higher re-rupture rate) versus operative repair (wound problems and sural nerve injuries).

These commonly occur during a forced inversion injury of the hindfoot. Generally the lateral ligaments are injured—anterior talo-fibular ligament and calcaneo-fibular ligament. Bruising and swelling may be severe, occurring within hours. Tenderness is usually maximal laterally.

A fracture may be difficult to exclude clinically; however, the Ottawa rules suggest that X-rays should be arranged if the patient is unable to weight-bear (four steps) or if there is tenderness behind the medial or lateral malleolus, over the navicular (proximal to base of first metatarsal), or at the base of the fifth metatarsal. Palpate the fibular head as ankle injuries can cause fracture of the fibular head.

RICE and analgesics. Strapping may be beneficial and supporting the ankle initially whilst allowing weight-bearing as tolerated. Active exercises should begin immediately, as pain allows, to regain full movement. Persistent or worsening pain on weight bearing after 1 week may require further review.

Normally the talus sits in the mortise of the tibia and fibula; twisting may rupture the ligaments or fracture the malleoli. This occurs when the foot is anchored on the ground and the momentum of the body continues forwards. There is swelling, pain, and bruising, with deformity and tenderness along the bony landmarks of the medial and lateral malleoli.

If the ankle is obviously dislocated, this may cause pressure necrosis on the soft tissues and neurovascular compromise. Reduction by traction and relocation is indicated urgently (with suitable analgesia). After reduction, check pulses and sensation then immobilize in a suitable splint. Treat with RICE. X-rays are needed to confirm the nature of the fracture. Evacuate for definitive treatment; many displaced ankle fractures will require operative fixation.

Foot injuries can be devastating on trekking expeditions as the victim may require stretcher evacuation. The feet are particularly vulnerable when inadequately protected by lightweight footwear in the tropics or jungle.

Falls from a height onto the feet can result in fractures around the heel. These may be bilateral and are associated with other significant injuries such as to the spine, pelvis, hips, or knees.

Give strong analgesia, elevate, and immobilize in a splint. Early definitive treatment is necessary to prevent long-term disability.

Heavy weights such as vehicle wheels or large machinery may break multiple metatarsal bones. Ankle inversion may lead to a small avulsion fracture at the base of the fifth metatarsal.

Check for pulses and evacuate for injury assessment and definitive care.

These most commonly affect the metatarsals, but can occasionally occur in the tibia, the calcaneum, or talus. They follow repeated trauma such as occurs in over-training. There is an underlying biomechanical problem that may be resolved with a change in shoes/boots.

In all cases give analgesia and remove the cause, often necessitating a reduction in training/exercise. Reduce weight-bearing with crutches until comfortable and then start mobilization, as tolerated.

These rarely require any more than ‘buddy strapping’ to relieve pain for 2–3 weeks. If there is obvious deformity, this may be reduced under ring block (inject 1 mL plain lidocaine 1% on each side of the base of the digit).

These are painful, difficult to manage, and prone to infection. To anaesthetise the area, consider topical LA such as Ametop^®, or regional anaesthesia by performing a nerve block of the posterior tibial nerve just posterior to the artery where it runs behind the medial malleolus. This will anaesthetize the majority of the sole of the foot. If the wound is on the lateral sole, consider a nerve block of the sural nerve as it runs behind the lateral malleolus. The tough skin of the sole makes local infiltration of LA painful and ineffective. Remove any foreign bodies and close the wound with glue or Steri-Strips™. There is a significant risk of infection—puncture wounds should be treated with antibiotics prophylactically. Ensure tetanus immunization is up to date.

This is inflammation of the connective tissue that forms the sole of the foot. There may be pain over the heel, under the arch of the foot forward to the metatarsal heads. It commonly occurs in individuals not accustomed to exercise who suddenly increase exercise intensity. Pain is common for the first few steps of the day or on dorsiflexion of the foot. The condition can be eased with calf stretching exercises and orthotics or cushioned footwear. It can last for up to 2 years.

(See also Chapter 7 and Chapter 14.)

Spinal cord injuries are relatively rare. However, it is vital that the possibility of spinal injuries is considered in all trauma patients especially:

The implications of missing one of these can be life-changing or life-threatening for the patient. Manipulation or inadequate management/ immobilization of the spinal-injured patient can cause additional neurological damage and worsen outcome.

Injuries most frequently occur at junctions of mobile and fixed sections of the spine (C6,7/T1, T12/L1). In patients with multiple injuries who have a spinal injury, over half will have a cervical spinal injury. About 10–15% of patients with one spinal fracture will be found to have another.

The aim of spinal management is to prevent any secondary injury to the spinal cord. If a casualty with a spinal injury is moved carefully, they are unlikely to come to further harm but do follow these precautions:

Not all patients who are involved in trauma need to have full spinal precautions maintained. Box 14.2 indicates when a spinal injury can safely be excluded clinically.

If the patient has any of these signs then imaging of the neck is required before cervical spinal immobilization can be removed.

If it is necessary to move the patient, they should be moved carefully, keeping the spine in alignment throughout and should be kept horizontal if at all possible. This is because blood vessels below the level of a spinal cord injury may have lost their spinal reflexes and so cannot contract in response to hypotension. This can cause a precipitous drop in BP and hence further damage to the spinal cord.

Back pain is a common complaint and on expeditions may be provoked by unaccustomed activity or injuries such as lifting awkwardly, falls, or twisting injury. 80% will resolve within 2–8 weeks. Low back pain is very common. Sort into:

Consider other systemic disease, such as back pain associated with weight loss, fever/rigors, cough/haemoptysis.

‘Unwell’ patient—immediately assess ABCs and check for presence of pulsatile expansile abdominal mass and presence/absence of femoral pulses (abdominal aortic aneurysm often presents with back pain).

‘Well’ patient—look for signs of weight loss, scoliosis, and muscle spasm. Watch the patient walk, looking for limping or abnormal posture. Assess spinal movements and note any significant loss. With the patient supine, palpate for tenderness over lumbar spine and sacrum, ribs, and renal angles. Look for muscle wasting in the legs. Perform on both legs:

See Table 14.1.

Manage symptoms with:

Gentle range of motion exercises should start as soon as possible. Aim for graded exercises which move joints slightly more each day. Avoid excessive stretching and try to normalize movement as early as possible within the limits of pain. Always provide adequate analgesia.

Taping or strapping is simply the application of adhesive tape to provide extrinsic stability and/or to offload weakened structures. Its proprioceptive qualities play a significant part in protection and rehabilitation. The principal aim of applying tape is to prevent disability and thus improve otherwise impaired physical function. Techniques can be used for a multitude of musculoskeletal conditions, either following tissue injury or as a preventative measure when a history or risk of injury is present. (See Fig 14.8.)

The most commonly used types of taping material are the adhesive elastic type (such as Elastoplast^®) and zinc oxide tape (a non-stretch, highly adhesive tape). The indications for each type depend on the aim of the technique being used, but often both types will be used concurrently; e.g. elastic adhesive tape is ideal for providing anchor strips as these are often circumferential strips of tape and must stretch to allow contraction of muscle from these anchor strips. Zinc oxide tape can be used to act as a non-stretchy stabilizer to prevent particular joint movements. Zinc oxide tape requires changing every day as after stretching it over a day, it will be no longer supportive.

In a number of techniques a pre-taping under-wrap can be used to prevent direct contact of the tape with the skin. However, it is the traction of the skin–tape interface that is thought to give the techniques their effectiveness and therefore the use of under-wrap can be questioned.

Prior to undertaking any taping technique, patients should have undergone a comprehensive assessment of the injury with particular reference to mechanism of injury, precise direction of any resultant instability/ weakness, and the phase of healing that is likely to be ongoing. These factors will lead to a clinical decision being made regarding the selection of taping material as well as the technique that is to be applied. Patients should also be questioned as to whether any known allergy to the taping materials is known.

Adequate preparation of the contact area is vital to ensure ease of technique and a good skin–tape interface. The following can be used as a guide:

Acutely injured joints are at greater risk of further injury owing to the loss of proprioceptive input caused by painful stimuli. The use of taping as an adjunct to improving joint stability extrinsically is commonly used in the sports setting and is aimed at restoring function at an early stage whilst protecting structures from further injury. Adhesive tape has been found to provide compression to acute ankle sprains for up to 10 days post injury.² It should be noted, though, that applying tape for such prolonged periods can be counterproductive as it will limit venous flow from the injured area and thus prevent resolution of swelling.

In the presence of swelling around an acutely injured joint, it is often wise to ensure that the circumference of the joint and the surrounding muscular tissues are not completely covered. This allows for further swelling to take place without causing any vascular compromise.

In acute muscle strain, longitudinal taping crossing both the origin and insertion of the muscle can prevent further injury and reduce disability by limiting the muscle’s potential to lengthen. This technique, known as physiological taping, can also be used during rehabilitation to offload the muscle at the point of stretch and, through the elastic quality of the tape, it can assist muscle contraction.

The most common use of musculoskeletal taping is as a preventative measure when returning athletes to sporting activity. Taping itself has been compared to functional sports bracing as a means of providing effective joint stability. No difference was found between the overall effectiveness and practicality of taping versus a laced ankle support across a number of sporting activities, but taping has the advantage of being adaptable to the individual athlete or expedition team member.