ORTHOPEDICS 8 – Hip, Thigh, Kneecap, Knee, Ankle, Foot, Chest - Fractures, Dislocations and Sprains
Updated: Nov 13, 2020
Excerpt from The Prepper's Medical Handbook. Page reference numbers point to more in-depth treatment and self-reliant care available within the book.
Hip Dislocation and Fracture
Hip injuries are very serious.Tremendous blood loss occurs internally. Fractures of the hip cause pain in the anterior medial aspect (front and side) of the thigh. Dislocations in younger people may be associated with fractures; in older people fractures are very common and are the probable cause of the deformity. See figure 7-15 for positions of fracture and dislocation.
Posterior dislocation of the hip is more common in healthy young adults compared to central fracture/dislocation and anterior hip dislocation. All these injuries are infrequent when compared, for instance, with dislocation of the shoulder. Posterior dislocations can cause injury to the sciatic nerve, the main nerve of the leg. This can cause shooting pains down the back of the leg and/or numbness of the lower leg. It is most important that reduction of the dislocation not be delayed longer than 24 hours. Muscle relaxants and pain medication must be given. To reduce, place the victim on her back with the knee and hip in a 90-degree position. The line of the femur should point vertically upward. The thigh should be pulled steadily upward while simultaneously rotating the femur externally, as shown in figure 7-16.
If possible, evacuate this patient back to the grid. For evacuation purposes, pad well and buddy splint to the other leg. This victim is a litter case. Continued pressure on, or severe injury to, the sciatic nerve will cause muscle wasting and loss of sensation to practically the whole leg. This damage must be surgically repaired as soon as possible. In the extreme case of survival without possible repair, brace the affected leg to allow mobility by the victim and take care of numb skin areas to prevent sores and infection.
Central fracture/dislocations result when the head of the femur is driven through the socket into the pelvis. As in all orthopedic injuries, an X-ray is almost essential for the diagnosis. If the fragments can be replaced surgically, this is the treatment of choice. In the extreme survival situation (when there is no hope of medical care for many months), this injury can be left alone and still result in a stable and relatively painless joint. Light traction can be applied to the lower leg for comfort. After 3 weeks, ambulation with crutches, gradually increasing weight, can be encouraged. Range-of-motion exercises should be started from the beginning to help mold the healing fragments into a relatively smoother joint surface. Sciatic nerve injury should not occur with this injury, but an arthritic joint will result.
Anterior dislocation results from forceful injuries such as airplane crashes and motorcycle accidents. Examination of the lower leg demonstrates considerable lateral rotation, or outward tilting, of the foot when the victim is lying on his back. Reduction is as described under posterior dislocation, with traction on the flexed limb but combined with medial rotation, or rotating the limb inward rather than outward.
Fractures of the thigh (femur) can, of course, occur from the hip to the knee. They are classified and treated by the orthopedic specialist differently according to the location of the break.
First aid treatment consists of treating for shock and immobilizing, initially using hand traction splinting. Start by providing pain relief with gentle hands-on in-line traction. Traction splinting is initially helpful, as spasms from the powerful muscles in this region cause considerable overriding of bone fragments, increasing the extent of the injury.Traction also reestablishes the normal length and configuration of the musculature and tightens the membranes that surround the muscle (the fascia), which very importantly decreases the bleeding that occurs with this injury.
The amount of pull required is minimal due to Pascal’s law of hydrodynamics. It indicates that any change in pressure applied at any point in the fluid is transmitted undiminished throughout the fluid. As the thigh is a closed cylinder, the massive bleeding that occurs with a fractured femur will have a tamponade applied by lengthening, ever so slightly, the sack of fascia or tissue covering the muscle and broken bone.This elongation of a slight sphere into more of a cylinder reduces the surface area of the sphere into that of a cylinder, but the volume of blood inside remains the same. Thus, through the magic of Pascal’s law, there is a significant increase in the deep tamponade on the bleeding bone and muscle tissues with even slight traction. Partial pain relief is the guide by which you will generally know how much pull to exert. This traction is initially performed by pulling on the ankle/foot gently in line, with the patient lying on their back.
The patient should do quite well with simple buddy splinting to the other leg during litter transport. The best traction method for the person in a fixed camp situation is to have them on a thoroughly padded and comfortable bed with a foot board rigged to accept a sash tied around the ankle with an appropriate tug (about 2 pounds [1.6 kilograms] of tug). A person kept in bed with a traction splint will be at a higher risk of developing leg blood clots (thrombophlebitis). Initially, bleeding into the leg muscle is your biggest concern. Coupled with severe pain, this can lead to shock. After a few days, bleeding is less of a concern, but developing a blood clot in an immobilized patient is one. At that time, it is appropriate to start aspirin, 81 mg per day. If you have the 325 mg aspirin, give one initially and then 1 every 2 days.
After the traction splinting period, buddy splint with non-weightbearing ambulation. A fractured femur will take 8 to 12 weeks to firmly stabilize.
The kneecap (patella) usually dislocates laterally, or to the outside of the knee. This dislocation results in a locking of the knee with a bump to one side, making the diagnosis obvious. Relocate the patella by flexing the hip and the knee. When straightening the knee, the patella usually snaps back into place by itself. If not, just push it back into place while straightening the knee on the next try. Splint with a tube splint (closed-cell foam sleeping pad) with the knee slightly flexed. This patient should be able to walk to the base camp. No further care will be necessary in an off-grid situation, except physical therapy performed by attaching a light weight (4 pounds [1.8 kilograms]) to the ankle and having the person sit with the leg dangling and repeatedly extending the knee. This exercise strengthens the quadriceps muscle, providing the chance for tightening the patella when under actual use stress against the knee joint and allowing less laxity, decreasing the chance of future dislocations. An on-grid orthopedic referral for recurrent patella dislocations is appropriate to repair the torn capsule for better ensured stability.
Knee Sprains, Dislocations, and Fractures
The initial care of sprains, or acute joint injuries, is described on page 159. If the pain in the knee is severe, several diagnoses are possible. There may be tears of ligaments, tendon, cartilage, or synovial membranes. There may be associated dislocations or fractures. All you really can assess is the amount of pain that the patient is experiencing, and you have to take his word for that. You can visually assess the amount of swelling or deformity and that might tell the tale, but the most important aspect of care will be handling pain as the patient interprets it.
Have the patient lie as comfortably as possible. Apply RICE (see page 160) to the knee. In case of significant pain or swelling, remove the boot (weather permitting) and check the pulse on top of the foot (the dorsal pedal pulse); question the victim about sensation in the feet. Check the dorsal pedal pulse on the opposite side for comparison. If the injury appears minor, this is not necessary.
Significant deformity means that a dislocation may have occurred. Serious disruption of the blood vessels and nerve damage can happen. Check the pulses and for sensation in the foot. If these are all right, splint the knee as it lies. If not, have a helper hold the lower thigh while you grip the ankle with one hand and the calf with the other. Use in-line traction while you gently flex the knee to see if you can reposition it better. If the pain is too great, you meet resistance, or you cannot do it, splint in the most comfortable position and evacuate as soon as possible back to the grid. If there is no grid return possible, then you MUST succeed with reduction technique just described.
Even without obvious deformity, an immediate complaint, or continuing complaint, about significant pain means that you now have a litter case, and you should make plans accordingly. If in 2 hours, the next morning, or 2 days later, the patient feels better and wishes to walk on the knee, great! Let it happen. You had best remove all weight from the patient’s shoulders and provide a cane to use on the side opposite the injury. This places a more natural force vector on the injured joint. Continue the compressive dressing. After 2 days begin applying heat packs during rest stops and in the evenings. The patient’s perception of pain should be the key to managing these injuries, although this approach can be complicated by varying pain thresholds, from macho to wimp.
Ankle Sprains, Dislocations, and Fractures
Generally, fractures of both sides of the ankle (a tibula-fibula fracture) are associated with a dislocation. The severe pain associated with the fracture is an early indication that this patient is a litter case. Splint the ankle with a single SAM Splint, or form a trough of Ensolite foam and tape it on. The latter is not a walking splint, but if the pain is significant enough, the patient isn’t walking anyway. A flail ankle, caused by complete disruption of the ankle ligaments, readily slops back into position and can be held in place with a trough splint of Ensolite padding.
Allow the patient to rest after the injury, before attempting to walk on the ankle. If there is severe pain, it might be broken or badly sprained. Either way, if the pain is too severe, the patient won’t be walking—at least not until it quiets down. As with the knee, if the pain diminishes enough that the victim can walk, allow him to do so without carrying equipment but using a cane for added support and decreased weight-bearing.
Stubbed toes can be buddy splinted to provide pain relief. If they have been stubbed to the extent that they deviate at crazy angles sideways, they should be repositioned before buddy taping. Place a pencil (or a similar-width object) on the side opposite the bend, and use it as a fulcrum to help snap the toe back into alignment. Blood under the toenail can be treated as described on page 146.
Severe pain in the arch of the foot or in the metatarsals can represent fractures or sprains. Apply RICE as described for Knee Sprains, Dislocations, and Fractures on page 189). Allowing a little time to lapse before use might result in decreased pain in minor injuries, but it would take weeks for a fracture to decrease in severity. Reduce the patient’s weight load and provide a cane. If the foot swells to the extent that the boot cannot be placed on the foot, consider cutting it along the sides and taping the boot circumferentially around the ankle to hold it on. This provides support for the foot, ankle, and the patient’s favorite on-grid retailer.
Broken ribs may develop after a blow to the chest. Even a severe cough or sneeze can crack ribs! Broken ribs have point tenderness or exquisite pain with the lightest touch over the fracture site. The pain at this site will be reproduced by squeezing the rib cage in such a manner as to put a stress across the fracture site. Deep breathing will also produce pain at that location.
It is not necessary to strap or band the chest, except that such a band might prevent some rib movement and make the patient more comfortable. It is very important for the patient to breathe and have some cough reflex to aid in pulmonary hygiene, namely to prevent the accumulation of fluid in the lungs, which can rapidly lead to pneumonia. For that reason, emergency departments do not discharge patients with compression rib belts. However, if I fracture a rib, I will definitely want one. Simply tying a large towel or undershirt around the victim’s chest should suffice. A fractured rib takes 6 to 8 weeks to heal. A similar pain may initially be present due to a tear of the intercostal muscles or separation of cartilage from the bone of the rib near the sternum or breastbone. These problems are treated as above. They heal much more quickly, generally in 3 to 5 weeks.
If several adjacent ribs are broken in more than one location, a section of the chest wall is literally detached and held in place by the muscles and skin. This section of the chest wall can bulge out when the patient exhales instead of contracting as the chest would normally do. It can also move in when the rest of the chest expands during inhalation. This paradoxical motion of the chest wall is called a flail chest. Treatment includes placing an adequately sized rolled cloth against the flail portion to stabilize the motion. This cloth roll will have to be bound in place.
Treat all of the above conditions with pain medication as described on page 31. Avoid unnecessary movement. Have the patient hold his hand or a soft object against his chest when coughing to prevent rib movement and decrease the pain. Allow the patient to assume the most comfortable position, which is usually sitting up. If a fever starts, treat with an antibiotic such as Levaquin, 750 mg once daily.
Broken ribs usually heal well even though considerable movement seems to occur due to breathing or even flailing of the chest. They are always so painful that patients feel like they might puncture a lung at any minute. This does not usually happen, but if it does, there is a chance that air will leak into the chest cavity, causing a pneumothorax. This can lead to significant respiratory distress, including cyanosis (blue discoloration of the skin due to inadequate oxygen in the blood). Crepitation can form in the skin. This is a crackling sensation that is very noticeable to the examiner when running the fingers over the skin in the upper part of the chest. It is not painful, but it indicates that air leakage and a pneumothorax have occurred. A pneumothorax can resolve on its own or it can expand, causing death. There is nothing you can do for this unless you are trained in its management. Similarly, bleeding into lung tissue can result in a hemothorax, which can either resolve on its own or progress to death. Cyanosis with difficult breathing may also result due to this condition.