Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

94

Wilderness and Rescue Medicine

When the recommended amount of traction is applied with a traction splint, the pressure at the anchor points will inevitably cause skin and soft tissue ischemia. For these reasons, the use of a traction splint is not appropriate for backcountry rescue or long-term care. In this setting, femur fractures are best stabilized in a well-padded litter Shock and distal ischemia are anticipated prob- lems due to the proximity of the iliac arteries and veins. The assessment is made by feeling pelvic instability as motion or crepitus on gentle exam, or by noting obvious deformity. There is the potential for catastrophic internal bleeding, so the patient should be handled gently, and the exam should not be repeated. Pelvic binding with a padded strap or wide com- pression bandage may be useful to help stabilize a pelvic fracture and reduce the space available for internal blood loss. This can be accomplished by wrapping a tarp or backpack hip belt around the pelvis and tightening gently to restore anatomy. The patient is then further stabilized by a litter, vacuum mattress, or well-padded backboard. Emergent evacuation is indicated. or vacuum mattress. Pelvic Fracture

right up to about age 70. If your work or play involves falls at speed you will probably experi- ence or see one eventually. As with other bones, it is not the fracture itself that presents much of a problem. We worry more about the possibility of associated respiratory sys- tem injury, significant pain, and incapacitation in a high-risk environment. It is very rare for the lung to be injured by a frag- ment of clavicle. It is more likely, but still rare, that the same mechanism that fractured the clavicle also caused fractured ribs and possible lung injury. Your primary survey should focus on the respira- tory system, not the clavicle or the pain. Most clavicle fractures are uncomplicated. They hurt, sometimes a lot, and the patient may feel the bone ends grinding together with movement of the arm or torso. Use a sling if it reduces pain.

Tenting or trapping of the skin by clavicle fragments can cause problems with ischemia. Prolonged deformity can result in skin breakdown if not corrected. In rare cases, a clavicle fracture will be compli- cated by tenting or trapping of the skin by frac- ture fragments causing skin ischemia. While this is not a critical system problem, it will result in infarction and skin breakdown if not corrected. Usually the problem can be relieved by the patient changing position, moving the arm, or the res- cuer pressing the fragments into better position. If the ischemia cannot be relieved, early surgical intervention is ideal. In the absence of a serious respiratory or circulatory problem, there is no emergency and the patient remains ambulatory and otherwise functional.

Effective pelvic binding can be accomplished by wrapping a tarp, sheet, tent fly or backpack hip belt around the pelvis and tightening gently to restore anatomy and reduce pain and instability. Clavicle Fracture We mention this here because the clavicle is the most frequently fractured bone in childhood,