Bones, Joints and Muscles
Accidents cause many different types of injuries to bones, joints and muscles. When
rendering first aid, you must be alert for signs of broken bones (fractures),
dislocations, sprains, strains, and bruises (contusions). Injuries to the joints and
muscles often occur together, and it is difficult to tell whether the injury is to a
joint, muscle, or tendon. It is difficult to tell joint or muscle injuries from fractures.
When in doubt, always treat the injury as a fracture.
The primary process of first aid for fractures consists of immobilizing the injured
part to prevent the ends of broken bones from moving and causing further damage to the
nerves, blood vessels, or internal organs. Splints are also used to immunize injured
joints or muscles and to prevent the enlargement of severe wounds. Before learning first
aid for injuries to the bones, joints, and muscles, you need to have a general
understanding of the use of splints.
Splints
In an emergency, almost any firm object or material will serve as a splint. Thus,
umbrellas, canes, rifles, sticks, oars, wire mesh, boards, cardboard, pillows, and folded
newspapers can be used. A fractured leg can be immobilized by securing it to the uninjured
leg. Whenever possible, use ready-made splints such as the pneumatic or traction splints.
Splints should be lightweight, padded, strong, rigid, and long enough to reach the
joint above and below the fracture. If they are not properly padded, they will not
adequately immobilize the injured part. Articles of clothing, bandages, blankets, or any
soft material may be used as padding. If the casualty is wearing heavy clothes, you may be
able to apply the splint on the outside, allowing the clothing to serve as a part of the
required padding.
Fasten splints in place with bandages, adhesive tape, clothing, or any suitable
material. One person should hold the splints in position while another person fastens
them.
Splints should be applied tight, but never tight enough to stop the circulation
of blood. When applying splints to the arms or legs, leave the fingers or toes exposed. If
the tips of the fingers or toes turn blue or cold, loosen the splints or bandages.
Injuries will probably swell, and splints or bandages that were applied correctly may
later be too tight.
Fractures
A break or rupture in a bone is called a fracture. There are two basic types;
open and closed. A closed fracture does not produce an open wound in the skin, also
known as a simple fracture (Fig. 6-lA). An open fracture produces an open wound in
the skin, also known as a compound fracture (Fig. 6-1B). Open wounds are caused by the
sharp end of broken bones pushing through the skin; or by an object such as a bullet that
enters the skin from the outside.
Open fractures are usually more serious than closed fractures. They involve extensive
tissue damage and are likely to become infected. Closed fractures can be turned into open
fractures by rough or careless handling of the casualty. Always use extreme care when
treating a suspected fracture.
Figure 6-1 - Types of Fractures
It is not easy to recognize a fracture. All fractures, whether open or closed, can
cause severe pain or shock. Fractures can cause the injured part to become deformed, or to
take an unnatural position. Compare the injured to the uninjured part if you are unsure of
a deformity. Pain, discoloration, and swelling may be at the fracture site, and there may
be instability if the bone is broken clear through. It may be difficult or impossible for
the casualty to move the injured part. If movement is possible, the casualty may feel a
grating sensation (crepitus) as the ends of the bones rub against each other. If a bone is
cracked rather than broken, the casualty may be able to move the injured part without much
difficulty. An open fracture is easy to see if the end of the bone sticks out through the
skin. If the bone does not stick out, you might see a wound but fail to see the broken
bone. It can be difficult to tell if an injury is a fracture, dislocation, sprain, or
strain. When in doubt, splint.
If you suspect a fracture, do the following:
1. Control bleeding with direct pressure, indirect pressure, or tourniquet only
as a last resort.
2. Treat for shock.
3. Monitor the airway, breathing, and circulation (ABCs).
4. Remove all jewelry from the injury site, unless the casualty objects. Gently
cut clothing away so that you don't move the injured part and cause further damage.
5. Check the distal pulse of the injured part, if pulse is absent, gently move
injured part to restore circulation.
6. Cover all wounds with sterile dressings, including open fractures. Do not
push bone ends back into the skin. Avoid excessive pressure on the wound.
7. Apply splint - Do not attempt to straighten borken bones.
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a. Apply and maintain traction until the splint has been secured.
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b. Wrap from the bottom of the splint to the top, firmly but not too tight.
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c. Check the distal pulse to ensure that circulation is still present. If the pulse is
absent, loosen the splint until circulation returns. Do not move the casualty until the
injury has been splinted.
8. Request medical assistance - All suspected fractures require professional
medical treatment.
Fracture of the Forearm
There are two long bones in the forearm, the radius and the ulna. When both are broken,
the arm usually appears to be deformed. When only one is broken, the other acts as a
splint and the arm retains a more natural appearance. Fractures usually result in pain,
tenderness, swelling, and loss of movement.
In addition to the general procedures above, apply a pneumatic (air) splint if
available; if not, apply two padded splints; one on the top (backhand side), and one on
the bottom (palm side). Make sure the splints are long enough to extend from the elbow to
the wrist.
Once the forearm is sprinted, place the forearm across the chest. The palm of the hand
should be turned in with the thumb pointing up. Support the forearm in this position (Fig.
6-2) with a wide sling and cravat bandage. The band should be raised about 4 inches above
the level of the elbow.
Figure 6-2 - Sling Used to Support a Fractured Forearm
Fracture of the Upper Arm
There is one bone in the upper arm, the humerus. If the fracture is near the elbow, the
arm is likely to be straight with no bend at the elbow. Fractures usually result in pain,
tenderness, swelling, and loss of movement. In addition to the general procedures above,
do the following:
If the fracture is in the upper part of the arm, near the shoulder, place a pad or
folded towel in the armpit, bandage the arm securely to the body, and support the forearm
in a narrow sling. If the fracture is in the middle of the upper arm, you can use one well
padded splint on the outside of the arm. The splint should extend from the shoulder to the
elbow. Secure the arm firmly to the body and support the forearm in a sling (Fig. 6-3).
If the fracture is at or near the elbow, the arm may be either bent or straight.
Regardless what position you find the arm, do not attempt to straighten or move it.
Gently splint the arm in the position in which you find it.
Figure 6-3 - Splint and Sling for a Fractured Upper Arm
Fracture of the Rib
Make the casualty as comfortable as possible so that the chances of further damage to
the lungs, heart, or chest wall is minimized.
A common finding in all casualties with fractured ribs is pain at the site of the
fracture. Ask the casualty to point to the exact area of pain to assist you in determining
the location of the fracture. Deep breathing, coughing, or movement is usually painful.
The casualty should remain still and may lean toward the injured side, with a hand over
the fracture to immobilize the chest and ease the pain.
Simple rib fractures are not bound, strapped, or taped if the casualty is comfortable.
If the casualty is more comfortable with the chest immobilized, use a sling and swathe
(Fig. 6-4). Place the arm on the injured side against the chest, with the palm flat, thumb
up, and the forearm raised to a 45-degree angle. Immobilize the chest, using wide strips
of bandage (ace wrap) to secure the arm to the chest.
Figure 6-4 - Swathe Bandage for Fractured Rib Victim
Fracture of the Thigh
There is one long bone in the upper leg between the kneecap and the pelvis, the femur.
When the femur is fractured, any attempt to move the leg results in a spasm of the muscles
that causes severe pain. The leg is not stable, and there is complete loss of control
below the fracture. The leg usually assumes an unnatural position, with the toes pointing
outward. The injured leg is shorter than the uninjured one due to the pulling of the thigh
muscles. Serious bleeding is a real danger since the broken bone may cut the large
(femoral) artery. Shock usually is severe.
Figure 6-5 - Boards Used as Emergency Splint for Fractured Thigh
In addition to the general procedures above, gently straighten the leg, apply two
padded splints, one on the outside and inside of the injured leg. The outside splint
should reach from the armpit to the foot, the inside splint from the groin to the foot.
The splint should be secured in five places: (1) around the ankle, (2) over the knee, (3)
just below the hip, (4) around the pelvis, and (5) just below the armpit (Fig. 6-5). The
legs can then be tied together to support the injured leg. Do not move the casualty
until the leg has been splinted.
Fracture of the Lower Leg
There are two long bones in the lower leg, the tibia and fibula. When both are broken,
the leg usually appears to be deformed. When only one is broken, the other acts as a
splint and the leg retains a more natural appearance. Fractures usually result in pain,
tenderness, swelling, and loss of movement. A fracture just above the ankle is often
mistaken for a sprain.
In addition to the general procedures above, gently straighten the leg, apply a
pneumatic (air) splint if available; if not, apply three padded splints, one on each side
and underneath the leg. Place extra padding (Fig. 6-6) under the knee and just above the
heel. The splint should be secured in four places: (1) just below the hip, (2) just above
the knee, (3) just below the knee, and (4) just above the ankle. Do not place the
straps over the area of the fracture.
A pillow and two side splints also work well. Place a pillow beside the injured leg,
then gently lift the leg and place it in the middle of the pillow. Bring the edges of the
pillow around to the front of the leg and pin them together. Then place one splint on each
side of the leg, over the pillow, and secure them in place with a bandage or tape.
Fracture of the Kneecap
The kneecap is also known as the patella. Although fractures of the kneecap do occur,
the more common injuries are dislocations and sprains.
In addition to the general procedures above, gently straighten the leg, apply a
pneumatic (air) splint if available; if not, apply a padded board under the injured leg.
The board should be at least 4 inches wide and should reach from the buttock to the heel.
Place extra padding under the knee and just above the heel. The splint should be secured
in four places: (1) just below the hip, (2) just above the knee, (3) just below the knee,
and (4) just above the ankle. Do not place the straps directly over the kneecap.
Figure 6-6 - Immobilization of Fractured Kneecap
Fracture of the Collarbone
The collarbone is also known as the clavicle. When standing, the injured shoulder is
lower, and the casualty is unable to raise the arm above the shoulder. The casualty
attempts to support the shoulder by holding the elbow. This is the typical stance taken by
a casualty with a broken collarbone. Since the collarbone lies near the surface of the
skin, you may be able to see the point of fracture by the deformity and tenderness.
In addition to the general procedures above, gently bend the casualty's arm and place
the forearm across the chest. The palm of the hand should be turned in, with the thumb
pointing up. Support the arm in this position (Fig. 6-7) with a wide sling. The hand
should be raised about 4 inches above the level of the elbow. A wide roller bandage (or
any wide strip of cloth) may be used to secure the casualty's arm to the body.
Figure 6-7 - Sling for Imobilizing Fractured Clavicle
Fracture of the Jaw
The lower jaw is also known as the mandible. The casualty may have difficulty
breathing, difficulty in talking, chewing, and swallowing, and have pain of movement of
the jaw. The teeth may be out of line, and the gums may bleed, and swelling may develop. The
most important consideration is to maintain an adequate open airway.
In addition to the general procedures above, apply a four-tailed bandage (Fig. 6-8), be
sure the bandage pulls the lower jaw forward. Never apply a bandage that forces the jaw
backward, since this may interfere with breathing. The bandage must be firm enough to
support and immobilize the lower jaw, but it must not press against the casualty's throat.
The casualty should have scissors or a knife to cut the bandage in case of vomiting.
Figure 6-8 - Four Tailed Bandage for a Fractured Jaw
Fracture of the Skull
The skull is also known as the cranium. The primary danger is that the brain may be
damaged. Whether or not the skull is fractured is of secondary importance. The first aid
procedures are the same in either case, and the primary intent is to prevent further
damage. Some injuries that fracture the skull do not cause brain damage. But brain damage
can result from minor injuries that do not cause damage to the skull.
It is difficult to determine whether an injury has affected the brain, because symptoms
of brain damage vary. A casualty who has suffered a head injury must be handled carefully
and given immediate medical attention.
Signs and symptoms that may indicate brain damage include:
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1. Wounds of the scalp, deformity of the skull.
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2. Dizziness, weakness, conscious or unconscious.
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3. Pain, tenderness, or swelling.
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4. Severe headache, nausea and vomiting.
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5. Restlessness, confusion, and disorientation.
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6. Paralysis of the arms, legs, or face.
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7. Unequal pupils, abnormal reaction to light.
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8. Blood or clear fluid from the ears, nose, or mouth.
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9. Pale, flushed skin.
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10. Bruising behind the ear (Batlle's Sign).
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11. Bruising under or around the eyes in the absence of trauma to the eyes (Raccoon's
Sign).
If you suspect a head injury, do the following:
1. Position the casualty flat, stabilize the head and neck as you found them by
placing your hands on both sides of the head.
2. Establish and maintain an open airway - jaw-thrust maneuver. Note that the
head is not tilted and the neck is not extended. Check the airway, breathing, and
circulation (ABCs).
3. Finger sweep to remove any foreign bodies from the mouth.
4. Maintain neutral position of head and neck and, if possible, apply a cervical
collar or improvised (towel) collar.
5. Apply dressing - Do not use direct pressure or tie knots over the wound.
Apply ice or cold packs if available. (For blood or clear fluid from the nose or ears,
cover loosely with a sterile dressing to absorb but not stop the flow).
6. Treat for shock - Casualties with suspected head and neck injuries are to
remain flat. Do not raise the casualty's feet. If they are vomiting or bleeding
around the mouth, place them on their side keeping the neck straight. Do not give
anything to eat or drink.
7.Request medical assistance immediately - Time is critical. Head and neck
injuries should be treated by professional medical personnel, if possible. Do not attempt
procedures that you are not trained to do.
Fracture of the Spine
The spine is also known as the backbone or spinal column. If the spine is fractured,
the spinal cord may be crushed, cut, or damaged so severely that death or paralysis may
occur. If the fracture occurs in a way that the spinal cord is not damaged, there is a
chance of complete recovery. Twisting or bending of the neck or back, whether due to the
original injury or careless handling, is likely to cause irreparable damage. The primary
symptoms of a fractured spine are pain, shock, and paralysis. Pain may be acute at the
point of fracture and radiate to other parts of the body. Shock is usually severe, but the
symptoms may be delayed. Paralysis occurs if the spinal cord is damaged. If the casualty
cannot move the legs, the injury is probably in the back; if the arms and legs cannot
move, the injury is probably in the neck. A casualty who has back or neck pain
following an injury should be treated for a fractured spine.
If you suspect a fractured spine, do the following:
1. Position the casualty flat, stabilize the head and neck as you found them by
placing your hands on both sides of the head.
2. Establish and maintain an open airway - jaw-thrust maneuver. Note that the
head is not tilted and the neck is not extended. Check the airway, breathing, and
circulation (ABCs).
3. Finger sweep to remove any foreign bodies from the mouth.
4. Maintain neutral position of head and neck and, if possible, apply a cervical
collar or improvised (towel) collar.
5. Keep the casualty comfortable and warm enough to maintain normal body temperature.
6. Treat for shock - Casualties with suspected spinal injuries are to remain
flat. Do not raise the casualty's feet. If the casualty is vomiting or bleeding
around the mouth, place them on their side keeping the neck straight. Do not give
anything to eat or drink.
7. Request medical assistance immediately - Time is critical. Do not move the
casualty unless it is absolutely necessary. Do not bend or twist the casualty's body. Do
not move the head forward, backward, or sideways. Do not allow the casualty to sit up.
Fracture of the Pelvis
Fractures often result from falls, heavy blows, and crushing accidents. The greatest
danger is damage to the organs that are enclosed by the pelvis. There is danger that the
bladder will be ruptured or that severe internal bleeding may occur, due to the large
blood vessels being torn by broken bone. The primary symptoms are severe pain, shock, and
loss of the ability to use the lower part of the body. The casualty is unable to sit or
stand and may feel like the body is "coming apart."
Treat for shock, but do not raise the casualty's feet. Do not move the casualty
unless absolutely necessary. Request medical assistance immediately.
Dislocations
A dislocation occurs when a bone is forcibly displaced from its joint. Many
times the bone slips back into its normal position; other times, it becomes locked and
remains dislocated until it is put back into place (reduction). Dislocations are caused by
falls or blows and occasionally by violent muscular exertion. The joints that are most
frequently dislocated are the shoulder, hip, finger, and jaw.
A dislocation may bruise or tear muscles, ligaments, blood vessels, and tendons. The
primary symptoms are rapid swelling, discoloration, loss of movement, pain, and shock. You
should not attempt to reduce a dislocation. Unskilled attempts at reduction may cause
damage to the nerves and blood vessels or may fracture a bone. You should leave this
treatment to professional medical personnel and concentrate your efforts on making the
casualty comfortable.
If you suspect a dislocation, do the following:
1. Loosen clothing from around the injury.
2. Place the casualty in the most comfortable position.
3. Support the injured part with a sling, pillow, or splint.
4. Treat for shock.
5. Request medical assistance as soon as possible.
Sprains
A sprain is an injury to the ligaments that support a joint. It usually involves
a sudden dislocation, with the bone slipping back into place on its own. Sprains are
caused by the violent pulling or twisting of the joint beyond its normal limits of
movement. The joints that are most frequently sprained are the ankle, wrist, knee, and
finger. Tearing of the ligaments is the most serious aspect of a sprain, and there is a
considerable amount of damage to the blood vessels. When the blood vessels are damaged,
blood may escape into the joint, causing pain and swelling.
If you suspect a sprain, do the following:
1. Splint to support the joint and put the ligaments at rest. Gently loosen the
splint if it becomes so tight that it interferes with circulation.
2. Elevate & rest the joint to help reduce the pain and swelling.
3. Apply ice or cold packs, with cloth to prevent damage to the skin, the first
24 hours, then apply warm compresses to increase circulation.
4. Request medical assistance as soon as possible.
Treat all sprains as fractures until ruled out by x-rays.
Strains
A strain is caused by the forcible over-stretching or tearing of a muscle or
tendon. They are caused by lifting heavy loads, sudden or violent movements, or by any
action that pulls the muscles beyond their normal limits. The primary symptoms are pain,
lameness, stiffness, swelling, and discoloration.
If you suspect a strain, do the following:
1. Elevate & rest the injured area to help reduce the pain and swelling.
2. Apply ice or cold packs, with cloth to prevent damage to the skin, the first
24 hours, then apply warm compresses to increase circulation.
3. Request medical assistance as soon as possible.
Treat all strains as fractures until ruled out by x-rays.
Contusions
A contusion (bruise) is an injury that causes bleeding into or beneath the skin,
but it does not break the skin. The primary symptoms are pain, tenderness, swelling, and
discoloration. At first, the injured area is red due to local irritation; as time passes
the characteristic "black and blue" (ecchymosis) mark appears. Several days
after the injury, the skin becomes yellow or green in color. Usually, minor contusions do
not require treatment.
If you suspect a contusion, do the following:
1. Elevate & rest the injured area to help reduce the pain and swelling.
2. Apply ice or cold packs, with cloth to prevent damage to the skin, the first
24 hours, then apply warm compresses to increase circulation.
3. Request medical assistance as soon as possible.
References
1. NAVEDTRA 10669-C, Hospital Corpsman 3 & 2
Department of the Navy
Bureau of Medicine and Surgery
2300 E Street, NW
Washington, DC 20372-5300
Approved for public release; Distribution is unlimited.
The listing of any non-Federal product in this CD is not an
endorsement of the product itself, but simply an acknowledgement of the source.
Operational Medicine 2001
Health Care in Military Settings
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