How to Recognize and Treat Musculoskeletal Injuries

Learn to treat common wilderness injuries, and the difference between treatment protocol: RICE, HIRICE, POLICE, MEAT, PEACE & LOVE

You’re hiking down a steep gravel trail and slip, hear a “pop!” and your ankle start to swell up.   Or you’re mountain biking and hit a big root and go over the handlebars, and when you sit up your collarbone hurts and is deformed.  Or you catch an edge on your snowboard, put your arms out to break your fall, and break your wrist instead.  Or a wave catches you off guard while kayaking, you throw a high brace while leaning back and pop your shoulder out of socket. Ouch!  What do you do next?

Broken bones, sprains, strains, and dislocations are super common injuries in wilderness activities.  You can probably imagine a dozen more likely scenarios than the four listed above.  Unfortunately, chances are that if you work or play outside you will eventually have to treat a musculoskeletal injury in the field.

What are common musculoskeletal injuries?

After an accident in a remote place without access to an x-ray machine or CT scanner, it can be really difficult to tell exactly what type of injury the patient has suffered.  Let’s start by understanding the most likely problems.  There are four common types of musculoskeletal injuries:

• Fractures: A fracture is a break in a bone, caused by application of force.  They range from simple hairline fractures to deformed or angulated injuries where the bone ends are significantly displaced.  You may also see “open” or “compound” fractures where sharp bones ends have broken through the skin.   
• Sprains: Ligaments are the tough, fibrous tissues that connect bones to other bones.  A sprain is when those ligaments are stretched or torn.
• Strains: Strains refer to injuries to muscles or the tendons that connect muscles to bone.
• Dislocations: When the end of a bone moves out of its appropriate socket or junction, that’s a dislocation.

Assessing Musculoskeletal Injuries

When someone suffers a musculoskeletal injury, start with a thorough patient assessment to ensure that you find and treat all the problems in order of importance, starting with any life threats.  Even a simple twisted ankle might have resulted from a more serious underlying medical condition like dehydration or altitude sickness.  Once you’ve completed your primary and secondary assessment, take a closer look at the specific problems you’ve uncovered.  

Depending on the injury, there is a wide scope of techniques available to assess the specific injury.  In wilderness and remote medicine, though, we’re not that concerned with determining exactly what type of injury the patient has.  Three things that are very important to determine, though, are:

1. Are there any imminent life threats?  Broken bone ends are sharp and can lacerate arteries or veins, causing significant internal or external bleeding.  Identify and treat any life threats before focusing on the lower priority musculoskeletal injuries.
2. Is there a chance that they will lose the limb or suffer long-term disability due to the injury?  If so, start the rescue process early to prioritize rapid evacuation to a hospital.  If circulation, sensation, or motion (CSM) is diminished or absent and you face long evacuation times, you may need to try to restore those functions as a part of treatment.
3. Finally, can they use it?  Carrying someone out of the wilderness, even with a capable team and a wheeled litter, is a time consuming and difficult proposition.  I’ve seen patients with broken fibulas walk out with assistance, and folks with torn ACLs ski to the trailhead.  I’ve also carried out patients with a really bad sprain. I’m much more concerned with determining if the patient can use the injured extremity to support their own evacuation than classifying it as a break, sprain, or strain.

Common Signs and Symptoms of Musculoskeletal Injuries

Musculoskeletal injuries can present with a wide range of signs and symptoms.  These may include:

• Pain and/or tenderness
• Swelling 
• Bruising
• Stiffness
• Decreased range or motion
• Weakness or inability to bear weight
• Deformity or angulation
• Visible bone ends
• Crepitus, the sound and feeling of broken bone ends grinding.
• Numbness, tingling, pricking, or burning sensations, also known as “paresthesia”
• Lack of blood flow distal to the injury (away from the body) as seen by lack of a pulse or cold, pale skin

How to Treat Musculoskeletal Injuries

As a wilderness medicine provider, your goals in treating any musculoskeletal injury are to minimize suffering, prevent further injury, and promote healing while getting the patient to definitive care for the injury.  This means stabilizing the injured body part, managing pain, and providing for evacuation.   Here are some next steps for treating musculoskeletal injuries:

• Assess: Always start with a complete patient assessment including a primary survey for life threats, as well as vital signs, a SAMPLE history, and focused head-to-toe physical exam.  Once you’ve treated any life threats and finished your assessment, you can treat the non-life-threatening injuries.  
• Consider Traction: If the patient has diminished CSM in a deformed extremity, you many need to gently pull traction to restore the limb to a more natural anatomical position.  This is called “traction in line” (TIL) or “traction into position” (TIP).  You should only consider this technique to restore circulation when transport time to definitive care is long, as there is a risk of causing more damage.  You may also choose to use traction to help reduce a dislocation, or return it to a normal anatomical position.  This is also a technique you should only attempt in wilderness, on certain injuries. We’ll discuss reduction of dislocations in another article.
• Stabilize: Stabilizing the limb in an appropriate splint will help with pain and minimize further damage.  Splints should be well padded, adjustable, rigid, and allow monitoring of the injured extremity.  We’ll talk more about specifics of splinting including techniques for improvised splints in another post.
• Manage Pain: Good splinting is one of the most powerful tools we have as wilderness medicine providers for managing pain.  You may also consider over the counter pain medication like ibuprofen or acetaminophen.  Ibuprofen will also help reduce swelling, although there is debate as to whether or not that should be our goal.  (More on that later.)  Avoid aspirin in the case of severe bleeding or possible internal bleeding, as it can reduce the blood’s ability to clot.
• Monitor: Keep an eye on the injured area to make sure it doesn’t worsen.  Also, track patient vitals over time to ensure that you are aware of any major changes.
• Evacuate:  Get the patient to definitive care.  This may mean walking to the trailhead and driving to an urgent care, calling 911 or using a satellite messaging device to request a search and rescue (SAR) team for a litter carry-out then taking an ambulance to the hospital, or even transport via helicopter from rugged and remote locations.

Long term care for musculoskeletal injuries: RICE or MEAT...or HIRICE, or POLICE, or PEACE & LOVE???

Not all musculoskeletal injuries require evacuation, and on long wilderness expeditions or after a natural disaster when resources are scarce or evacuation is extremely lengthy, it may be necessary to treat an injury for hours or days in the field.  Knowing how to provide long term care for these injures can be invaluable.

For decades, we’ve relied on the helpful RICE or HIRICE acronym to remember treatment guidelines for musculoskeletal injuries.  However, research does not substantiate the use of RICE or HIRICE for long term recovery.  Specifically, anti-inflammatories like ibuprofen as well as the use of ice and rest may help with pain but long term have been shown to slow the healing process.  To address these problems, medical providers have turned to alternative protocols like POLICE, MEAT, or even PEACE & LOVE for the management of musculoskeletal injuries.  

At Backcountry Medical Training, we recognize the efficacy of RICE as a first aid treatment for injuries, particularly for the first 48 hours.  However, there are compelling reasons to shift away from anti-inflammatories and rest based care towards a more active, load based rehabilitation program.  Follow the links to learn more:

HIRICE

• Hydration
• Ibuprofen
• Rest
• Ice
• Compression
• Elevation

POLICE

• Protect
• Optimal Loading
• Ice
• Compression 
• Elevation

MEAT

• Movement
• Analgesics (pain medicine)
• Exercise 
• Treatment, such as physical therapy

PEACE & LOVE

Initial Phase:

• Protect
• Elevate
• Avoid anti-inflammatories
• Compress
• Educate

For rehabilitation:

• Load
• Optimism
• Vascularization 
• Exercise

Learning More

Congratulations!  Now you understand the basics of assessing and treating musculoskeletal injuries in the wilderness.  We’ll address the intricacies of reduction of dislocations and splinting in separate articles.  Wilderness medicine is an ever-changing field, and as you see, even long-standing principles are subject to ongoing reassessment to ensure the best possible patient care in remote places.  To learn more or stay up-to-date, I highly recommend taking our two-day Wilderness First Aid course, Wilderness First Responder Recertification, or a complete  Wilderness First Responder certification course.  I hope to see you in class soon.  Stay safe out there!