Identify fractures versus sprains, apply the RICE method, improvise field splints, manage suspected spinal injuries, and know when dislocation reduction is appropriate.
Musculoskeletal injuries — fractures, dislocations, and sprains — are among the most common injuries in disasters, accidents, and emergencies. An earthquake survivor may have multiple limb fractures. A fall during an evacuation can produce a broken ankle. A sporting accident far from medical care can result in a dislocated shoulder. In most cases, you will not have an X-ray to confirm the diagnosis. You will be making decisions based on mechanism, appearance, pain, and movement — and your job is to reduce further harm, manage pain, and get the casualty to definitive care.
This guide covers how to distinguish these injuries, the RICE method, field splinting techniques, spinal injury management, and the narrow circumstances in which dislocation reduction might be considered outside a hospital setting.
A fracture is a break in the continuity of a bone — from a hairline crack to a complete break. Fractures range from stable (the bone has not moved out of alignment) to unstable (the fragments are displaced and may move further).
Signs of a fracture:
A dislocation is displacement of a joint — the bone end moves out of its normal articulation. Common dislocations include shoulder, finger, patella (kneecap), hip, and elbow.
Signs of a dislocation:
⚠️ Fractures and dislocations often coexist — a dislocated joint may also have fractures in the surrounding bone (fracture-dislocation). Do not assume one rules out the other.
A sprain is injury to ligaments — the connective tissue that holds joints together. They range from Grade 1 (minor stretch) to Grade 3 (complete rupture).
Signs of a sprain:
Distinguishing fracture from severe sprain in the field: It can be extremely difficult without imaging. The key question is whether there is point tenderness directly over a bone. The Ottawa rules (used clinically) assess specific bony landmarks around the ankle and foot — if tenderness is present at certain bony points, a fracture must be assumed until X-ray proves otherwise.
In a field setting, if you cannot confidently differentiate: treat as a fracture.
RICE (or the newer PRICE/POLICE frameworks) is the standard initial management for soft tissue injuries and stable fractures:
| Letter | Action | Detail |
|---|---|---|
| R | Rest | Protect from further injury; no weight bearing |
| I | Ice | 15–20 minutes every 2 hours for the first 48–72 hours |
| C | Compression | Elastic bandage to reduce swelling — not so tight as to restrict circulation |
| E | Elevation | Raise the limb above heart level to reduce swelling |
Ice application: Never apply ice directly to skin — wrap in a cloth. Frozen peas in a bag work as an improvised ice pack. Stop if the area becomes numb or if skin begins to look white.
Compression: Check fingers or toes below the bandage regularly for colour, warmth, and ability to feel sensation. A bandage that is too tight is a circulation hazard.
A splint immobilises a fracture to prevent further bone movement, reduce pain, and protect adjacent soft tissue, blood vessels, and nerves from sharp bone ends.
In a field setting without commercial splints:
Upper arm fracture (humerus): A sling and swathe — arm in a sling against the chest, with an outer bandage (swathe) binding the arm to the chest wall — immobilises effectively without a rigid splint.
Forearm and wrist: Rigid splint along the forearm from mid-upper arm to the palm; pad the wrist; secure at multiple points; add a sling.
Femur (thigh): A femur fracture is a medical emergency — significant blood loss can occur internally. A traction splint (stretching the leg to reduce muscle spasm and blood loss) requires a proper device (Kendrick traction, SAGER). Improvised traction is high-risk. Immobilise with the casualty lying flat, splint both legs together with padding between them, and arrange urgent evacuation.
Ankle and foot: A blanket or jacket fold under the foot and around the ankle secured with bandages (a pillow splint) provides effective immobilisation for transport.
When bone is visible through the skin or the wound overlies the fracture site:
Suspect spinal injury when:
If you suspect a spinal injury and the casualty is breathing and not in immediate danger:
If an unresponsive casualty with suspected spinal injury is not breathing or is in immediate danger (fire, rising water), you must act:
⚠️ The risk of spinal cord injury from careful movement is much lower than the risk of death from airway obstruction. If a spinal injury victim is not breathing, prioritise airway and CPR.
Reduction (putting the joint back in place) should ideally be performed in a hospital setting where imaging can confirm no associated fracture and anaesthesia can manage pain and muscle spasm. However, in scenarios where definitive care is many hours or days away, reduction may need to be considered.
The safest dislocations to reduce in the field:
Do not attempt reduction if:
| Injury | Field Action |
|---|---|
| Suspected fracture | RICE; splint in position found; splint above and below fracture |
| Open fracture | Sterile dressing; immobilise gently; urgent evacuation |
| Femur fracture | Immobilise flat; splint legs together; urgent evacuation |
| Spinal injury suspected | Do not move; call emergency services; inline stabilisation |
| Spinal + no breathing | Airway and CPR take priority; minimise but do not avoid movement |
| Severe sprain | RICE; reassess — if doubt, treat as fracture |
| Shoulder dislocation | Immobilise in position; evacuation preferred over field reduction |
| Check after splinting | Capillary refill; sensation; movement of distal digits |
This guide provides general first aid information for musculoskeletal injuries. It does not replace clinical assessment, imaging, or definitive medical care. All suspected fractures and dislocations should receive medical evaluation as soon as possible. Dislocation reduction should be performed by trained medical personnel whenever accessible.
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