Fractures, Dislocations & Sprains

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.

Distinguishing Between Fractures, Dislocations, and Sprains

Fractures

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:

• Pain, especially on movement or pressure over the bone
• Swelling and bruising developing over the site
• Visible deformity — the limb looks abnormal in shape or angle
• Loss of function — the casualty cannot bear weight or use the limb normally
• Bone ends visible through the skin (open/compound fracture — serious contamination risk)
• Tenderness on pressing directly over the bone (point tenderness)
• Crepitus — a grating sensation if fractured ends move (do not deliberately produce this)

Dislocations

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:

• Visible deformity of the joint — shoulder will look "squared off"; finger will look angled wrong
• Loss of normal movement — the joint will not move in its usual range
• Significant pain, especially with any movement attempt
• Muscle spasm around the joint
• Numbness or tingling if nearby nerves are affected

⚠️ 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.

Sprains

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:

• Pain and tenderness around the joint rather than along a bone
• Swelling developing quickly (particularly Grade 2–3)
• Bruising appearing over hours to days
• The joint may feel unstable (Grade 3)
• Reduced range of movement but often some movement retained

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.

The RICE Method

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.

Splinting Fractures

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.

General Splinting Principles

1. Splint the joint above and below the fracture — a femur (thigh) fracture needs the hip and the knee immobilised; an ankle fracture needs the lower leg and foot
2. Splint in the position of comfort — do not force a limb into a different position; splint it as you find it (unless circulation is compromised — see below)
3. Check neurovascular status before and after splinting: capillary refill (press the fingertip until white, release — should refill pink within 2 seconds), sensation, movement of fingers or toes
4. Pad the splint at bony prominences to prevent pressure sores during transport
5. Secure with bandages or strips of cloth at multiple points above and below the fracture site — not directly over it

Improvised Splints

In a field setting without commercial splints:

• Rigid materials: Straight branches, boards, trekking poles, cardboard folded multiple times, rolled magazines, umbrellas
• Soft padding: Clothing, foam sleeping mat pieces, folded clothing between the rigid material and the skin
• Securing materials: Belts, strips of clothing, paracord, bandages

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.

Open (Compound) Fractures

When bone is visible through the skin or the wound overlies the fracture site:

1. Cover the wound with a clean dressing before splinting
2. Do not push bone back in or probe the wound
3. This injury has a high infection risk — requires antibiotic treatment and urgent surgical management
4. Handle with extreme care to avoid further contamination

Suspected Spinal Injury

Suspect spinal injury when:

• Mechanism: high-energy (road traffic collision, fall from height, diving injury, impact sports, explosion)
• The casualty complains of neck or back pain
• Tingling, numbness, or weakness in arms or legs
• The casualty is unconscious and mechanism is unknown

When Not to Move

If you suspect a spinal injury and the casualty is breathing and not in immediate danger:

• Do not move them — keep them exactly as found
• Call emergency services and wait for immobilisation equipment (cervical collar, spinal board)
• Keep the casualty calm and still; support the head in the position it is found

When You Must Move

If an unresponsive casualty with suspected spinal injury is not breathing or is in immediate danger (fire, rising water), you must act:

• Maintain inline cervical stabilisation — one person holds the head with both hands, keeping it aligned with the body
• Move as a unit — "log roll" with multiple rescuers if possible (one person per body segment: head, torso, pelvis, legs)
• Even imperfect movement of an unconscious non-breathing person is far better than not performing CPR

⚠️ 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.

Dislocation Reduction

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:

• Finger dislocations (PIP joint): With gentle traction along the axis of the finger while stabilising the hand, many PIP dislocations reduce simply. Apply traction, very gently flex the finger, and the joint usually reduces with a noticeable click.
• Shoulder dislocation: Various techniques exist (Cunningham technique — muscle relaxation without traction; Stimson — gravity traction lying prone). These require the patient to be able to relax their musculature. Without adequate pain control, attempts may be unsuccessful and risk fracture.

Do not attempt reduction if:

• There is any suggestion of a fracture-dislocation
• You lack confidence in the technique
• Medical care is available within a reasonable timeframe
• Neurovascular compromise is not present (if pulses and sensation are intact, waiting is safer than attempting reduction)

Quick Reference

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.