For February, we’re focusing on the body parts that shape us, oxygenate us, and power us as we take long walks on the beach. Bony bonafide bones. These skeletal building blocks inspire curiosity and spark fear in different folks—we hope our stories, covering everything from surgeries and supplements to good old-fashioned boning, will only do the first. Once you’ve thoroughly blasted your mind with bone facts, check out our previous themed months: muscle and fat.
Picture this: While descending a precarious slope, you lose your balance, land awkwardly on a rock, and your foot wrenches sideways. Immediately, you hear a distinct cracking sound—one you’ll probably never be able to forget—and you fall to the ground in pain. What moments ago was a pleasant weekend hike has officially become a lot less enjoyable: you’re in the wilderness with a broken bone.
While an injury like this means the end to an excursion, it’s rarely a life-and-death situation. In fact, with the right training, the appropriate tools, and a level head, you can make it back to civilization in one piece and with a hell of a story to tell.
Stay calm and assess the situation
The most common musculoskeletal injury in the outdoors is a sprained ankle, but fractured or broken bones are also a concern, especially ankles, wrists, and ribs. If this happens to you or a fellow hiker in the backcountry, stay calm and evaluate the situation. It is the job of whoever’s not injured to take control and decide the best course of action to keep everyone safe.
“Try not to make more patients,” says Dr. Martin Musi, fellowship director of wilderness medicine at the University of Colorado and director of the Diploma in Mountain Medicine of the Andes.
But before being able to assess the situation, you’ll need to get closer—and in the wild, that’s often easier said than done. First, you’ll need to make sure it’s safe for you to approach the injured person. If they’ve tumbled down a slippery slope or wrenched an ankle in a boulder field, for example, make certain you won’t succumb to the same fate by leaping after them. Anchor yourself to a sturdy tree with a rope before navigating a steep decline, or crawl slowly on your hands and knees if there’s a chance you could trip and fall as well.
Once it’s safe, approach the person with caution and check their vitals—make sure they can breathe and that they’re lucid and aware. Next, look for blood—if there is any, protect yourself and the patient by using gloves. You should always have a pair in your first aid kit, but if you don’t, you can improvise them with plastic bags. Try to control the bleeding by applying pressure with a clean piece of fabric or cloth. Once you’ve determined the person is stable, move them to a more secure location if necessary.
Finally, take stock of the severity of the injury—which is not always easy, according to Shana Tarter, EMT and assistant director of NOLS Wilderness Medicine. What you may think is a fracture may be a sprain, strain, or a dislocation, or vice versa. Unless there’s obvious angulation (when you see a limb bent in a way it shouldn’t be) or an open fracture (a broken bone protruding through the skin) you often can’t be sure if it’s a simple fracture or something else.
But when it comes to treating any musculoskeletal injury, it often doesn’t matter what you call it—keeping the person safe and stable is the priority. Take your time, keep everybody calm, and proceed to treatment.
Attend to the injury
Next, make sure the person doesn’t have additional injuries. If they do, always tend to the most serious or life-threatening first. If you’re dealing with a single musculoskeletal injury, start by performing a complete assessment of the wounded area—this involves checking circulation, sensation, and motion.
To get a good look, remove anything that might impede circulation—this includes rings, bracelets, accessories, and boots. Keep in mind that even if they aren’t causing problems now, they eventually might. When removing shoes or boots, do so carefully by loosening them up as much as you can.
First, check for a pulse below the injured area to make sure blood is flowing correctly. If the arm is hurt, for example, try the the wrist; or if the ankle is the issue, try the foot. If you find a pulse, that means circulation is good. If you see any bruising, swelling, visible bones protruding from the skin, or any unnatural colors in the injured extremity, this could be a sign of a circulation issue. These may cause complications like tissue and nerve damage if the person doesn’t get medical care in a timely manner.
Then, check for sensation above and below the injury by tapping or lightly scratching the person’s skin. If there’s a pulse and no numbness or tingling, it means nerves are likely intact. If not, and you don’t possess the proper wilderness medicine training, a speedy evacuation becomes the top priority before nerve or tissue damage sets in.
Lastly, find out if the person can move or put any weight on the injured area. There will likely be pain, but if they can move it, it means they may be able to help get themselves back to the trailhead.
If there’s visible angulation, and you’ve been trained in wilderness first aid, Tarter recommends attempting to put the extremity back in its normal anatomical alignment. Doing so will most likely improve circulation, sensation, and motion. If that is the case, you can make your way to civilization safely and calmly. But if you can’t be certain the bone is broken, you lack training, or straightening the limb doesn’t improve circulation and sensation, emergency evacuation becomes the absolute priority. Leave this procedure to the trained professionals.
Immobilize, manage pain, and make an exit
If the injured extremity is usable, you may be able to stick to managing symptoms, like pain, and helping the person hike back to the trailhead. Treat symptoms by administering painkillers like ibuprofen. If you’re hiking in the winter or at high altitudes, you can also use snow or ice in a bag or bandana to alleviate pain and swelling. Immersing a limb in a cold creek will also work, but only for brief periods of time so the person doesn’t end up with frostbite.
But if it’s not usable, you’ll need to make a splint so the patient doesn’t hurt themselves worse. Some first-aid kits include a packable splint, but a little improvisation can work, too. Use sticks, trekking poles, even the suspension system from your backpack (if it has one), to create a rigid structure around the injured limb. Thoroughly pad the space between the skin and the splint with clothing or gauze, then use elastic bandages, strips of clothing, or paracord to hold the splint snugly in place.
Immobilize the joint above and below the injury, but make sure to fix it in a natural position. If the forearm is the issue, make sure the wrist and elbow are both immobilized but that the elbow is bent and the hand rests in a curved position.
It’s important to ensure the splint is sturdy and durable in case of inclement weather, but don’t use tape unless absolutely necessary—if the splint becomes too tight or uncomfortable, having it secured with tape won’t allow you to easily adjust it. After splinting, check for a pulse below the injury once more to ensure you haven’t worsened the situation by cutting off blood flow before you make your way back.
Open fracture: a hiker’s true nightmare
The type of broken bone people often fear most is an open fracture—and for good reason. Fortunately, these kinds of fractures, especially those that involve dangerous amounts of blood loss, are fairly uncommon in the backcountry. In fact, the biggest risk with an open fracture is the risk of infection.
To prevent that from happening, use an irrigation syringe—the kind found in most comprehensive first aid kits—to squirt clean, drinkable water on the end of the exposed bone, rinsing it clean. If you don’t have an irrigation syringe on hand, improvise by pouring or squirting water from a water bottle. Then, only if you have the training, attempt to straighten the broken bone and get it back into the skin before you create a splint.
If you don’t have any first aid training in this area, cover the exposed bone end with a moist piece of gauze so it doesn’t dry out, wrap the area with a bandage, splint the limb, and evacuate. You will want to get the person to a hospital as quickly as possible.
After you’ve assessed the injury, made a splint, and treated some of the patient’s symptoms, it’s time to figure out how to get help. If the affected limb is even remotely unusable, that means leaving the backcountry is the next step.
If you have an emergency beacon or satellite phone, use it to call for help. If Search and Rescue (SAR) is available, give them your location; if not, call to inform authorities that you’re hiking out and need help. If the trailhead isn’t far and the person can walk, even slowly, help them hike out, keeping a close eye on them and regularly checking for circulation issues.
As Tarter points out, self-evacuation, if at all possible, is often the safest option, as it doesn’t put rescuers or fellow hikers at risk. Besides, Musi says, SAR may not be available in all locations and circumstances, so attempting to be self-reliant is often the best course of action.
If the person can’t walk, they must remain in place while you or someone who’s able goes out looking for help. Make sure they are comfortable, in a safe place, and have plenty of food, water, and shelter. And before your hike out to get help, make sure you know their location as accurately as possible—you will need to describe their position and surroundings to rescuers, and every detail counts.
If you’re the injured party and hiking alone, use tools like a whistle, mirror (to reflect light as an emergency beacon), or even a small fire to signal that you need help.
Before you attempt to straighten or treat a bone you think may be broken, make sure you get the proper training. In fact, according to Musi, anyone who often treks out into the backcountry should have some level of first aid training.
If you spend any amount of time in wilderness situations, sign up for a backcountry first-aid training course from an organization like NOLS or at an education center near you. That way, if you find yourself in a situation where you or a companion must deal with a broken limb far from medical care, you’ll know how to treat it and make it out of the woods in one piece.