FRACTURES & DISLOCATIONS IN THE BACKCOUNTRY
Fractures & Dislocations in the Backcountry
Splinting, Immobilization & When to Evacuate: The skills you need for the most common wilderness emergency.
The Most Common Wilderness Emergency
When people think about wilderness emergencies, they imagine bear attacks, lightning strikes, or falling off cliffs. The reality is far more mundane—and far more common.
Figure 1: Musculoskeletal injuries dominate wilderness emergencies. Sources: NIH, NOLS, Wilderness Medical Society
According to research from the National Institutes of Health and the National Outdoor Leadership School (NOLS), 80% of wilderness accidents are musculoskeletal injuries—fractures, dislocations, sprains, and strains. The most common? Ankle fractures from simple trail falls.
This isn't dramatic. It doesn't make the news. But it's the injury you're most likely to face in the backcountry. And how you respond in the first hour can mean the difference between a painful walk out and a helicopter evacuation.
Fracture vs. Dislocation vs. Sprain: Know the Difference
Before you can treat an injury, you need to understand what you're dealing with. Here's how to tell them apart in the field. Remember, I am an Orthopedic Surgeon and this is what I deal with all day every day. It is very important to understand the differences here:
| Type | What It Is | Signs & Symptoms | Severity |
|---|---|---|---|
| Sprain | Ligament stretched or torn | Swelling, bruising, pain with movement, can bear some weight | Mild to Moderate |
| Dislocation | Bone forced out of joint | Visible deformity, intense pain, joint "locked" in wrong position | Serious |
| Fracture (Closed) | Bone broken, skin intact | Deformity, swelling, inability to bear weight, point tenderness | Serious |
| Fracture (Open) | Bone broken through skin | Bone visible, bleeding, high infection risk | EMERGENCY |
The CSM Check: Your First Priority
Before you do anything else—before you splint, before you wrap, before you even think about moving the patient—you need to check CSM: Circulation, Sensation, and Movement.
Circulation
- Check the pulse below the injury (wrist for arm injuries, foot for leg injuries)
- Press a fingernail or toenail until it blanches white, then release
- Color should return within 2 seconds (capillary refill)
- If no pulse or slow refill, the injury may be compromising blood flow—this is an emergency
Sensation
- Ask the patient if they can feel you touching their fingers/toes
- Check for numbness or tingling ("pins and needles")
- Numbness may indicate nerve damage or compromised circulation
Movement
- Ask the patient to wiggle their fingers or toes
- Inability to move may indicate nerve damage or severe injury
- Never force movement—this can cause further damage
Document your CSM check. Write down pulse quality, sensation, and movement. Recheck after splinting. If CSM deteriorates, the splint is too tight or the injury is worsening.
How to Splint: The Five-Step Method
Figure 2: The five-step splinting method for wilderness emergencies
Step 1: Assess
Check CSM before you do anything. Look for deformity, swelling, bruising, and open wounds. Check the pulse below the injury. Document everything.
Step 2: Gather Materials
In the backcountry, you improvise. Look for:
- Rigid items: Trekking poles, tent poles, sticks, SAM splint from your kit
- Padding: Clothing, jacket, sleeping pad, backpack hip belt
- Ties: Bandanas, belts, paracord, ACE wrap, shoelaces, straps
Step 3: Pad
Padding is critical. Without it, the splint will cause pressure sores and skin breakdown. Pad between the splint and skin, especially at bony prominences (ankle bone, shin, wrist). Use clothing, jacket material, or foam from your sleeping pad.
Step 4: Apply the Splint
The golden rule: Immobilize the joint above AND below the injury.
- Ankle injury? Splint the ankle AND the knee.
- Wrist injury? Splint the wrist AND the elbow.
- Use two splints when possible—one on each side of the limb for stability
- Keep the limb in a position of function (slightly bent, not fully straight)
- Leave fingers and toes exposed so you can check circulation
Step 5: Secure and Recheck CSM
Secure the splint with ties—snug but not tight. Use the two-finger rule: you should be able to slide two fingers under the ties. Then recheck CSM immediately. If circulation, sensation, or movement has worsened, the splint is too tight. Loosen and recheck.
When to Evacuate vs. When to Continue
Not every fracture requires immediate evacuation. Some can be managed in the field. Here's how to decide:
| EVACUATE IMMEDIATELY | MAY BE ABLE TO CONTINUE |
|---|---|
| Open fracture (bone through skin) | Closed ankle fracture, patient can bear some weight with support |
| No pulse below injury | Wrist fracture with intact circulation |
| Numbness/tingling that doesn't improve | Finger or toe fracture, can self-ambulate |
| Dislocation that won't reduce | Sprain with good CSM and ability to bear weight |
| Femur or hip fracture | — |
| Patient cannot bear any weight | — |
When in doubt, evacuate. It's better to call for help and not need it than to need help and not call for it.
Improvised Splinting: When You Don't Have a SAM Splint
The Beacon Pro includes a SAM splint in the Yellow Ortho pouch—but what if you're using your supplies or need to improvise? Here's how to splint with what you have:
Ankle Fracture (Most Common)
- Rigid: Two trekking poles or sturdy sticks, one on each side of the leg
- Padding: Roll up a jacket or shirt, place between leg and poles
- Ties: Bandanas, belts, or paracord above knee, at ankle, and at foot
- Key: Immobilize the ankle AND the knee. Keep the foot at 90 degrees.
Wrist/Forearm Fracture
- Rigid: Magazine rolled tightly, tent pole, or flat stick
- Padding: Clothing or gauze wrap
- Ties: Bandanas above elbow, at wrist, and at hand
- Key: Immobilize the wrist AND the elbow. Keep fingers exposed.
Shoulder Dislocation
- Do NOT try to reduce (pop back in) unless trained.
- Splint the arm against the body using a sling and swathe
- Sling: Support the forearm with a triangular bandana or shirt
- Swathe: Wrap around the arm and torso to immobilize against the chest
- This is an evacuation. Shoulder dislocations require medical attention.
Pain Management in the Field
Fractures hurt. A lot. Managing pain isn't just about comfort—it helps prevent shock and allows the patient to assist in their own evacuation.
- Splinting reduces pain by immobilizing the injury. Do this first.
- Cold therapy: Apply cold packs (from your Blue Environmental pouch) for 20 minutes to reduce swelling
- Elevation: Elevate the injured limb above heart level if possible
- Medication: The Beacon Pro includes ibuprofen and acetaminophen in the Gray Meds pouch. These can help with pain and inflammation
KIT CHECK: The Beacon Pro Orthopedic Supplies (Yellow Pouch)
The Yellow Ortho pouch in the Beacon Pro contains everything you need for fracture and dislocation management:
SAM Splint: Moldable aluminum splint that can be shaped for any limb. Reusable, radiolucent (X-ray transparent).
ACE Wrap (4-inch): Elastic compression wrap for securing splints and reducing swelling.
Triangular Bandage: Multi-purpose—sling, swathe, pressure dressing, or improvised splint tie.
Safety Pins: For securing bandages and slings.
Tape (1-inch): Medical tape for securing dressings and splint components.
WHAT CHEAP KITS DON'T HAVE: That $20 first aid kit has Band-Aids. It doesn't have a SAM splint, ACE wrap, or the knowledge that you need to immobilize joints above AND below the injury. The manufacturer saved $10. Your hiking partner pays with mobility.
SKILL TO PRACTICE: Time yourself creating a splint for a simulated ankle fracture using only items from your pack (not the medical kit). Can you do it in under 5 minutes? Under 10? Speed matters when someone is in pain and shock is setting in.
The Bottom Line
Musculoskeletal injuries are the most common wilderness emergency you'll face. They're not dramatic, but they can end a trip—or worse, lead to serious complications if not managed properly.
The key skills are simple: check CSM, splint properly (joint above and below), pad well, secure snugly, and recheck CSM. Know when to evacuate. Know when you can continue.
And most importantly: have the right equipment. A box of Band-Aids won't splint a fractured ankle. A medical kit with a SAM splint, ACE wrap, and triangular bandage will.
Sources & References
National Institutes of Health. "Musculoskeletal injuries in wilderness settings." NIH National Library of Medicine. https://pubmed.ncbi.nlm.nih.gov
National Outdoor Leadership School (NOLS). "Wilderness Medicine: Fracture and Dislocation Management." https://www.nols.edu
Wilderness Medical Society. "Practice Guidelines for Wilderness Emergency Care." https://wms.org
Red Cross. "First Aid for Broken Bones and Fractures." https://www.redcross.org
Verywell Health. "Sprains vs. Strains vs. Fractures: What's the Difference?" https://www.verywellhealth.com
UC Irvine Health. "Fractures: Types, Symptoms, and Treatment." https://www.ucihealth.org