You are holed up in a snow cave waiting out a heavy winter storm at 10,500 feet in the Colorado Rockies. Your sleeping area is raised a few feet above your entrance. You have been cooking outside with your stove sheltered from the wind by strategically placed snow blocks. A ski pole poked through the roof of the cave provides much needed ventilation. To save batteries, you have been using two candle lanterns to provide enough light to read and play cards. After a day, the air inside the cave is slightly stuffy and both you and your partner have a slight headache.

What's wrong and what can you do about it? Click here to find out.

Pathophysiology
While posterior hip dislocations are somewhat common in head-on motor vehicle accidents and occasionally occur in elderly people with prosthetic hip joints during a minor slip or fall, they are quite rare in a wilderness environment. Most posterior hip dislocations require a significant traumatic MOI and many patients die from internal injuries to the pelvis, abdomen, chest, and head. Greater than 50% of patients have long-term disability after reduction. The femoral head is highly vascular and may die if not quickly reduced. Posterior hip dislocations are increasing along with the popularity of extreme sports; one study indicated that snowboarders were more likely to suffer a posterior hip dislocation than skiers.

The hip joint is a ball-and-socket synovial joint: the ball is the femoral head, and the socket is the acetabulum. The adult hip is quite stable. As such, knee and lower leg injuries are often seen in conjunction with posterior hip dislocations. Due to the potential for significant complications, an attempt should be made to reduce posterior hip dislocations in the field.

Posterior Hip Dislocation Signs & Symptoms

• Patient presents on back or side with hip slightly flexed and the leg on the affected side shorter and rotated inward.
• Moderate to severe pain; associated nerve injury and loss of nerve function is possible.
• Patient may have fractures to the knee, patella, femoral head, neck, shaft, or socket (acetabulum).

Posterior Hip Dislocation Treatment

• If the leg on the side of the dislocation has no significant fracture, one rescuer stabilizes patient’s hips while the second squats with arms crossed under patient’s knee and lifts, using their legs, until femoral head relocates.
• If reduction is successful, there is no nerve damage, and no indication of internal injuries, begin a Level 3 Evacuation.
• Begin a Level 2 Evacuation for patients with an unreduced posterior hip dislocation; death of the femoral head and permanent nerve damage may occur anytime within the following 24 hrs without reduction.
  

While mountain biking down a steep single track your friend catches his front wheel and is thrown forward with his bike. During the fall the handlebars smash into the left side of his chest. Asa has difficulty sitting up and catching his breath, and appears to have injured his left wrist. After assisting him to a sitting position and coaching him to breathe with his abdomen, his respiratory distress appears to resolve. During your physical exam, he reports a sharp pain (7) in the ribs on his lower left chest when he tries to take a deep breath. While his left wrist hurts (4) and has a slightly decreased ROM with good distal CSM, it appears weak: Asa is unable to easily hold and lift a full 1-liter water bottle. His helmet is cracked, he reports feeling a bit woozy, and has a headache (4); the remainder of his physical exam is unremarkable. With abdominal breathing, the pain in his ribs is manageable (3). 20 minutes after his accident his pulse is 94 and regular and his respiratory rate is 22 and remarkably easy; he reports his normal pulse rate is in the mid-60's and he doesn't know his normal respiratory rate. While awake, he still feels a bit "out of it." A focused spine assessment reveals cervical pain and tenderness at C-7 with no shooting pain and normal motor and sensory exams.

What is wrong with Asa and what should you do? Click here to find out.

While skiing back to your vehicle after a day of touring in the backcountry, your friend skis directly into a 10-inch lodgepole pine at a moderate rate of speed. When you reach her, she is out of breath and struggling to sit up. You carefully assist her to a sitting position and begin your assessment. Jenny's breathing quickly returns to normal. She tells you she got the wind knocked out of her and the right side of her chest is sore (2); on exam, her chest is slightly tender. She did not hit her head. Her pulse and respiratory rates are normal. A focused spine assessment reveals no spine pain, tenderness, or shooting pain and normal motor and sensory exams. Jenny doesn't think she is badly injured and is ready to continue skiing, albeit slightly slower and under better control.​

What is wrong with Jenny and what should you do? Click here to find out.

While on a day tour in the backcountry, one of your snowboarding friends landed on their right shoulder after grabbing some air off a terrain feature. Jose says his shoulder hurts (6) and he doesn't want to move it. Removing his outer and inner layers, you take a quick look (see photo below), and then carefully replace his clothing. He did not hit his head. After roughly ten minutes the pain in his shoulder abates to a mild, deep throbbing (4) and 

Rib Fractures
In most cases, a simple, isolated rib fracture elicits sharp, knife-like pain, and respiratory distress; however, as the patient relaxes and begins to breathe with their diaphragm, the respiratory distress subsides. Depending on the location of the fracture and it's severity, if there are multiple rib fractures especially to the same rib or ribs (flail chest), the patient may present with or develop respiratory distress due to lung damage and/or internal bleeding.

Isolated Rib Fracture S/Sx

• Sharp knife-like pain on inspiration that resolves with abdominal breathing.
• Lung damage and/or internal bleeding are possible.

Isolated Rib Fracture Treatment

• Position patient in position of comfort. Reassure & coach abdominal breathing.
• Begin a Level 3 EVAC. Depending on pain, patients may be able to self-evac; minimize patient’s work load (no/light pack). Do not bind patient’s ribs; instead, encourage them to take a deep breath every 20 minutes; both help prevent a secondary pneumonia.
• Begin an urgent, level 1 evacuation if lung damage and/or volume shock is suspected.

Multiple Rib Fractures S/Sx

• Sharp knife-like pain on inspiration that is usually not relieved by abdominal breathing; lung damage and/or internal bleeding are likely.

Multiple Rib Fractures Treatment

• Position patient in position of comfort: sitting if awake; lying on injured side if voice-responsive, pain-responsive, or unresponsive.
• Reassure & coach patient to abdominal breathe. Do not bind the patient’s ribs; instead, encourage them to take a deep breath every 20 minutes; both help prevent a secondary pneumonia.
• Begin an urgent, level 1 evacuation if lung damage and/or volume shock is suspected.