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April 2014 Issue
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If the injury is a sprain apply the RICE principles and wait to see if the pain subsides. If it’s a fracture, seek urgent medical assistance
A fracture requires an immediate evac, but for a painful sprain it’s best to play the waiting game, writes Dr Craig Ellis

It’s common to hear a snap or crack when someone goes over on their ankle or twists their knee, but this does not automatically mean there’s a fracture.

If the bone or joint is bent at a funny angle, the bone is protruding through skin or the limb is grossly swollen or deformed to the extent the patient can’t use it, then immediate evacuation is required.

But if the limb looks normal, aside from some swelling, and the main problem is pain and weight-bearing, then it may only be a severe sprain or a less significant fracture. There is no real risk waiting for 24-48 hours if you are otherwise safe and well supplied. It’s important to check that the patient has sensation and blood flow to the affected limb. This can be done by comparing the sensation and skin temperature between the injured and non-injured limb.

Most patients with a sprain or less significant injury will be able to partially weight-bear through their knee or ankle and even hobble or walk after 24 hours.


If the limb is grossly deformed and you are waiting for evacuation, minimise movement until help arrives. This can be achieved with some sort of splint. Ensure the limb is well-padded and toes or fingers remain pink with normal sensation in them. If the limb is at a funny angle, make a single attempt to straighten or restore it, but if it’s too painful or there is mechanical resistance, stop and splint it in the position it’s in.

If you have decided to wait and see, the first priority is ensuring your location is safe with adequate shelter.

Doctors recommend applying the ‘RICE’ principles to the injury – Rest, Ice, Compression and Elevation (in conjunction with pain control).

  • Rest: Sit the patient down and keep them off the injured limb for the next 24 hours.
  • Ice: Ideally you will have a first aid kit containing an instant cold pack. Ice or snow packed into a sock and applied to the swollen area or a towel soaked in cold water from a stream and applied for 10 minutes once an hour can offer relief and limits swelling.
  • Compression: If you don’t have a crepe bandage, set an ankle injury by sliding on a pair of socks a couple of sizes too small. For an injured knee, cut off the sock toes and pull this up around the knee. Ensure the support isn’t too tight and that toes remain pink without pins and needles.
  • Elevation: Try and keep the affected limb elevated, ideally above the heart, to help fluids and tissue swelling to drain under the influence of gravity.
  • Pain relief: Give an anti-inflammatory, such as Ibuprofen along with regular paracetamol (be careful your Ibuprofen doesn’t also contain paracetamol). Combining both medications together increases their effectiveness but it’s important to take them regularly, even if the pain reduces, in order to achieve a cumulative effect.

What next?

After 24 hours, try to get the patient moving.  If they still cannot get out under their own steam, it is time to consider evacuation again.

– Dr Craig Ellis is the deputy medical director at St John