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Old 10-12-1999
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William Mahaffy is on a distinguished road
Orthopedic Injuries: Strains and Sprains

The marine environment can and will exhibit the entire spectrum of nature's extremes. From the windless millpond of the Doldrums to the raging tumult of a Northeast gale. For those who frequently venture offshore, there will be unavoidable experiences with heavy weather. It is during these times that the likelihood of traumatic injury increases and, unfortunately, it is also the time at which it is most difficult to manage. This is not to say that traumatic injuries will not occur during a quite sail in the harbor (or even at the dock!) but the assessment and management of the problem is far more complicated in the offshore environment.

As with virtually every topic discussed thus far, the best approach to on-board traumatic injuries is prevention. Heavy weather and storm tactics are a frequently discussed topic and a variety of texts and seminars by notable experts are widely available. Heaving to, lying ahull, streaming warps and sea-anchor deployment are methods used to lessen damage to both vessel and crew. However, no matter how well prepared and practiced you may be with these techniques, the risk of strains, sprains, fractures and dislocations still exists. In this three part series, we will discuss the assessment and treatment of on-board orthopedic injuries.

Strains

A strain is defined as “the separation or tear of a musculotendinous unit from a bone.” Strains are graded by their severity with the least serious (and most common) being a Grade I, usually referred to as a “pulled muscle”. This is usually seen on board as back strain and occurs most frequently in the early part of the sailing season. Those first few weekend Yacht Club races put stress on muscle groups we have not aggressively used since the last season as we grind winches and hoist halyards.

A strain will present as pain with movement or palpation of the affected muscle group. There is no definitive swelling nor is there any circulatory or neurologic impairment. The treatment consists of rest and pain relief with an anti-inflammatory such as ibuprofen. (I have several friends who also promote shoreside "Anheuser-Busch" therapy but I have no documented literature on its effectiveness!)

The most severe strain (Grade III) will result in complete disruption and separation of muscle from muscle, muscle from tendon, or tendon from bone. When a tendon is pulled away from bone there is frequently an associated avulsion fracture at the site of the bony attachment. These injuries occur with sudden violet contractions of the muscle and in some cases you will see the muscle “bulging or bunching up” under the skin. The muscles of the calf (gastrocnemius and soleus) and Achilles tendon are most commonly affected in the lower extremity and the biceps in the upper extremity. There will be noticeable swelling, ecchymosis (bruising) and loss of use to the affected joint with the more severe injuries. Grade III strains are treated much like fractures. Immobilization and pain control are the primary goals on board and advanced medical care will be needed as surgery is often required to repair the damage.

Sprains

A sprain consists of injury to the supporting ligaments around a joint and is marked by pain, swelling and ecchymosis (bruising) over the joint. While a sprain can occur at any joint, by far the most common location is the ankle. An "inversion" (known as a Varus) injury accounts for about 85% of cases and occurs when the ankle "rolls over" with the sole facing the opposite foot. Movement around a wet, pitching deck, especially in the dark, can easily promote the occurrence of this injury.

The severity can range from only momentary tenderness with minimal loss of function (Grade I) to immediate severe pain and swelling with complete loss of weight-bearing capability. Patients will often report hearing a "pop" with the more severe insults. The most severe (Grade III) sprains result in significant joint instability secondary to rupture of specific lateral ankle ligaments. These injuries may take weeks or months to heal and may even require surgical intervention to repair chronically unstable joints. Clearly, the phrase "It's probably just a sprain" is misleading an inaccurate as these injuries often take longer to heal than a simple fracture.

Regardless of the severity, the treatment of a sprain is identical. Remember RICE: Rest, Ice, Compression, and Elevation. As we noted in an earlier article on minor trauma, be sure to apply the ice OVER the ACE wrap (compression) as direct contact can lead to a cold injury to the skin. To this acronym I would also add Immobilization (RIICE) since the more severe ankle sprains will need support, especially in the active offshore environment. The ankle joint can be immobilized using a commercial splint (air, rigid or malleable) or by a makeshift method using a pillow, magazine or other conforming material. I have spoken with crew who have used several folded charts as an expensive but useful splinting material. More discussion of splinting and packaging techniques will follow in Part II covering fractures. Pain relief can be accomplished with non-steroidal anti-inflammatories (NSAIDs such as Motrin, Advil) or more powerful analgesics such as Darvocet or Percocet. Significant swelling and inability to bear weight warrant definitive medical evaluation but do not require immediate diversion to the nearest port.

Sailing can be a vigorous activity, particularly in the offshore environment. Attention to safety and acknowledging potentially hazardous situations will limit traumatic injuries. Above all, assessment of injury extent and severity are the key point to successful management.

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