Wilderness Medical Series — Module 12

Stabilizing Suspected Spinal and Pelvic Injuries in the Field

Learn how to stabilize suspected spinal, pelvic, and femur fractures in the field when evacuation is the only outcome and time is the variable.

By Joshua Enyart · Founder & Head Instructor, Gray Bearded Green Beret

Former Army Ranger, Green Beret, and full-time survival instructor · three decades of professional instructor experience

Most injuries covered in the Wilderness Medical Course have one primary goal: restore function so the patient can move. A splinted ankle gets the person back on the trail. A properly dressed wound cleans up and heals. The patient keeps moving.

The injuries covered in this module do not work that way. A suspected spinal fracture, a pelvic fracture, and a mid-shaft femur fracture all require evacuation as the primary response. Your field role is not to fix these injuries — it is to stabilize the patient, prevent them from getting worse, and get rescue moving as fast as possible. That distinction matters because it changes everything about how you respond.

These are the injuries that justify using a satellite communicator the moment you suspect them, not after you have assessed and re-assessed for twenty minutes. Get the rescue request out early, then begin stabilization.

Suspected Spinal Injuries: A Different Decision Standard

In a wilderness context, you are not diagnosing a spinal injury — you do not have the tools or training to do that definitively in the field. What you are doing is applying a different decision standard: mechanism and presentation. If the mechanism of injury could have loaded the spine — a fall from height, a high-impact collision, a diving accident in shallow water — and the patient presents with any neurological symptoms including numbness, tingling, or weakness in the extremities, you treat it as a spinal injury until proven otherwise.

The cost of treating a non-spinal injury as spinal is a slower evacuation and some patient discomfort. The cost of treating a spinal injury as non-spinal can be permanent paralysis. In the field with no imaging capability, that asymmetry drives the decision.

Manual Stabilization

The first intervention for a suspected cervical spine injury is manual stabilization. A second person positions at the patient's head and holds both sides of the skull — hands cradling the temporal bones, thumbs pointing toward the chin. The goal is to eliminate rotation, flexion, and extension in the cervical spine until a more stable intervention is in place. This is not a tight grip — it is a controlled, neutral hold.

Manual stabilization cannot be released until you have mechanical stabilization in place. That means your hands stay on the patient's head through the entire collar and head-block process.

Improvised Cervical Collar — SAM® Splint

A 36-inch SAM® splint can be shaped into a functional cervical collar. Begin by building the chin rest: fold one end of the SAM® splint into a shallow pocket that will cradle the chin. The depth of this pocket determines the cervical angle — build it to match the patient's neutral head position.

Once the chin pocket is formed, position it under the patient's chin at the correct angle and work the splint around both sides of the neck. The splint should wrap snugly without compressing the airway or the carotid arteries — check that the patient can still breathe and speak comfortably. The collar holds the chin up and the neck neutral, reducing the range of motion in the cervical spine.

The improvised SAM® C-collar is functionally similar to a commercial cervical collar. In some configurations it is easier to apply in the field because you can custom-shape it to the patient's anatomy. Commercial collars come in fixed sizes; the SAM® splint does not.

Head Blocks

After the collar is in place, the next step is blocking the head laterally to prevent rotation. Roll a wool blanket into a horseshoe shape and position it around the patient's head — each arm of the horseshoe parallel to the sides of the skull, the curve behind the head. Secure the blanket to the patient's forehead with tape or a bandage to prevent the head from rolling.

The wool blanket is also the patient's primary insulation. Before committing it as a head block, assess the environment. If conditions are cold and the patient is at risk for hypothermia, you may need to source a second insulation layer. A head block that costs the patient their warmth introduces a new problem while solving the original one.

Pelvic Fractures: Stabilization and Internal Hemorrhage Control

A pelvic fracture is immediately obvious: the patient is in severe pain and cannot stand or walk. The specific injury pattern of concern is an open-book pelvic fracture — the two halves of the pelvis are spreading apart at the front. Beyond the pain and mobility loss, this pattern creates a significant internal hemorrhage risk. The pelvic basin can hold a large volume of blood, and an unstable pelvic fracture allows that volume to expand.

An improvised pelvic sling addresses both concerns: it reduces pain by compressing the pelvic bones back toward each other, and it limits the internal space available for blood pooling. This is not a definitive treatment — it is a stabilization measure that buys time for evacuation.

Applying the Improvised Pelvic Sling

Locate the iliac crests — the prominent ridges at the top of each hip bone. Come down slightly below the level of the iliac crests to position the sling at the widest point of the pelvis. A folded sleeping bag, a SAM® splint pad, or a bundled piece of clothing works as padding material.

Wrap the material circumferentially around the pelvis at that level. Secure both ends with a triangular bandage or a piece of webbing, tying in the front with enough tension to bring the pelvic bones toward midline without over-compressing. The goal is gentle, steady compression — not a tourniquet-level wrap. Once applied, the sling stays in place until the patient reaches definitive care. Do not repeatedly loosen and reapply.

Mid-Shaft Femur Fracture: The Backcountry Emergency That Escalates Fast

A mid-shaft femur fracture or higher is among the most dangerous musculoskeletal injuries in a wilderness setting, and it is dangerous for a specific reason: blood loss. The femur is the largest bone in the body, and a fracture at mid-shaft or above can result in one to two liters of blood loss internally into the thigh — even with no external wound visible.

To put that in context: the average adult has approximately five liters of total blood volume. A loss of 30 percent — roughly 1.5 liters — brings on serious hypovolemic shock. The thigh is a large space that can accommodate exactly that volume. A patient with a mid-shaft femur fracture may be going into shock from internal hemorrhage while you are focused on the visible deformity.

Recognizing the Injury

Signs of a mid-shaft or above femur fracture include rapid-onset swelling of the thigh, rapid bruising, pinpoint tenderness at the fracture site, visible deformity, unnatural leg positioning, and severe pain. The patient typically cannot bear any weight. Mechanism matters here: high-energy trauma — a fall from significant height, a vehicle incident, crushing force — is the usual cause.

Manual Traction Before Splinting

Before splinting, apply manual traction to the leg — ten to fifteen pounds of steady pull along the long axis of the femur. This is not an aggressive yank; it is controlled, sustained traction that helps bring the bone ends closer to alignment, reduces internal hemorrhage risk from sharp bone ends, and significantly reduces pain.

Apply traction and hold it. Your goal is to maintain that traction continuously while the splint is applied. Releasing traction before the splint is secured can cause a painful spike and re-initiate bone end movement.

Anatomical Splint — Improvised for Field Conditions

A traction splint is the correct equipment for this injury, but most backcountry travelers do not carry one. The improvised alternative is an anatomical splint using the uninjured leg: pad the space between the legs thoroughly — the natural void behind the knees needs particular attention. Secure the injured leg to the uninjured leg with multiple wraps above and below the fracture site, using the good leg as the rigid structural element.

This is a functional but imperfect solution. The patient's evacuation becomes the top priority the moment a mid-shaft femur fracture is suspected. Get rescue moving — this is not an injury where you splint and continue the trip.

Hypovolemic Shock: Know It and Treat It

Because pelvic fractures and femur fractures both carry significant internal hemorrhage risk, recognizing and managing hypovolemic shock is essential alongside the mechanical stabilization work. Shock occurs when the body cannot circulate sufficient oxygenated blood to vital organs. In the field, your shock management tools are limited — but they are not zero.

Signs of developing shock include heart rate greater than 120 beats per minute (measure at the wrist or carotid), breathing faster than 30 breaths per minute, skin that is pale and cool to the touch, altered mental status — confusion, agitation, or unexpected drowsiness — and cyanosis around the lips indicating poor circulation.

Field treatment for shock: protect the airway and maintain normal breathing. Keep the patient from getting cold — lay them on insulation, cover them with whatever you have. Cold dramatically worsens shock. Elevate the feet 8 to 12 inches if there is no spinal concern and no lower extremity fracture preventing it. Keep the patient hydrated if they are conscious and can swallow. These are supportive measures, not cures — they buy time for evacuation.

Anatomical Splinting for Fingers and Toes

The anatomical splint principle scales directly to small injuries. A broken or dislocated finger is splinted to the adjacent finger with padding between them. A broken toe is splinted to the neighboring toe the same way. The buddy system works because the uninjured digit provides both the rigid structure and the correct anatomical alignment. Keep the splint padded and check sensation below the splint regularly.

Signal First, Then Stabilize

Spinal, pelvic, and femur fractures share one operational principle: the moment you suspect the injury, signal for rescue. Do not finish your assessment, do not stabilize first and communicate second. Get the rescue request out while you are still working on the patient.

Your stabilization work runs in parallel with the rescue response, not instead of it. Every minute between injury and evacuation matters for these patients. Your field job is to keep them from getting worse and keep them warm while that response is en route.

About the Author: Joshua Enyart is a Former Army Ranger and Green Beret, and full-time survival instructor with three decades of professional teaching experience in wilderness medicine, survival, and field craft.

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