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support. Splint or cast if necessary.
- If unable to walk or bear weight, and even with suspected fracture, ambulating with improvised crutches or
cane is preferred over a litter patient from an operational perspective. - If infection is suspected, and MedEvac is unavailable, treat with antibiotic regimen (see Knee Pain
section) - Provide pain relief as needed- NSAIDs for sprains, narcotics for fracture.
Patient Education
General: Describe level of injury - suspected fracture vs. sprain
Activity: As tolerated. Rest and elevation if possible.
Diet: No special requirements
Medications: NSAIDs may cause bleeding ulcers, narcotics may cause respiratory depression, all drugs
may cause allergic reactions
Prevention and Hygiene: If compound fracture, try to keep as clean as possible to prevent infection.
No Improvement/Deterioration: If infected joint or compound fracture, concern for systemic infection/sepsis.
Monitor blood pressure, mental status
Wound Care: Keep wounds clean, dry
Follow-up Actions
Return evaluation: If available, start rehab program for ankle sprain ASAP, return to full duty when able to
run a gure eight at full speed pain-free. The theory is to use the ankle as rapidly as possible while protecting
from reinjury. Under normal conditions, this would take 3-6 weeks depending on the severity of the sprain and
number of previous sprains. Providing ankle support such as with an Aircast or slide-on brace with laces may
help speed return to activity. Obviously, if under operational constraints, ankle sprains are not life threatening
and the injured person may use the ankle to the best of their ability as tolerated.
Evacuation/Consultation Criteria: Suspected fractures should have x-rays as soon as practical. Surgical
incision and drainage ASAP treatment of choice for infected joint. If compound fracture, refer for denitive
care ASAP. Infected joints and compound fractures wreak much havoc quickly, making the earliest available
MedEvac most appropriate for denitive care.
Symptom: Male Genital Problems:
Genital Inflammation
CAPT Leo Kusuda, MC, USNIntroduction: Genital ulcers and urethral discharge are covered in the STD chapter. Most inflammation of the
penis is related to the presence of foreskin and may be an early sign of diabetes mellitus. Skin infections in
the genital area are similar to cellulitis in other parts of the body, in that they present with pain and redness
and are usually caused by staphylococcal or streptococcal organisms. Skin inflammation/infection in this
region can lead to urethral stricture or perirectal abscess. This later infection can involve multiple organisms,
including gram-negative rods, that can lead to life threatening necrotizing fasciitis (Fournier’s gangrene),
particularly in the severely injured or diabetic patient. With severe inflammation of the penis, patients may
have difficulty voiding or may experience symptoms of septicemia: fever, fatigue and shock.
Phimosis/paraphimosis: Inflammation of the foreskin in the uncircumcised male. Phimosis patients will
be unable to retract their foreskin, and in severe cases, the glans and urethral meatus cannot be seen.
In paraphimosis, the foreskin is trapped behind the glans with a doughnut-shaped swelling of the foreskin
between a tight constricting band in the penile skin and the glans. Both conditions are a result of scar tissue
forming on the foreskin at the most distal aspect of the foreskin when the foreskin is extended.
Balanitis: Inflammation of the glans penis and foreskin occurs primarily in the uncircumcised male but is rare
in the circumcised male. The glans will look wet, red and may have multiple small red bumps and a whitish
material on the surface consistent with yeast. This condition should raise suspicion for diabetes mellitus. If the
foreskin cannot be retracted easily, leave it extended. There are a number of non-infectious causes of a wet,
red patch of skin on the glans penis. Differentiation often requires a biopsy. When in doubt treat for infection,