Advanced Trauma Life Support ATLS Student Course Manual 2018

SECONDARY SURVEY 155
Physical Examination
For a complete examination, completely undress the
patient, taking care to prevent hypothermia. Obvious
extremity injuries are often splinted before the patient
arrives at the ED. The three goals for assessing the
extremities are:
1. Identify life-threatening injuries (primary survey).
2. Identify limb-threatening injuries (secondary survey).
3. Conduct a systematic review to avoid missing
any other musculoskeletal injury (i.e.,
continuous reevaluation).
Assessment of musculoskeletal trauma includes
looking at and talking to the patient, palpating the
patient’s extremities, and performing a logical, systematic
review of each extremity. Extremity assessment
must include the following four components to avoid
missing an injury: skin, which protects the patient
from excessive fluid loss and infection; neuromuscular
function; circulatory status; and skeletal and ligamentous
integrity. (See Appendix G: Secondary Survey.)
Look and Ask
Visually assess the extremities for color and perfusion,
wounds, deformity (e.g., angulation or shortening),
swelling, and bruising.
A rapid visual inspection of the entire patient will
help identify sites of major external bleeding. A pale
or white distal extremity is indicative of a lack of
arterial inflow. Extremities that are swollen in the
region of major muscle groups may indicate a crush
injury with an impending compartment syndrome.
Swelling or ecchymosis in or around a joint and/or
over the subcutaneous surface of a bone is a sign of
a musculoskeletal injury. Extremity deformity is an
obvious sign of major extremity injury. n TABLE 8-1
outlines common joint dislocation deformities.
Inspect the patient’s entire body for lacerations
and abrasions. Open wounds may not be obvious on
the dorsum of the body; therefore, carefully logroll
patients to assess for possible hidden injuries. (See
Logroll video on MyATLS mobile app.) Any open wound
to a limb with an associated fracture is considered
to be an open fracture until proven otherwise by
a surgeon.
Observe the patient’s spontaneous extremity motor
function to help identify any neurologic and/or
muscular impairment. If the patient is unconscious,
absent spontaneous extremity movement may be the
only sign of impaired function. With a cooperative
table 8-1 common joint dislocation
deformities
patient, trauma team members can assess active
voluntary muscle and peripheral nerve function by
asking the patient to contract major muscle groups.
The ability to move all major joints through a full range
of motion usually indicates that the nerve-muscle unit
is intact and the joint is stable.
Feel
JOINT DIRECTION DEFORMITY
Shoulder
Anterior
Posterior
Squared off
Locked in internal
rotation
Elbow Posterior Olecranon
prominent
posteriorly
Hip
Anterior
Posterior
Extended, abducted,
externally rotated
Flexed, adducted,
internally rotated
Knee Anteroposterior Loss of normal
contour, extended
Ankle
Subtalar
joint
Lateral is most
common
Lateral is most
common
*May spontaneously
reduce prior to
evaluation
Externally rotated,
prominent medial
malleolus
Laterally displaced
os calcis (calcaneus)
Palpate the extremities to determine sensation to
the skin (i.e., neurologic function) and identify areas
of tenderness, which may indicate fracture. Loss
of sensation to pain and touch demonstrates the
presence of a spinal or peripheral nerve injury. Areas
of tenderness or pain over muscles may indicate a
muscle contusion or fracture. If pain, tenderness, and
swelling are associated with deformity or abnormal
motion through the bone, fracture should be suspected
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