Advanced Trauma Life Support ATLS Student Course Manual 2018

156
CHAPTER 8 n Musculoskeletal Trauma
Do not attempt to elicit crepitus or demonstrate
abnormal motion.
Joint stability can be determined only by clinical
examination. Abnormal motion through a joint
segment is indicative of a tendon or ligamentous
rupture. Palpate the joint to identify any swelling and
tenderness of the ligaments as well as intraarticular
fluid. Following this, cautious stressing of the specific
ligaments can be performed. Excessive pain can mask
abnormal ligament motion due to guarding of the joint
by muscular contraction or spasm; this condition may
need to be reassessed later.
Circulatory Evaluation
Palpate the distal pulses in each extremity, and assess
capillary refill of the digits. If hypotension limits digital
examination of the pulse, the use of a Doppler probe
may detect blood flow to an extremity. The Doppler
signal must have a triphasic quality to ensure no
proximal lesion. Loss of sensation in a stocking or glove
distribution is an early sign of vascular impairment.
In patients with normal blood pressure, an arterial
injury can be indicated by pulse discrepancies,
coolness, pallor, paresthesia, and even motor function
abnormalities. Open wounds and fractures close
to arteries can be clues to an arterial injury. Knee
dislocations can reduce spontaneously and may
not present with any gross external or radiographic
anomalies until a physical exam of the joint is
performed and instability is detected clinically.
An ankle/brachial index of less than 0.9 indicates
abnormal arterial flow secondary to injury or
peripheral vascular disease. Expanding hematomas
and pulsatile hemorrhage from an open wound also
indicate arterial injury.
X-ray Examination
The clinical examination of patients with musculoskeletal
injuries often suggests the need for x-ray
examination. Tenderness with associated bony
deformity likely represents a fracture. Obtain x-ray
films in patients who are hemodynamically normal.
Joint effusion, abnormal joint tenderness, and joint
deformity indicate a joint injury or dislocation that
must also be x-rayed. The only reason to forgo x-ray
examination before treating a dislocation or a fracture
is the presence of vascular compromise or impending
skin breakdown. This condition is commonly seen
with fracture-dislocations of the ankle (n FIGURE 8-5).
If a delay in obtaining x-rays is unavoidable, immediately
reduce or realign the extremity to reestablish
n FIGURE 8-5 Blanched skin associated with fractures and
dislocations will quickly lead to soft tissue necrosis. The purpose of
promptly reducing this injury is to prevent pressure necrosis on the
lateral ankle soft tissue.
the arterial blood supply and reduce the pressure on
the skin. Alignment can be maintained by appropriate
immobilization techniques.
Limb-Threatening Injuries
Extremity injuries that are considered potentially
limb-threatening include open fractures and joint
injuries, ischemic vascular injuries, compartment
syndrome, and neurologic injury secondary to fracture
or dislocation.
Open Fractures and Open Joint
Injuries
Open fractures and open joint injuries result from
communication between the external environment
and the bone or joint (n FIGURE 8-6). Muscle and
skin must be injured for this to occur, and the
degree of soft-tissue injury is proportional to the
energy applied. This damage, along with bacterial
contamination, makes open fractures and joint
injuries prone to problems with infection, healing,
and function.
Assessment
The presence of an open fracture or an open joint injury
should be promptly determined. The diagnosis of an
open fracture is based on a physical examination of
the extremity that demonstrates an open wound on
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