Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 8 n Musculoskeletal Trauma
pressure and the longer it remains elevated, the greater
the degree of resulting neuromuscular damage and
resulting functional deficit. If compartment syndrome
is suspected, promptly release all constrictive dressings,
casts, and splints applied over the affected extremity
and immediately obtain a surgical consultation.
The only treatment for a compartment syndrome is
a fasciotomy (n FIGURE 8-8). A delay in performing a
fasciotomy may result in myoglobinuria, which may
cause decreased renal function. Immediately obtain
surgical consultation for suspected or diagnosed
compartment syndrome.
Neurological Injury Secondary to
Fracture or Dislocation
Fractures and particularly dislocations can cause significant
neurologic injury due to the anatomic relationship
and proximity of nerves to bones and joints
(e.g., sciatic nerve compression from posterior hip
dislocation and axillary nerve injury from anterior shoulder
dislocation). Optimal functional outcome depends
on prompt recognition and treatment of the injury.
Pitfall
prevention
Assessment
A thorough examination of the neurologic system
is essential in patients with musculoskeletal injury.
Determination of neurologic impairment is important,
and progressive changes must be documented.
Assessment usually demonstrates a deformity of
the extremity. Assessment of nerve function typically
requires a cooperative patient. For each significant
peripheral nerve, voluntary motor function
and sensation must be confirmed systematically.
n TABLE 8-3 and n TABLE 8-4 outline peripheral nerve
assessment of the upper extremities and lower
extremities, respectively. (Also see Peripheral Nerve
Assessment of Upper Extremities and Peripheral Nerve
Assessment of Lower Extremities on MyATLS mobile
app.) Muscle testing must include palpation of the
contracting muscle.
In most patients with multiple injuries, it is difficult
to initially assess nerve function.However,
assessment must be continually repeated, especially
after the patient is stabilized. Progression of neurologic
findings is indicative of continued nerve compression.
The most important aspect of any neurologic assessment
is to document the progression of neurologic
findings. It is also an important aspect of surgical
decision making.
Delayed
diagnosis of
compartment
syndrome.
• Maintain a high index of suspicion
for compartment syndrome in
any patient with a significant
musculoskeletal injury.
• Be aware that compartment syndrome
can be difficult to recognize in
patients with altered mental status.
• Frequently reevaluate patients with
altered mental status for signs of
compartment syndrome.
Management
Reduce and splint fracture deformities. Qualified
clinicians may attempt to carefully reduce dislocations,
after which neurologic function should
be reevaluated and the limb splinted. If reduction
is successful, the subsequent treating doctor
must be notified that the joint was dislocated and
successfully reduced.
A
B
n FIGURE 8-8 Fasciotomy to Treat Compartment Syndrome. A. Intraoperative photo showing fasciotomy of upper extremity compartment
syndrome secondary to crush injury. B. Postsurgical decompression of compartment syndrome of the lower leg, showing medial incision.
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