Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 8 n Musculoskeletal Trauma
necrosis of muscle can occur. Soft-tissue avulsion can
shear the skin from the deep fascia, allowing for the
significant accumulation of blood in the resulting cavity
(i.e., Morel-Lavallée lesion). Alternatively, the skin may
be sheared from its blood supply and undergo necrosis
over a few days. This area may have overlying abrasions
or bruised skin, which are clues to a more severe degree
of muscle damage and potential compartment or crush
syndromes. These soft-tissue injuries are best evaluated
by knowing the mechanism of injury and by palpating
the specific component involved. Consider obtaining
surgical consultation, as drainage or debridement may
be indicated.
The risk of tetanus is increased with wounds that are
more than 6 hours old, contused or abraded, more than
1 cm in depth, from high-velocity missiles, due to burns
or cold, and significantly contaminated, particularly
wounds with denervated or ischemic tissue (See
Tetanus Immunization.)
Joint and Ligament Injuries
When a joint has sustained significant ligamentous
injury but is not dislocated, the injury is not usually
limb-threatening. However, prompt diagnosis and
treatment are important to optimize limb function.
Assessment
With joint injuries, the patient usually reports abnormal
stress to the joint, for example, impact to the
anterior tibia that subluxed the knee posteriorly, impact
to the lateral aspect of the leg that resulted in a valgus
strain to the knee, or a fall onto an outstretched arm
that caused hyperextension of the elbow.
Physical examination reveals tenderness throughout
the affected joint. A hemarthrosis is usually present
unless the joint capsule is disrupted and the bleeding
diffuses into the soft tissues. Passive ligamentous
testing of the affected joint reveals instability. X-ray
examination is usually negative, although some small
avulsion fractures from ligamentous insertions or
origins may be present radiographically.
curred and placed the limb at risk for neurovascular
injury. Surgical consultation is usually required for
joint stabilization.
Fractures
Fractures are defined as a break in the continuity of the
bone cortex. They may be associated with abnormal
motion, soft-tissue injury, bony crepitus, and pain. A
fracture can be open or closed.
Assessment
Examination of the extremity typically demonstrates
pain, swelling, deformity, tenderness, crepitus, and
abnormal motion at the fracture site. Evaluation for
crepitus and abnormal motion is painful and may
increase soft-tissue damage. These maneuvers are
seldom necessary to make the diagnosis and must not
be done routinely or repetitively. Be sure to periodically
reassess the neurovascular status of a fractured limb,
particularly if a splint is in place.
X-ray films taken at right angles to one another
confirm the history and physical examination findings
of fracture (n FIGURE 8-9). Depending on the patient’s
hemodynamic status, x-ray examination may need to
be delayed until the patient is stabilized. To exclude
occult dislocation and concomitant injury, x-ray films
must include the joints above and below the suspected
fracture site.
Management
Immobilize joint injuries, and serially reassess the
vascular and neurologic status of the limb distal
to the injury. Knee dislocations frequently return
to near anatomic position and may not be obvious
at presentation. In a patient with a multiligament
knee injury, a dislocation may have oc-
A
n FIGURE 8-9 X-ray films taken at right angles to one another
confirm the history and physical examination findings of fracture.
A. AP view of the distal femur. B. Lateral view of the distal femur.
Satisfactory x-rays of an injured long bone should include two
orthogonal views, and the entire bone should be visualized. Thus
the images alone would be inadequate.
B
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