Chapter 40 Musculoskeletal Trauma

According to the Centers for Disease Control and Prevention, approximately 53% of all hospitalized injuries are because of fractures.¹ Trauma to the bony skeleton produces pain, affects a person’s ability to do activities of daily living, and in some cases can be life threatening or limb threatening. The goals of caring for any trauma patient are to prioritize care to protect life, preserve function, and reduce long-term disability. All trauma patients should have a primary assessment to rule out problems with airway, breathing, circulation, and disability before attention is focused on injury-specific conditions. See Chapter 35, Assessment and Stabilization of the Trauma Patient, for a description of the primary assessment of the trauma patient. The purpose of this chapter is to provide an overview of initial and specific assessments and emergency care for musculoskeletal injuries.

Initial Assessment

Focused History

• The history helps the health care provider do a more thorough assessment by following a general rule as stated below. Always examine the joints above and below the obvious injury.

• Ask the patient to identify areas of pain, altered nerve function, and loss of extremity motor function.

• Mechanism of injury is used to direct primary and secondary assessments. It is important to distinguish low-energy forces (e.g., falls from level heights) from high-energy forces (e.g., motor vehicle crashes, falls from distance, high-velocity gunshots). In the latter, the force from the point of impact can be transmitted to distal structures and produce patterns of multiple injuries.

Inspection

Inspect the injured extremity for general appearance, deformity, and motion.

• Skin signs suggestive of a musculoskeletal injury include ecchymosis, pallor, dusky color, edema, and any open soft tissue wounds.

• Always examine the joints above and below the obvious injury.

• Note obvious deformities such as changes in size, shape, or alignment. It is helpful to compare an injured extremity with the uninjured one. Observe hand position in patients with hand injuries and decreased level of consciousness. Turn hand with palm up and note if all fingers are flexed in a gentle cascade. If any one finger remains extended, suspect tendon injury.²

• Loss of range of motion and subtle signs and symptoms suggestive of an extremity injury include the person favoring or hesitating to move the extremity (e.g., limping, holding the injured part).

The following guidelines can be used to guide the triage nurse in determining the necessity of ankle or knee radiographs.³

• Ottawa ankle rules

• Tenderness on palpation at (posterior) tip of lateral malleolus

• Tenderness on palpation at (posterior) tip of medial malleolus

• Inability to bear weight (four steps) at the time of injury or the time of physical examination

• Pittsburgh knee rules

• Blunt trauma or fall as mechanism of injury plus either of the following:

Age younger than 12 years or older than 50 years

Inability to walk four weight-bearing steps in the emergency department

Palpation

• Determine skin temperature, which is a rough estimate of arterial perfusion. Compare an injured extremity to the uninjured extremity.

• Put the extremity through active range of motion. Check motor strength distal to the injury, rating it on an objective scale and comparing it to the uninjured side. This allows for more consistent interrater assessments and identification of subtle changes.

• Palpate the limb or joint for tenderness and crepitus.

• Assess for limb or joint instability.

Assessing Neurovascular Status

Major peripheral blood vessels and nerves tend to lie in close proximity to bones and share joint space with other structures. Because extremity injuries may affect these structures, carefully evaluate the distal neurovascular status, not only to protect the patient but also to reduce liability. Documenting “neurovascular status intact” in the patient’s chart is considered medical-legal proof that the patient’s functions were assessed and intact on admission. Any deficits identified after that documentation can be presumed to have occurred while the patient was under the care of that staff.

• Assess function at the time of admission, after any manipulation, when the injured part is immobilized, and at intervals until after swelling has minimized.

• Check the patient’s ability to feel light touch in the injured extremity. It may be necessary to check for two-point discrimination. Assess response to pain if the patient has decreased level of consciousness.

• Assessment includes inspecting and palpating the involved structures. Significant findings are known as the Six P’s:

• Pain can result from the initial injury or a complication that produces nerve or vascular compromise. Ask the patient to describe the pain (e.g., burning, throbbing, knifelike), if it is localized (i.e., “point tenderness”) or more generalized, and to rate the severity on a scale such as 0 to 10 (10 being the worst). Serial assessments help identify potential causes, significant changes, and response to interventions. See Chapter 11, Care of the Patient with Pain, for further discussion of pain and pain management.

• Absence of a pulse in the injured extremity or joint is a serious complication and must be identified immediately. The pulses distal to the injury should be palpated for strength and quality. If unable to palpate the pulse, an ultrasound device (e.g., Doppler) may be used to auscultate over the vessel. Injuries that produce severe angulation or distal neurovascular compromise need to be reduced promptly to prevent ischemic complications.

• Pallor is reflected in a quick check of skin perfusion. Pale, cool skin can result from obstructed arterial flow or capillary vasoconstriction. It is helpful to do a blanch test to check perfusion status (press on the area distal to the injury and count until the skin color returns). Normal refill should occur in less than two seconds. The blanch test for capillary refill is a rough estimate since other factors, such as ambient temperature, use of vasoconstrictive medications, and ice packs, can also affect refill time.

• Paresthesias indicate abnormal sensory nerve responses, such as tingling, burning, or numbness. The major peripheral nerves supplying the extremities conduct both sensory and motor impulses. Damage can occur to the entire nerve or to partial fibers. Therefore it is important to evaluate both motor and sensory functions to identify or rule out nerve injury. Table 40-1 lists the functions of peripheral nerves, how to assess their function, and common mechanisms of injury.

• Paralysis refers to the loss of voluntary motor function and may result from nerve injury or the patient guarding a painful extremity. Any decrease in motor activity in an injured extremity needs to be carefully assessed for potential nerve injury.

• Pressure or a tense feeling of the extremity on palpation could be an indication of compartment syndrome or muscle spasms.

TABLE 40-1 PERIPHERAL NERVE FUNCTIONS, HOW TO ASSESS FUNCTION, AND COMMON MECHANISMS OF INJURY

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