Injuries To Arms & Legs: Examination & Evaluation

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The kid was skating all over the place. Down the stairs, down the rails, over onto the fountain...just everywhere. I'm not surprised that he crashed. He never wanted to wear the protective equipment. I guess that he got what he deserved...one broken wrist and a broken arm too."

As a first responder, you will treat many patients who have suffered various types of open or closed painful, swollen or deformed extremities. It is important that you recognize the signs and symptoms of injuries of the musculoskeletal system. Proper care given at the scene can prevent additional injury or disability.

The skeleton has 206 bones and provides support and form for the body. It also protects the body's vital organs. The skull protects the brain, the spinal column protects the spinal cord, the ribs and sternum protect the heart and lungs, and the pelvis protects the organs of the lower abdomen.

The four primary functions of the skeletal system are to provide support, protect the body, assist in body movement and produce red blood cells. Because muscles and bones work together to produce movement, they are often called the musculoskeletal system. This movement occurs at joints, the contact points between bones that are next to one another. The joints are held together by ligaments, thick bands that arise from one bone, span the joint and insert into the adjacent bone.

A vital but often overlooked function of the skeletal system is the production of red blood cells. Red blood cells are made primarily in the spaces inside the bone called the marrow.

There are three major types of musculoskeletal injuries: fractures, dislocations and sprains. It is often difficult to distinguish one type of extremity injury from the other. All three types are serious and all extremity injuries must be identified so they can receive appropriate medical treatment. Since we are often not sure of the type of exact injury, we now are using new terminology to describe an injured extremity as "painful, swollen and deformed."

A fracture is a broken bone. Fractures can be caused by a variety of mechanisms but a significant force is almost always required. Fractures are generally classified as either closed or open. Closed fractures are more common. In the case of a closed fracture, the bone is broken but does not cause a break in the skin.

In an open fracture, the bone is broken and the overlying skin is lacerated. The open wound can be caused by penetrating objects, such as a bullet, or by the fractured bone end protruding through the skin. The open fracture is contaminated by dirt and bacteria; this contamination may lead to infection. Every fracture injures adjacent soft tissues, resulting in bleeding at the fracture site. Fractures also can injure adjacent nerves and blood vessels, causing severe nerve injury and excessive bleeding. Open fractures result in more bleeding than do closed fractures.

A dislocation is a disruption of the joint that tears the supporting ligaments. The bone ends that make up the joint separate completely from each other and lock in one position. Any attempted motion of a dislocated joint is very painful. Because many nerves and blood vessels lie near joints, a dislocation also can damage these structures.

A sprain is a joint injury in which the joint is partially, temporarily dislocated, and some of the supporting ligaments are either stretched or torn. It can be thought of as a partial dislocation. The following are the primary signs and symptoms of extremity injuries:

  • Pain at the injury site.
  • An open wound.
  • Swelling and discoloration (bruising).
  • The patient's inability or unwillingness to move the part.
  • Deformity.
  • Tenderness at the injury site.

There are three essential steps involved in examining all persons with limb injuries:

  1. General overall assessment of the patient.
  2. Examination of the injured part.
  3. Evaluation of the circulation and sensation in the injured limb.

A general, primary assessment of the injured patient must be carried out before attention is focused on any injured limb. All the steps in the initial patient survey must be followed. Once the patient's airway, breathing and circulation (ABCs) are stabilized, attention can then be directed to the injured limbs identified during the secondary survey.

Limb injuries are not life threatening unless there is excessive bleeding from an open wound. Therefore, it is essential to stabilize the ABCs before focusing on a limb injury, regardless of the pain or deformity which may be present at that injury site. Initially, the first responder should inspect the injured limb and compare it to the opposite, uninjured limb. To do this, the clothing should be gently and carefully cut away, if necessary. (Do not ever hesitate to cut clothing order to uncover a suspected injury.) When examining the limb, you may find an open wound, deformity, swelling and/or bruising.

After you have uncovered and looked at the injured limb, you should gently feel it for any points of tenderness. Tenderness is the best indicator of an underlying fracture, dislocation or sprain. To detect limb injury, start at the top of each limb and, using both hands, squeeze the entire limb in a systematic, firm (yet gentle) manner, moving toward the distal aspect. Make sure you have examined the entire extremity.

While you carry out your hands-on examination, it is important to ask the patient where it hurts most; the location of greatest pain is probably the injury site. Also ask whether the patient feels tingling or numbness in the extremity, as this may indicate nerve damage or lack of circulation. Listen to the patient. He or she is usually right about the location and type of injury.

Careful inspection and a gentle hands-on examination will identify most musculoskeletal injuries. If, after a careful visual and hands-on examination, the patient shows no sign of injury ask the patient to move the limb carefully. If there is an injury, the patient will complain of pain and refuse to move the limb. If even a slight motion causes pain, no further motion should be attempted.

Any of the signs or symptoms described above (deformity, swelling, bruising, tenderness or pain with motion) indicate the presence of a limb injury. Only one sign is necessary to indicate an "injury to the limb." All limb injuries are managed in the same way.

Once you suspect limb injury, you must evaluate the circulation and sensation in that limb. Many important blood vessels and nerves lie close to the bone, especially around major joints. Therefore, any injury may have associated blood vessel or nerve damage. It is also essential to check circulation and sensation after any movement of the limb (such as for splinting). Movement during splinting might have caused a bone fragment to press against or even cut a blood vessel or nerve. The following exam should be carried out for each injured limb:

  • Pulse. Feel the pulse distal to the point of injury. If the patient has an upper extremity injury, check the radial pulse. If the patient has a lower extremity injury, check the posterior ankle pulse (tibial pulse).
  • Capillary refill. Test the capillary refill in a finger or toe of any injured limb. Firm pressure on the tip of the nail will cause the nail bed to turn white. Upon release of the pressure, the normal pink color should return by the time it takes to say "capillary refill." If the pink color does not return in this two-second interval, it is considered to be delayed or absent, and indicates a problem with circulation in the limb. The absence of a pulse or capillary refill indicates that a limb is in immediate danger. Impaired circulation demands prompt transportation and prompt treatment at an appropriate medical facility.
  • Sensation. The patient's ability to feel your light touch on the fingers or toes is a good indication that the nerve supply is intact. In the hand, check sensation by touching lightly the tips of the index and little fingers. In the foot, the tip of the big toe and the top of the foot should be checked for sensation
  • Movement. If the hand or foot is injured, do not have the patient do this part of the test. When the injury is proximal to the hand or foot, have the patient open and close the fist or wiggle the toes of the injured limb. These simple movements indicate that the nerves to these muscles are working. Sometimes, any attempt at motion will produce pain. In such a case, do not ask the patient to move the limb any further. Any open wound, deformity, swelling or bruising of a limb should be considered evidence of a possible limb injury.

Garry Briese is the executive director of the International Association of Fire Chiefs (IAFC) and, along with David Schottke, co-author of the new edition of First Responder: Your First Response In Emergency Care, available from Jones & Bartlett Publishers. The book is produced by the American Academy of Orthopaedic Surgeons and the National Safety Council.

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