Physical Examination

Essential components of the examination for musculoskeletal trauma are (1) inspection for swelling, discoloration, or deformity; (2) assessment of active and passive range of motion of the joints proximal and distal to the injury; (3) palpation for tenderness or subtle deformity; and (4) verification of neurovascular status.

INSPECTION AND RANGE OF MOTION Gross deformity along the shaft of a long bone is of course pathognomonic for fracture. The presence of most dislocations or fractures near a joint can be inferred by deformity at the joint, loss of range of motion, and severe pain at rest. An exception is posterior dislocation of the shoulder, which, while intensely painful, may not be accompanied by obvious deformity. Chaptei.2§3 has a more complete discussion of this entity.

PALPATION When gross deformity is not present, presumptive orthopedic diagnosis depends strongly on the findings noted on palpation. Palpation will disclose areas of bony step-off, as well as the precise location of point tenderness. If films are ordered before performing this phase of the examination, the wrong area may be x-rayed, because pain is commonly referred to a location distant from the injury site.

The palpation examination should be done systematically and consistently from one patient to the next. The area palpated should extend well beyond the location of the patient's subjective pain. For example, when an injured patient complains of shoulder pain, palpation should begin at the sternoclavicular joint and then proceed along the extent of the clavicle, onto the acromioclavicular joint, onto the humeral head, and along the entire humeral shaft. In addition, the scapula should be palpated for tenderness and the posterior aspect of the shoulder palpated for any unnatural prominence that might suggest a posterior dislocation. Injury to any of these areas may be reported by the patient as pain in the shoulder. Only a meticulous palpation examination may protect the physician from being misled by referred pain and missing a crucial diagnosis.

NEUROVASCULAR ASSESSMENT When injury involves an extremity, as opposed to the vertebral column, sensorimotor testing should be performed on the basis of peripheral nerve function, rather than nerve root and dermatomal distribution. In the upper extremity, the radial, median, and ulnar nerves should be tested. When the shoulder is anteriorly dislocated, two additional nerves—the axillary (supplying sensation to the lateral aspect of the shoulder) and the musculocutaneous (supplying sensation to the extensor aspect of the forearm)—should be checked as well. In the lower extremity, examination of the saphenous (sensory only), peroneal, and tibial nerves should be performed. Neurologic deficit, although not necessarily immediately reversible, is important to document early, particularly before the patient has undergone any significant manipulation or reduction maneuvers.

Assessment of vascular status should also be performed early. The sooner circulatory compromise is identified and addressed, the greater the chance of avoiding tissue infarction and necrosis. Such injuries as dislocation of the knee (tibiofemoral joint), fracture-dislocation of the ankle, and displaced supracondylar fracture of the elbow in children are commonly associated with vascular occlusion or disruption, with resulting circulatory impairment.

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