Recording oral temperature, comparing extremity pulses and limb blood pressure, and auscultating the heart and lungs should be a common routine in any examination. Traumatic injury is no exception. However, the state of the patient must set priorities.


The History Interview

The personal data collected should be similar to that recorded routinely such as name, address, date of birth, age, sex, present complaints, present and past occupations, type of work and the number of hours, recreational activities, medical and surgical history, accidents and injuries history, drug and food sensitivities, allergies, congenital difficulties, diet, smoking and drinking habits, insurance data, etc. The history should also define the types of primary and secondary physical activities, the number of hours involved, the level of achievement, the age at which active involvement began, etc.

A thorough history forms the basis for differentiating acute from chronic disorders. See Table 1.


Table 1. Differentiation of Acute and Chronic Disorders

Clinical Finding	Acute Inflammation	Chronic Inflammation
Pain	Relatively constant; likely referred over a diffuse segmental area. In intrinsic disorders, pain is increased on movement in any direction. In periarticular disorders, pain is increased on movement only in certain planes.	Increased by specific movements, relieved by rest; likely to be relatively localized near, but not necessarily over, the site of the lesion.
Passive motion	Muscle spasm or empty end-feel at the end of motion.	No muscle spasm or empty end-feel at the end of motion, possible blocking.
Tenderness	Severe.	From slight to moderate.
Skin temperature	Measurable increase.	No measurable increase.
Sleeping pattern	Difficulty in falling asleep, staying asleep, or both.	No sleeping difficulty unless a hip or shoulder is involved.

Typical Early Findings

Typical overt changes (traumatic or nontraumatic) commonly discovered in disorders of the musculoskeletal system include:

• Color changes such as ecchymosis and redness
• Local heat
• Swelling from synovial thickening, periarticular edema, nodules, or bony enlargement
• Deformity from abnormal bone angulation or subluxation
• Wasting from atrophy or dystrophy
• Tenderness on palpation
• Pain on motion
• Limitation of motion
• Joint instability
• Carriage and gait abnormalities.

In examining a patient in pain, certain types of pain are clinically significant. For example, a sharp severe pain associated with muscle changes and sensory disturbances radiating along the distribution of a nerve is characteristic of acute nerve compression. Pain from fracture is severe, throbbing, and acutely aggravated by movement of the part.


Spine-Board Transportation of the Injured

Moving an injured person frequently requires extreme care. In moving a severely injured person from one location to another, a spine board is more appropriate than the common stretcher because the board helps to prevent further aggravation of a possible vertebral or spinal cord lesion. Craig ³ warns that transporting an injured athlete from the field must be well-planned, orderly, and conducted in an unhurried manner.

Four general steps are involved in transporting any injured person:

1. The patient should be placed supine with care taken that the head, neck, and spine are in normal alignment. The spine board is placed close and parallel to the patient's body. Note, however, that a conscious patient with a painful disorder is understandably reluctant to change a position that seems comfortable, thus tending to favor a position usually involving minimum movement.

2. Usually, the patient's arm next to the board is placed at the subject's side and the patient's other arm is extended over the head if it is not injured. The patient is then gently rolled onto the side opposite the patient's extended arm. The patient should be rolled like a "log" to maintain body alignment. An exception to this would be suspicion of a spinal fracture, whereon the player should be kept on the side and not rolled supine. This may require seven people in a spinal or head injury, otherwise two people will usually suffice unless the player is extremely large.

3. The spine board is inserted under the back of the patient (not under the patient's side). Then, gently roll the patient onto the spine board. In cases of unconsciousness, facial or mouth fractures, bleeding from the mouth or nose, the patient is kept laterally recumbent to allow drainage and an open airway.

4. Assure that the injured person is in a comfortable position, then snug straps around the board and patient to secure the injured person to the spine board during transportation. If possible, remove rings from injured hands before swelling occurs.

Emergency Immobilization by Splints

To prevent further damage during referral, a fractured bone should be immobilized by immediately splinting the joints above and below the fracture because movement of these joints would disturb the bony segments. The splint should be well padded to protect the skin from injury, loss of circulation, inflammation, and infection.

A pneumatic inflatable splint is especially useful in limb fracture because it allows both immobilization and compression to minimize effusion and hemorrhage. It must be applied only snug enough to support any fracture fragments without inhibiting circulation.

To immobilize a fractured bone in the thigh or hip, an improvised splint must extend from the groin and the armpit to several inches below the foot. Padding should extend over the ends of the splint at the groin and the armpit. The bandages or straps used to secure a splint must not be applied so tightly that they impair circulation even for a few minutes. A bluish discoloration of the nailbeds or skin of the affected limb would suggest that one or more bandages are too taut. Security bandages should never be tied directly across the site of injury.

A dislocation is immobilized during referral in the same way as a fracture: close to the joint. Area ligaments are usually torn and may require surgical repair. Cold compresses can be applied to the area to relieve pain and reduce swelling. The patient's temperature must not be lowered because hyperthermia invites shock.

Postreduction immobilization of a dislocation in the lower extremity usually requires 6 weeks and in the upper extremity requires 3 weeks. Inadequate care, especially for ankle and shoulder dislocations, leads to chronic weakness, movement restrictions, instability, and recurrent dislocation in which subsequent surgery has a poor prognosis in restoring preinjury status. Except for recurring dislocations, almost all overt dislocations require anesthesia before reduction.


Roentgenology

Roentgenography should be used to confirm or dispose of suspicions arising during the history and physical examination, and not used as the sole basis of the diagnosis. When a film is used alone to confirm a prior clinical opinion, other clues exhibited on a view may be missed that indicate a different approach. This occurs when an outstanding feature, visible at a distance, overwhelms a desire to seek other evidence. Nevertheless, whatever is presented on the film must be evaluated; eg, an asymptomatic chronic disease process may be underlying an acute injury.

X-ray films are often helpful in determining dislocations, overt fractures, stress fractures, joint-space alterations, ossification, calcification, and sometimes cartilage fractures, fat pad alterations, and masses and swelling. Common radiographic signs of various bone lesions are shown in Table 2. Once relevant features classify an abnormality, a search should be made for details enabling it to be distinguished from others in the same class. This takes careful evaluation of frequently subtle soft-tissue changes which confirm osseous alterations.


Table 2. Radiologic Signs of Various Bone Lesions

Infection	Singular Malignant Bone Lesion
Formation of sequestration and involucrum	Permeactive or moth-eaten destruction (wide transition zone)
Irregular periosteal reaction frequent, no speculation	Extraosseous extension with soft-tissue mass, occasional fluffy calcifications
Diaphyseal site most common	Irregular (sometimes spiculated) periosteal reaction
Variable bone destruction	Metaphyseal area is the most common site
Destruction of adjacent cartilage crossing joints (most malignancies lack this trait)
Metastatic Lesions	Benign Bone Lesions
Moth-eaten destruction of cortex and medulla	Enlargement of an intact cortex
Pathologic fractures	Homogeneous periosteal reaction
Diaphyseal site most common	Sclerotic margins (narrow transition zone)
Periosteal reaction absent	Multiple bone involvement