Extremity Injuries Principle #1: H&P Predicts Diagnosis

00:01 Hello. In this lecture we’re gonna talk about extremity injuries.

00:05 It’s not possible to talk about every single individual injury that can happen in the extremities so what we’re gonna do is use a case based approached to cover basic principles that we should always be considered when dealing with patients who have extremity trauma.

00:21 We’re gonna start off with a case.

00:23 We have a 79-year-old woman who comes in to the Emergency Department after tripping on her cat.

00:27 Cats by the way are dangerous.

00:30 Her feet got tangled; she fell with her right foot planted.

00:34 So it got stuck and she twisted herself around.

00:37 When she fell to the ground, she caught herself on her right hand.

00:40 She denies head and neck injury and her only complaints right now are right lower leg and right wrist pain.

00:47 What are the essential “can’t miss” injuries that we have to think about for this patient? In other words, what’s the differential of consequence? First and foremost, we have to consider the possibility of fracture.

00:59 Very common and a major source of morbidity and litigation when it’s missed.

01:06 Vascular injury is something that we can’t afford to miss, also, nerve injuries.

01:11 Any kind of joint space penetration when we have injuries that involves lacerations and of course, compartment syndrome.

01:19 So the first principle I wanna talk about is the importance of history and physical exam and evaluating patients with extremity injury.

01:26 The H&P will predict the diagnosis in the vast majority of cases so you always wanna know when you obtain an H&P from a patient who has extremity injury what happened? What was the mechanism of injury? How much energy was involved? Was it a simple fall? Was it a fall from a height or is there any kind of motor vehicle involved? This is all gonna change the likely outcomes that you’re gonna be concerned about.

01:52 Are there other non-extremity injuries that we need to think about.

01:56 Clearly, a patient who has or had a neck injury we’re gonna wanna address that problem first before we start worrying about a wrist or an ankle.

02:05 What’s hurting the patient right now? Generally, conscious, alert patients are able to report what parts of their body hurt and that’s gonna correlate pretty well with where they’re injured.

02:16 Is there any numbness or paresthesia? That can be a clue to a potential nerve injury.

02:22 And is there any weakness? Now, weakness is difficult because patients a lot of times with extremity injuries will have pain when they try to move and they might misinterpret that as weakness so you wanna really try to differentiate.

02:33 Are you unable to move it or is it painful to move it? Patients with true weakness, again, we wanna be concerned about nerve injury.

02:41 On physical exam, we wanna look for any violation of the skin.

02:45 So lacerations, overlying fractures are open fractures and we wanna make sure that we don’t miss anything like that.

02:53 We wanna look for deformities, swelling, contusion, basically any external sign that there’s been an injury.

02:59 We wanna palpate along the bones and identify specific areas of tenderness.

03:04 We always wanna check pulses and we wanna feel is the extremity warm or cold? Is there a good capillary refill? We wanna assess the sensory function and the motor function.

03:15 So back to our case, the mechanism is as described; the patient tripped on the cat, twisted her foot, fell on her hand.

03:24 It’s a relatively low energy injury so really, this is just gravity.

03:29 She didn’t fall from a height, there wasn’t any kind of motor vehicle involved but she did strike her leg on a fixed object.

03:36 There were no other associated injuries.

03:39 We asked about head and neck.

03:41 We asked about pain anywhere else and she didn’t report any other injuries.

03:44 She’s not reporting any numbness or paresthesias in the leg but she is reporting some numbness in the dorsum of the right hand.

03:52 She hasn’t noticed any weakness but she really hasn’t tried to move the wrist or the ankle because of pain.

03:58 On physical exam, the skin is intact so there’s no lacerations, no signs of open fracture.

04:04 She does have marked swelling over both the wrist and the lower tibia but there’s no gross deformity so the extremity appears straight, it’s not bent in an abnormal direction.

04:16 She’s tender over both the right lower shin and the right lateral leg just below the knee.

04:22 She’s also tender over the right wrist from the first metacarpal up to the distal radius, so basically in this area.

04:31 She has 2+ plus pulses in the affected extremities but she does have decreased sensation over the dorsum of her right hand.

04:39 She is able to flex and extend the wrist and the ankle.

04:43 It’s painful but she’s able to give you full strength.

04:46 So clearly, based on this history and physical we should be concerned about fracture of the wrist and fracture of the lower leg.