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Musculoskeletal trauma is frequently encountered in the prehospital setting. In 2007, extremity injuries accounted for over 14 million emergency department visits within the United States.1 Injuries from falls, motor vehicle accidents, sports activities, and pedestrian versus vehicle accidents are commonly encountered. It is imperative that EMS physicians know how to appropriately stabilize and manage these injuries as many result in limb or life-threatening conditions.


  • Understand the epidemiology of musculoskeletal extremity injuries in the prehospital environment.

  • Recognize common injury patterns and their mechanisms.

  • Be familiar with common immobilization techniques and equipment.

  • Be familiar with common reduction techniques.

  • Select appropriate destination facilities based on patients' injuries.



After ensuring the scene of the injury is safe, it is reasonable to consider adhering to the methodology described by courses such as ATLS and PHTLS (prehospital trauma life support) for performance of the primary and secondary survey. Management of airway compromise, respiratory failure, and life-threatening hemorrhage will be addressed elsewhere in this text.


The secondary survey identifies limb-threatening extremity injuries within its later portion as injuries to the head and thorax take early precedence. ATLS guidelines recommend the “ask, look, and feel” approach to evaluation. “Ask:” Awake and alert patients will help identify painful injuries, bleeding, or deficits. “Look:” Expose the patient's extremities and look for evidence of injury such as bleeding, swelling, deformity, discoloration, or cyanosis. Swelling, especially over large muscle groups, may be indicative of underlying fractures, hematoma formation, or crush injuries. Discoloration and cyanosis of distal extremities suggests ischemia of the affected limb. “Feel:” Palpate extremities to assess for tenderness, loss of sensation, deformity, crepitus, and distal pulses plus perfusion.2

Prior to manipulating any injured extremities, a distal neurovascular examination should be performed. Assess for key extremity pulses, such as radial artery pulses in the upper extremities and dorsalis pedis and posterior tibial artery pulses in the lower extremity. Compare pulses to the contralateral extremity. Also observe and compare capillary refill in distal nail beds. Capillary refill exceeding 2 seconds is generally abnormal. Evaluation of key sensory and motor groups will also provide important information and should be done during this assessment.

Extremities with grossly contaminated open fractures should have dirt and debris removed by saline irrigation or wiping followed by sterile dressing application. Vaseline dressings may be utilized as an initial layer over an open fracture with soft bulky dressings overlying. Extremities with suspected fractures should be immobilized, preferably with a padded splint.

In general, prehospital reduction of fractures is discouraged. Fracture reduction is a painful process which is best accomplished with the assistance of procedural sedation in the emergency department setting. There are, however, situations ...

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