Musculoskeletal Emergencies and Wound Management
What to know
Musculoskeletal and wound items center on neurovascular assessment, infection, and timely surgical referral. For any fracture or dislocation, document the six Ps: pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia. Compartment syndrome's earliest and most reliable sign is pain out of proportion to the injury, especially pain with passive stretch; pulses often remain palpable. Keep the limb at heart level - not elevated above it - and report findings immediately, because fasciotomy is time-sensitive. Open fractures need antibiotics, tetanus prophylaxis, and irrigation. Necrotizing fasciitis is a surgical emergency with pain out of proportion, rapidly spreading erythema, bullae, and systemic toxicity; antibiotics are adjuncts to debridement. Animal bites are irrigated and often treated with amoxicillin-clavulanate, with rabies risk assessed. Know tetanus prophylaxis indications.
Traps
A palpable pulse does not rule out compartment syndrome. Do not elevate an ischemic or compartment-syndrome limb. Do not close contaminated wounds primarily. Fat embolism after long-bone fracture presents with hypoxemia, petechiae, and confusion.
Worked example
A patient with a tibial fracture has severe pain, tense swelling, and pain when the toes are passively flexed, but a strong pulse. This is compartment syndrome; notify the surgeon now. Rule of thumb: pain with passive stretch is the finding that should get you off the computer.