Trauma Primary and Secondary Survey — Part 4: Focused Injury-Specific Assessment
Head injury assessment, cervical spine clearance (Canadian C-Spine Rule, NEXUS), chest injury evaluation, abdominal assessment with AAST organ injury grading (liver, spleen, kidney), pelvic fracture management, extremity vascular injury and compartment syndrome, and spinal injury with TLICS scoring.
1. Head Injury Assessment
1.1 Scalp and Skull
The scalp is highly vascularized, and lacerations can cause significant hemorrhage, particularly in children and patients on anticoagulant therapy. Hemorrhage control is achieved with direct pressure, Raney clips, or a running locked suture. Palpate the entire scalp for depressed fractures (palpable step-off), open fractures (visible bone or brain tissue), and hematomas.1 2
1.2 Basilar Skull Fracture Signs
Basilar skull fractures are clinical diagnoses. Radiographic confirmation may require thin-cut CT of the temporal bones. Clinical signs include:1
| Sign | Description | Timing |
|---|---|---|
| Battle sign | Ecchymosis over the mastoid process (postauricular) | May take 12-24 hours to develop |
| Raccoon eyes (periorbital ecchymosis) | Bilateral periorbital ecchymosis not attributable to direct facial trauma | May take 12-24 hours to develop |
| CSF rhinorrhea | Clear fluid draining from the nose (through a fracture of the anterior cranial fossa / cribriform plate) | May be immediate or delayed |
| CSF otorrhea | Clear fluid draining from the ear (through a fracture of the temporal bone / petrous pyramid) | May be immediate or delayed |
| Hemotympanum | Blood behind the tympanic membrane (visible on otoscopic examination) | May be immediate |
| Cranial nerve palsies | CN VII (facial nerve) palsy with temporal bone fracture; CN I (anosmia) with anterior fossa fracture | Variable |
CSF leak confirmation:
- Halo/ring sign: Place a drop of fluid suspected to be CSF on gauze or filter paper — CSF will separate from blood to form a clear ring around a central blood stain (sensitive but not specific)
- Beta-2 transferrin: Laboratory test that is highly specific for CSF (not present in other body fluids); definitive confirmation
- Glucose testing: CSF contains glucose (> 30 mg/dL), but this test is not specific and is no longer recommended as a sole diagnostic method
1.3 Traumatic Brain Injury — Initial Management Priorities
| Priority | Action |
|---|---|
| Prevent secondary brain injury | Avoid hypoxemia (SpO2 ≥ 94%) and hypotension (SBP ≥ 100 mmHg); maintain PaCO2 35-40 mmHg; avoid hyperglycemia |
| CT head | Non-contrast CT of the head is the imaging study of choice; obtain as soon as the patient is hemodynamically stable enough for transport |
| Neurosurgical consultation | Mandatory for all moderate-to-severe TBI (GCS ≤ 12), any intracranial hemorrhage, depressed skull fracture, or neurologic deterioration |
| Intracranial pressure (ICP) management | Elevate head of bed to 30 degrees; avoid tight cervical collar (impedes venous drainage); osmotic therapy (mannitol 0.5-1 g/kg or hypertonic saline 3% 150-250 mL) for signs of herniation; emergent surgical decompression if indicated |
A comprehensive traumatic brain injury guideline is available as a cross-reference: Traumatic Brain Injury.
2. Cervical Spine Assessment and Clearance
2.1 Overview
Cervical spine injuries occur in approximately 2-5% of blunt trauma patients and may result in devastating neurologic injury if not identified and managed appropriately. The goals of C-spine assessment are to (1) identify patients who require imaging and (2) safely clear the cervical spine in patients at low risk of injury, allowing removal of the cervical collar.1 3 4
2.2 Canadian C-Spine Rule (CCR)
The Canadian C-Spine Rule is a validated clinical decision rule designed to identify alert (GCS 15), stable blunt trauma patients who are at low risk of cervical spine injury and can safely forego radiographic evaluation. It has a sensitivity of 99-100% and a negative predictive value approaching 100% for clinically significant cervical spine injury.3
The rule is applied in three sequential steps:
Step 1 — Are there any high-risk factors that mandate radiography?
| High-Risk Factor | If ANY are present: IMAGING REQUIRED |
|---|---|
| Age ≥ 65 years | |
| Dangerous mechanism: fall from ≥ 1 meter (3 feet) or 5 stairs; axial load to the head (e.g., diving); high-speed MVC (> 100 km/h / 62 mph), rollover, ejection; motorized recreational vehicle crash; bicycle collision with fixed object | |
| Paresthesias in any extremity |
If ANY high-risk factor is present: the C-spine CANNOT be cleared clinically. Obtain imaging.
Step 2 — Are there any low-risk factors that allow safe assessment of range of motion?
| Low-Risk Factor | If ANY are present: proceed to Step 3 |
|---|---|
| Simple rear-end motor vehicle collision (excludes being pushed into oncoming traffic, being hit by a bus or large truck, rollover, being hit by a high-speed vehicle) | |
| Sitting position in the ED | |
| Ambulatory at any time since the injury | |
| Delayed onset of neck pain (not immediate) | |
| Absence of midline cervical spine tenderness |
If NO low-risk factors are present (i.e., none of the above are true): the C-spine CANNOT be cleared clinically. Obtain imaging.
Step 3 — Is the patient able to actively rotate the neck 45 degrees to the left AND right?
- If YES: C-spine can be cleared clinically. No imaging required.
- If NO (unable to rotate 45 degrees in either direction due to pain): Obtain imaging.
2.3 NEXUS Criteria (National Emergency X-Radiography Utilization Study)
The NEXUS criteria provide an alternative, simpler clinical decision rule for cervical spine clearance. All five criteria must be met to clear the cervical spine without imaging. Sensitivity: 99.0% (though slightly lower than the CCR); specificity lower than the CCR.4
| Criterion | Definition |
|---|---|
| 1. No midline cervical tenderness | No tenderness on palpation of the posterior midline cervical spine from the nuchal ridge to the prominence of the first thoracic vertebra |
| 2. No focal neurologic deficit | No motor or sensory deficit attributable to cervical spine injury |
| 3. Normal alertness | GCS 15; oriented to person, place, time, and events; not drowsy or difficult to arouse; able to respond appropriately |
| 4. No intoxication | No evidence of alcohol or drug intoxication that could alter the reliability of the examination |
| 5. No painful distracting injury | No injury (e.g., long bone fracture, large laceration, crush injury, large burn, visceral injury) that may distract the patient from neck pain |
2.4 Comparison: CCR vs. NEXUS
| Feature | Canadian C-Spine Rule | NEXUS |
|---|---|---|
| Sensitivity | 99-100% | 99.0% |
| Specificity | ~43% | ~13% |
| Missed injuries | Fewer (0-0.07%) | Slightly more (0.13%) |
| Imaging reduction | Greater (~30-40% reduction) | Moderate (~12-15% reduction) |
| Application | Requires sequential 3-step algorithm; may be more complex but more specific | Simple 5-point checklist; easier to memorize |
| Patient eligibility | Alert (GCS 15), stable, blunt trauma, age > 16 | Any age, any mechanism |
| Recommended by | Most current guidelines favor CCR due to higher sensitivity and specificity | Widely used; acceptable alternative |
2.5 Cervical Spine Clearance Algorithm
| Patient Category | Clearance Approach |
|---|---|
| Alert, no distracting injuries, not intoxicated | Apply CCR or NEXUS; if criteria met, clear clinically; if not met, obtain imaging (CT cervical spine) |
| Obtunded, intubated, or unreliable exam | CT cervical spine; if CT is negative, options include: (1) MRI within 48-72 hours to clear, (2) maintain collar and reassess when the patient can participate in a reliable exam, or (3) remove the collar based on a negative, high-quality CT alone (increasingly supported by evidence — a high-quality CT cervical spine has a negative predictive value > 99% for unstable injury)5 |
| Pediatric (< 16 years) | Modified approach; CT carries higher radiation risk; if clinical assessment is reassuring, consider plain radiographs (AP, lateral, open-mouth odontoid) or MRI; CT should be used selectively |
2.6 Imaging Modality
| Modality | Role |
|---|---|
| CT cervical spine | Current gold standard for radiographic evaluation of the cervical spine in trauma; superior sensitivity and specificity compared to plain radiographs; should include the entire cervical spine from the occiput to T1 |
| Plain radiographs (3-view: AP, lateral, open-mouth odontoid) | Largely replaced by CT in adult trauma; still used in pediatric patients and resource-limited settings; sensitivity is only approximately 52-85% for cervical spine fractures |
| MRI | Most sensitive for ligamentous injury, spinal cord injury, disc herniation, and epidural hematoma; indicated when there is a neurologic deficit, when CT is negative but clinical suspicion remains high, or to clear the cervical spine in the obtunded patient |
3. Chest Injury — Detailed Assessment
3.1 Rib Fractures
Rib fractures are the most common chest injury in blunt trauma. Morbidity and mortality increase with the number of ribs fractured and patient age.1 6
| Finding | Clinical Significance |
|---|---|
| First and second rib fractures | High-energy mechanism required; associated with great vessel injury (though the association is weaker than historically taught); warrants CT angiography if significant mechanism |
| Lower rib fractures (9-12) | Associated with abdominal organ injury — right-sided (liver), left-sided (spleen) |
| Multiple (≥ 3) rib fractures | Increased risk of pulmonary contusion, pneumothorax, hemothorax; consider epidural or regional analgesia |
| Elderly patients (> 65 years) | Mortality increases approximately 19% for each additional rib fractured; aggressive pulmonary toilet and pain management are essential |
3.2 Pulmonary Contusion
- Most common potentially lethal chest injury
- Develops over 24-48 hours; initial chest X-ray may be normal — CT is far more sensitive
- Manifests as progressive hypoxemia, opacification on imaging, increased work of breathing
- Management: supplemental oxygen, pulmonary toilet, judicious fluid administration (avoid overhydration), positive pressure ventilation if respiratory failure develops1
3.3 Traumatic Aortic Injury
Traumatic aortic injury (blunt aortic injury) is the second most common cause of death in motor vehicle collisions (after TBI). The majority of patients die at the scene. Those who survive to the hospital typically have a contained aortic tear (pseudoaneurysm) at the aortic isthmus (just distal to the left subclavian artery at the ligamentum arteriosum).1 7
CT angiography indications (screening for aortic injury):
| Indication |
|---|
| Significant mechanism of deceleration injury (high-speed MVC, fall from height) |
| Mediastinal widening on chest X-ray (> 8 cm on supine AP film) |
| First or second rib fractures |
| Left apical pleural cap (apical hematoma) |
| Loss of aortic knob contour |
| Deviation of NG/OG tube to the right |
| Depression of the left mainstem bronchus |
| Wide paraspinal stripe |
| Left hemothorax without rib fracture |
Management:
- Medical: strict blood pressure and heart rate control (SBP < 120 mmHg, HR < 80 bpm) with IV beta-blocker (esmolol) and/or nicardipine
- Definitive: thoracic endovascular aortic repair (TEVAR) has replaced open surgical repair as the standard of care in most centers; timing depends on injury grade and patient stability7
3.4 Blunt Cardiac Injury (Cardiac Contusion)
Occurs with direct blunt trauma to the anterior chest (steering wheel, fall). The right ventricle, being the most anterior chamber, is most commonly affected.1 8
| Evaluation | Findings |
|---|---|
| ECG | Most common: sinus tachycardia, premature ventricular contractions, ST changes; may show new right bundle branch block, atrial fibrillation, or other arrhythmias |
| Troponin | Elevated troponin I or T suggests myocardial injury; a normal troponin at 4-6 hours post-injury effectively excludes significant cardiac contusion |
| Echocardiography | Wall motion abnormality, reduced ejection fraction, valvular injury (traumatic VSD, chordae rupture), pericardial effusion |
Management:
- Patients with a normal ECG AND normal troponin at 4-6 hours: no further cardiac workup needed; low risk
- Patients with ECG abnormalities and/or elevated troponin: admit for continuous cardiac monitoring for 24-48 hours; obtain echocardiography if hemodynamically significant
- Treat arrhythmias per standard algorithms
4. Abdominal Injury Assessment
4.1 Diagnostic Modalities
| Modality | Indication | Advantages | Limitations |
|---|---|---|---|
| FAST | Hemodynamically unstable patient; rapid bedside screen | Fast (< 3 minutes); no radiation; repeatable; detects free fluid | Cannot identify specific organ injury; misses retroperitoneal hemorrhage and hollow viscus injury; operator-dependent |
| CT abdomen/pelvis with IV contrast | Hemodynamically stable patient with suspected abdominal injury | Gold standard for diagnosis and grading of solid organ injury; identifies retroperitoneal hemorrhage; can identify active contrast extravasation (active bleeding) | Requires hemodynamic stability for transport; radiation exposure; may miss some hollow viscus injuries; contrast allergy/nephrotoxicity risk |
| Diagnostic peritoneal lavage (DPL) | Rarely used in modern practice; may be considered when FAST is indeterminate and CT is not available (resource-limited settings), or in hemodynamically unstable patients with equivocal FAST | Highly sensitive for hemoperitoneum (> 98%); rapid | Invasive; cannot grade injury or identify source; cannot detect retroperitoneal hemorrhage; largely replaced by FAST and CT |
DPL Positive Criteria (if performed):
| Finding | Positive |
|---|---|
| Gross blood on aspiration | > 10 mL of blood |
| RBC count (blunt trauma) | > 100,000/mm3 |
| RBC count (penetrating trauma) | > 10,000-20,000/mm3 |
| WBC count | > 500/mm3 |
| Amylase | > 175 IU/dL |
| Bile, food particles, fecal matter | Any amount |
4.2 AAST Solid Organ Injury Grading — Overview
The organ injury scaling system, developed by the organ injury scaling committee of the national trauma surgery professional society, provides a standardized grading system for solid organ injuries based on CT findings and/or operative observations. The grading system guides management decisions, particularly regarding non-operative versus operative management.9 10 11
4.3 AAST Liver Injury Scale (2018 Revision)
| Grade | CT / Imaging Findings | Operative Findings |
|---|---|---|
| I | Subcapsular hematoma < 10% surface area; parenchymal laceration < 1 cm depth | Capsular tear, non-bleeding; subcapsular hematoma < 10% surface area |
| II | Subcapsular hematoma 10-50% surface area; intraparenchymal hematoma < 10 cm; laceration 1-3 cm depth, < 10 cm length | Active bleeding within hepatic parenchyma; laceration 1-3 cm depth |
| III | Subcapsular hematoma > 50% surface area or expanding; ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma > 10 cm; laceration > 3 cm depth | Active bleeding extending beyond hepatic parenchyma into peritoneum; laceration > 3 cm depth |
| IV | Parenchymal disruption involving 25-75% of a hepatic lobe; active bleeding extending beyond hepatic parenchyma into peritoneum (contained by adjacent omentum or organ) | Parenchymal disruption of 25-75% of hepatic lobe |
| V | Parenchymal disruption > 75% of hepatic lobe; juxtahepatic venous injury (retrohepatic vena cava / central major hepatic veins) | Parenchymal disruption > 75% of hepatic lobe; juxtahepatic venous injury |
Vascular injury addendum: Any liver injury with active contrast extravasation (blush) on CT is upgraded by one grade. Hepatic vascular injury (pseudoaneurysm or AV fistula) = Grade IV. Juxtahepatic venous injury = Grade V.
Management principles:
- Non-operative management (NOM) is successful in 80-90% of blunt hepatic injuries in hemodynamically stable patients
- Angiographic embolization is indicated for active contrast extravasation (blush) on CT in hemodynamically stable patients
- Operative management is indicated for hemodynamic instability not responding to resuscitation, peritonitis, or Grade V vascular injury with hemorrhage9
4.4 AAST Spleen Injury Scale (2018 Revision)
| Grade | CT / Imaging Findings | Operative Findings |
|---|---|---|
| I | Subcapsular hematoma < 10% surface area; parenchymal laceration < 1 cm depth | Capsular tear, non-bleeding; subcapsular hematoma < 10% surface area |
| II | Subcapsular hematoma 10-50% surface area; intraparenchymal hematoma < 5 cm; laceration 1-3 cm depth not involving trabecular vessels | Active bleeding confined within splenic capsule; laceration 1-3 cm depth |
| III | Subcapsular hematoma > 50% surface area or expanding; ruptured subcapsular or intraparenchymal hematoma ≥ 5 cm; laceration > 3 cm depth or involving trabecular vessels | Active bleeding extending beyond the spleen into the peritoneum; laceration > 3 cm depth or involving trabecular vessels |
| IV | Laceration involving segmental or hilar vessels producing major devascularization (> 25% of spleen); active bleeding extending beyond the spleen into the peritoneum | Laceration of segmental or hilar splenic vessels with major devascularization (> 25% of the spleen) |
| V | Shattered spleen; hilar vascular injury that devascularizes the spleen | Completely shattered spleen; hilar vascular injury |
Vascular injury addendum: Active contrast extravasation (blush), pseudoaneurysm, or AV fistula upgrades the injury by one grade.
Management principles:
- NOM is successful in approximately 90% of Grade I-III and 60-70% of Grade IV-V blunt splenic injuries in hemodynamically stable patients
- Angiographic embolization (proximal or distal) is recommended for Grade III and above with active contrast extravasation, pseudoaneurysm, or AV fistula in hemodynamically stable patients
- Operative management (splenectomy or splenorrhaphy): indicated for hemodynamic instability, peritonitis, or failed NOM
- Post-splenectomy: Patients who undergo splenectomy require lifelong vaccination against encapsulated organisms (pneumococcus, meningococcus, Haemophilus influenzae type b) — ideally administered 14 days post-splenectomy10
4.5 AAST Kidney Injury Scale (2018 Revision)
| Grade | CT / Imaging Findings | Description |
|---|---|---|
| I | Subcapsular hematoma, non-expanding; no laceration | Renal contusion or non-expanding subcapsular hematoma |
| II | Perirenal hematoma confined to the retroperitoneum; renal laceration ≤ 1 cm depth without urinary extravasation | Non-expanding perirenal hematoma; superficial cortical laceration |
| III | Renal laceration > 1 cm depth without collecting system rupture or urinary extravasation | Deep cortical laceration without collecting system involvement |
| IV | Laceration extending through the renal cortex, medulla, and collecting system (urinary extravasation present); renal vascular injury (segmental renal artery or vein injury) with contained hemorrhage; segmental infarctions without associated active bleeding; renal pelvis laceration and/or complete ureteropelvic disruption | Deep laceration with collecting system involvement; segmental vascular injury |
| V | Shattered kidney; main renal artery or vein laceration or avulsion; devascularized kidney with active bleeding; main renal artery or vein thrombosis | Main renal hilar vascular injury; shattered/devascularized kidney |
Vascular injury addendum: Active contrast extravasation (blush) on CT upgrades by one grade. Vascular injury (pseudoaneurysm, AV fistula, or segmental artery injury) = Grade IV minimum.
Management principles:
- NOM is successful in > 95% of Grade I-III and approximately 80% of Grade IV renal injuries
- Indications for operative management: hemodynamic instability, expanding or pulsatile retroperitoneal hematoma (if explored operatively for other indications), Grade V vascular avulsion with hemorrhage
- Urologic consultation for Grade III and above, any collecting system involvement, and any vascular injury
- Follow-up CT at 48-72 hours for Grade III and above11
5. Pelvic Fracture Management
5.1 Assessment
Pelvic fractures can cause massive, life-threatening hemorrhage from disruption of the presacral venous plexus, bony surfaces, and (less commonly) major arterial branches of the internal iliac arteries.1 12
Classification (Young-Burgess):
| Pattern | Mechanism | Key Feature | Stability |
|---|---|---|---|
| Lateral Compression (LC) | Side impact; most common pattern | Internal rotation of hemipelvis; sacral buckle fracture; rami fractures | LC-I: stable; LC-II: rotationally unstable; LC-III: rotationally + vertically unstable (contralateral open-book) |
| Anterior-Posterior Compression (APC) | Frontal impact (head-on MVC, motorcycle, crush) | External rotation of hemipelvis; “open book” diastasis of pubic symphysis | APC-I: stable (< 2.5 cm diastasis); APC-II: rotationally unstable (> 2.5 cm diastasis, intact posterior ligaments); APC-III: fully unstable (disrupted posterior ligaments) |
| Vertical Shear (VS) | Fall from height; axial load | Vertical displacement of hemipelvis | Rotationally and vertically unstable; highest hemorrhage risk |
| Combined Mechanism (CM) | Multiple forces | Combination of the above patterns | Variable; often unstable |
5.2 Pelvic Binder Application
| Aspect | Detail |
|---|---|
| Indication | Suspected mechanically unstable pelvic fracture with hemorrhage; any pelvic fracture patient with hemodynamic instability |
| Placement | Center the binder at the level of the greater trochanters (NOT the iliac crests); the goal is to reduce the volume of the true pelvis and compress fracture fragments to tamponade venous and bony bleeding |
| Types | Commercial pelvic binders (T-POD, SAM Pelvic Sling); improvised: a folded bed sheet tied tightly around the pelvis at the level of the greater trochanters |
| Duration | Leave in place until definitive fixation or until ruled out by imaging; can be loosened periodically to check skin (risk of pressure necrosis if left too tight for > 24-48 hours) |
| Caution | Lateral compression injuries with internal rotation deformity may worsen with circumferential compression — clinical judgment required |
5.3 Hemorrhage Control in Pelvic Fractures
| Intervention | Indication |
|---|---|
| Pelvic binder | First-line for all suspected unstable pelvic fractures |
| Preperitoneal packing | Increasingly used as a rapid hemorrhage control technique; performed in the ED or OR; direct packing of the preperitoneal space through a low midline or Pfannenstiel incision |
| Angiographic embolization | Indicated when there is arterial contrast extravasation on CT (present in approximately 10-15% of pelvic fractures with hemorrhage); particularly for internal iliac artery branch bleeding |
| External fixation | Temporary mechanical stabilization; less commonly used acutely since the introduction of pelvic binders |
| REBOA | Zone 3 (infrarenal) balloon occlusion as a bridge to definitive hemorrhage control in extremis |
| Definitive fixation | Internal fixation performed once the patient is physiologically optimized12 |
6. Extremity Injury Assessment
6.1 Vascular Injury — Hard and Soft Signs
Vascular injuries must be rapidly identified because delayed diagnosis leads to limb ischemia and amputation. Signs are categorized into hard signs (requiring emergent operative exploration) and soft signs (requiring further evaluation).1 13
Hard Signs (Mandate Emergent Operative Exploration)
| Hard Sign | Description |
|---|---|
| Pulsatile external bleeding | Active arterial hemorrhage from the wound |
| Expanding or pulsatile hematoma | Suggests arterial injury with ongoing bleeding |
| Absent distal pulses | Absence of palpable pulses distal to the injury (compare to contralateral limb) |
| Signs of distal ischemia (“6 P’s”) | Pain (out of proportion), Pallor, Pulselessness, Paresthesias, Paralysis, Poikilothermia (cold) |
| Bruit or thrill over the wound | Suggests arteriovenous fistula or pseudoaneurysm |
Soft Signs (Require Further Evaluation — CTA or ABI Monitoring)
| Soft Sign | Description |
|---|---|
| Proximity of wound to major vessel | Penetrating or blunt injury near a major vascular structure |
| Diminished (but present) distal pulses | Compared to contralateral limb |
| Small, stable, non-pulsatile hematoma | Not expanding on serial examination |
| History of hemorrhage at scene (now controlled) | Reported by EMS; currently hemostatic |
| Peripheral nerve deficit | Adjacent nerves travel with arteries; nerve injury raises suspicion for vascular injury |
Ankle-Brachial Index (ABI) in Trauma
| ABI Value | Interpretation | Action |
|---|---|---|
| ≥ 0.9 | Normal — low risk of significant vascular injury | Serial exam; no further vascular workup required |
| < 0.9 | Abnormal — significant vascular injury likely | CT angiography or operative exploration |
6.2 Compartment Syndrome
Compartment syndrome occurs when pressure within a closed fascial compartment rises to a level that compromises perfusion of the muscles and nerves within that compartment. It is a surgical emergency requiring fasciotomy.1 14
Most common locations:
- Leg (4 compartments: anterior, lateral, superficial posterior, deep posterior) — most common site
- Forearm (3 compartments: volar, dorsal, mobile wad)
- Thigh (3 compartments: anterior, posterior, medial)
- Hand, foot (less common but occur)
Risk factors in trauma:
- Long bone fractures (especially tibial shaft fractures — most common cause)
- Crush injury
- Vascular injury with ischemia-reperfusion
- Tight casts or dressings
- Massive fluid resuscitation (bilateral lower extremity compartment syndrome)
- Burns (circumferential)
- Prolonged limb compression (found down)
Clinical findings (the “6 P’s”):
| Sign | Timing | Notes |
|---|---|---|
| Pain out of proportion to injury | Earliest and most reliable sign | Especially pain with passive stretch of the involved muscles |
| Pressure (tense, firm compartment on palpation) | Early | Compare bilaterally |
| Paresthesias | Early-intermediate | Nerve ischemia |
| Paralysis | Late sign — indicates irreversible muscle/nerve damage | |
| Pulselessness | Very late sign — compartment syndrome is a clinical diagnosis long before pulses are lost | |
| Pallor/Poikilothermia | Late |
Pressure thresholds:
| Measurement | Threshold for Fasciotomy |
|---|---|
| Absolute compartment pressure | > 30 mmHg (traditionally cited threshold) |
| Delta pressure (diastolic BP minus compartment pressure) | < 30 mmHg — this is the preferred criterion as it accounts for the patient’s perfusion pressure; a delta pressure < 30 mmHg indicates inadequate perfusion of the compartment |
Management:
- Immediate fasciotomy is the definitive treatment when clinical findings or pressure measurements indicate compartment syndrome
- Remove all circumferential dressings, casts, and splints
- Fasciotomy should be performed emergently — delay > 6-8 hours is associated with irreversible muscle necrosis, rhabdomyolysis, and potential need for amputation
- All compartments in the affected extremity must be released (e.g., all 4 compartments of the leg via two-incision technique)14
6.3 Fracture Management Priorities
In the multiply injured patient, fracture management priorities are guided by the principle that life-threatening conditions are addressed first, followed by limb-threatening conditions.1
| Priority | Injury | Rationale |
|---|---|---|
| Emergent | Open fractures; fractures with vascular injury; fractures with compartment syndrome; fracture-dislocations (hip, knee) | Limb-threatening; delay increases risk of amputation, infection, and long-term disability |
| Urgent (within 24 hours) | Femoral shaft fractures; unstable pelvic fractures (after initial hemorrhage control); spinal fractures with neurologic deficit | Early fixation reduces complications (fat embolism, ARDS, VTE); facilitates patient mobilization and nursing care |
| Delayed (after physiologic optimization) | Other long bone fractures; stable pelvic and acetabular fractures; stable spinal fractures without neurologic deficit | Can be addressed after the patient is resuscitated and physiologically stable |
Open fracture management:
- Gustilo-Anderson classification (Type I, II, IIIA, IIIB, IIIC) guides management
- All open fractures require: wound irrigation and debridement, prophylactic antibiotics (cefazolin 2 g IV; add gentamicin for Type III; add penicillin or metronidazole for farm/soil contamination), tetanus prophylaxis, and operative fixation
- Early definitive soft tissue coverage reduces infection risk
7. Spine Injury Assessment
7.1 Thoracolumbar Injury Classification and Severity Score (TLICS)
The TLICS is a scoring system developed by the national spine surgery study group to guide management of thoracolumbar spine injuries. It integrates three independent components to produce a severity score that recommends operative versus non-operative management.15
TLICS Scoring Components
Component 1 — Injury Morphology:
| Morphology | Points |
|---|---|
| Compression fracture | 1 |
| Burst fracture | 2 |
| Translational/rotational injury | 3 |
| Distraction injury | 4 |
Component 2 — Integrity of the Posterior Ligamentous Complex (PLC):
| PLC Status | Points |
|---|---|
| Intact | 0 |
| Indeterminate (suspected injury) | 2 |
| Disrupted | 3 |
Component 3 — Neurologic Status:
| Neurologic Status | Points |
|---|---|
| Intact (no deficit) | 0 |
| Nerve root injury | 2 |
| Complete spinal cord injury | 2 |
| Incomplete spinal cord injury | 3 |
| Cauda equina syndrome | 3 |
TLICS Management Algorithm
| Total TLICS Score | Recommended Management |
|---|---|
| ≤ 3 | Non-operative (brace/orthosis) |
| 4 | Equivocal — either operative or non-operative may be appropriate; clinical judgment |
| ≥ 5 | Operative (surgical stabilization and/or decompression) |
7.2 Neurologic Examination in Spinal Cord Injury
The neurologic examination follows the international standards for neurological classification of spinal cord injury, which defines the neurologic level and completeness of injury.16
Key motor levels:
| Root | Key Muscle | Action |
|---|---|---|
| C5 | Biceps, brachialis | Elbow flexion |
| C6 | Extensor carpi radialis | Wrist extension |
| C7 | Triceps | Elbow extension |
| C8 | Flexor digitorum profundus (middle finger) | Finger flexion |
| T1 | First dorsal interosseous, abductor digiti minimi | Finger abduction |
| L2 | Iliopsoas | Hip flexion |
| L3 | Quadriceps | Knee extension |
| L4 | Tibialis anterior | Ankle dorsiflexion |
| L5 | Extensor hallucis longus | Great toe extension |
| S1 | Gastrocnemius, soleus | Ankle plantarflexion |
Completeness classification (ASIA Impairment Scale):
| Grade | Description |
|---|---|
| A — Complete | No motor or sensory function preserved in sacral segments S4-S5 |
| B — Sensory Incomplete | Sensory but no motor function preserved below the neurologic level and includes sacral segments S4-S5 |
| C — Motor Incomplete | Motor function preserved below the neurologic level; more than half of key muscles below the level have a muscle grade < 3 |
| D — Motor Incomplete | Motor function preserved below the neurologic level; at least half of key muscles below the level have a muscle grade ≥ 3 |
| E — Normal | Motor and sensory function are normal |
7.3 Spinal Shock
Spinal shock is the temporary loss of all neurologic function (motor, sensory, reflex, and autonomic) below the level of spinal cord injury. It must be distinguished from neurogenic shock (hemodynamic instability from loss of sympathetic tone).1
| Feature | Spinal Shock | Neurogenic Shock |
|---|---|---|
| Definition | Temporary loss of all spinal cord function below injury level | Loss of sympathetic vascular tone causing vasodilation and bradycardia |
| Duration | Hours to weeks; end marked by return of bulbocavernosus reflex | Acute; resolves over days to weeks |
| Clinical significance | Cannot determine prognosis (complete vs. incomplete injury) until spinal shock resolves | Hemodynamic; must exclude hemorrhagic shock first |
| Management | Supportive; serial neurologic exams | Volume resuscitation + vasopressors (norepinephrine) |
7.4 Steroid Controversy in Spinal Cord Injury
The use of high-dose methylprednisolone (the former “NASCIS protocol”) for acute spinal cord injury is no longer recommended by the current guidelines of the major neurosurgical and trauma surgery professional societies.17 18
| Evidence | Summary |
|---|---|
| NASCIS II (1990) | Reported a small improvement in motor function at 6 months if methylprednisolone was given within 8 hours of injury; however, the analysis was a post-hoc subgroup analysis, and the results have been widely criticized |
| NASCIS III (1997) | Extended the protocol and reported modest benefit with 48 hours of treatment if started 3-8 hours after injury; again, post-hoc analysis with significant complications (wound infections, sepsis, pneumonia) |
| Current consensus | Multiple national and international spine and neurosurgery societies recommend against routine methylprednisolone use in acute SCI; the marginal neurologic benefit (if any) is outweighed by significant complications (infection, GI hemorrhage, hyperglycemia, wound healing impairment, sepsis) |
| Current recommendation | Methylprednisolone for SCI is not recommended as a standard treatment; if used at all, it should be considered an option only within 8 hours of injury after a risk-benefit discussion, and its use should not delay surgical decompression17 18 |
References
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