Page 99 Guide to Pain Management in Low-Resource Settings

Chapter 12

Physical Examination: Orthopedics

Richard Fisher

Clinical case story 1 (extremities) call anesthesiologist and instruct the operating theater to
perform a closed manipulation of the fracture and apply
You have been asked to see a patient in the emergency a long leg plaster splint. Th ey tell you they will be ready
room of your hospital. Th e patient is a 46-year-old male in 2 hours.
who was pinned between a loading dock and a truck Th e manipulation seems to work, and you apply
bumper several hours ago. His left lower extremity is in a a plaster splint to three sides of the limb—leaving the an-
temporary cardboard splint, and after a primary evalua- terior aspect open to allow room for swelling. Th e patient
tion, he seems not to have other signifi cant injuries. He is is comfortable with oral or intramuscular pain medica-
alert and will talk to you. tion, and things seem to be going well. Th e vascular and
Your initial examination of the left lower ex- neurological function of the left foot and ankle seems to
tremity shows a swollen calf with a mild angular defor- be improved following your reduction, although not com-
mity and bruised but closed skin. Examination of the pletely normal.
knee shows no eff usion, but range of motion and ligament Th e next day, just before you begin rounds, the
testing are not possible because of calf pain. Likewise, the nurse calls you because the patient is having extreme
range of motion of the hip cannot be tested. pain in his left calf. She has given all the pain medi-
Th e patient can move his toes and ankle in both cation ordered, and it is not helping. You go quickly to
directions. He states he can feel you touch the toes and examine him and fi nd that his splint is intact, but his
foot, but they have a tingling feeling; slightly diff erent left leg below the knee is swollen and tense. He cannot
than the right. Th e left foot is slightly cooler and seems extend or fl ex his toes. You can passively extend them
paler. You cannot palpate a dorsalis pedis or posterior with mild discomfort, but if you try to passively fl ex
tibial pulse. Capillary refi ll at the toes seems slower than them he screams with pain. Th ere is a diff use decrease
on the right, but intact. in sensation about the foot and calf, and there is no
X-ray is available, so you ask to have an X-ray feeling between the fi rst and second toes on the dorsal
taken of the tibia and fi bula. Th e X-ray shows transverse surface of the foot. Yesterday you could palpate weak
mid-shaft fractures of both bones with some angulation posterior tibial and dorsalis pedis pulses, but now there
and minimal displacement—but little comminution. is no dorsalis pedis pulse by palpation. His capillary
You decide that the fracture should be “reduced” refi ll is slower, and the foot feels cooler and looks paler
[placed in proper alignment], and so you contact the on- than yesterday.

Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. No responsibility is assumed by IASP 87
for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or
ideas contained in the material herein. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent
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