A secondary survey begins only after the primary survey is complete, abnormalities have been reassessed, resuscitation is underway, and the patient’s observations are improving. It involves a full head-to-toe assessment, including history, examination, and vital sign review.
At this stage, review the admission history and past medical history—especially prior falls, fracture risk, spinal conditions, and medications (notably antiplatelets or anticoagulants). Combine this with ward staff input and your initial assessment to consider possible causes of the fall.
i. History
- Has the patient reported pain or observed to be protecting use of a limb?
ii. Examination
Look for:
- Asymmetry, deformity, swelling, erythema, wounds
Feel for:
- Warmth, swelling, tenderness
Move:
- Active movement: ask patient to move
- Passive movement: if patient unable to move, gently move limb to elicit range of movement and any pain
- Compare sides, take into account previous limitations and injuries
In suspected fractures, assess neurovascular status distal to fracture looking for loss of sensation or weakness, absence or asymmetry of pulses and reflexes or acute compartment syndrome (in particular in forearm and lower leg injuries).
iii. Investigation
Have a low threshold for ordering X-rays of affected areas, guided by clinical examination. If X-rays are not readily available and uncertainty exists about whether they are required, NICE recommends using a clinical decision rule such as the Ottawa rules.
Following an ankle injury, if there is pain in the malleolar zone, and one of the following:
- inability to bear weight (walk four steps) immediately after the injury and when examined
- bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
- bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus.
Following a foot injury, if there is pain in the midfoot zone, and one of the following:
- inability to bear weight (walk four steps) immediately after the injury and when examined
- bone tenderness at the base of the fifth metatarsal
- bone tenderness of the navicular bone.
Following a knee injury, if there is one or more of the following:
- inability to bear weight (walk four steps) at the time of injury and when examined
- the person is aged 55 years or more
- tenderness at the head of the fibula
- isolated tenderness of the patella
- inability to flex the knee to 90°
Following a wrist injury, if there is:
- pain or tenderness over the scaphoid bone (palpate at the base of the anatomical snuff box and scaphoid tubercle).
Note: the Ottawa rules may be less applicable in certain clinical situations where clinical judgement should be used, for example in people who:
- are younger than 18 years of age
- are confused, have a cognitive deficit or communication problems, or are intoxicated, as the person’s expression or perception of pain can be altered
- have polytrauma, head injury or diminished sensation in the lower extremities (for example, due to neurological deficit)
- have gross swelling making palpation of the area impossible
- are pregnant.
X-ray the joint above and below the suspected injury and refer to orthopaedic services promptly if any fracture is identified or there is any uncertainty interpreting the X-ray.
To complete a full examination and to exclude any bony injuries, the patient’s mobility should be assessed. The patient should sit, stand, step, walk, observing for any pain or abnormal neurological symptoms (stop if this occurs). If equipment or specialist skills are required to assess safely, this may need to be done by the parent team.
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