Thorough neurovascular exam of all extremities: These patients have a high rate of missed injury, both due to distracting injuries and often because they present with altered mental status from a shock state and cannot communicate where they are experiencing pain. Any bony step-off, crepitus, laxity, or abnormal motion should be noted.

Skin exam: The skin overlying any fracture should be evaluated for dermal violation. Any wound violating the dermis in the area of a fracture should be considered an open fracture until deemed otherwise. Skin with poor perfusion or severely injured skin overlying a fracture should raise concern for a threatened fracture, or one that may progress to being open.

Concomitant injuries.

When any of the orthopaedic emergencies are present (See Chapter 5).