Clinical focus: Examination of wounds and injuries must be systematic, gentle and reproducible. Stabilise life threats first, obtain consent, expose enough to identify hidden injury, examine function and neurovascular status, use imaging selectively, and document both positive and relevant negative findings. The examination describes facts; it does not decide guilt, intent or legal responsibility.
Learning objectives
- Perform an ABCDE-informed primary and secondary survey in an injured patient.
- Examine skin, soft tissue, bones, joints, tendons, nerves, vessels and body cavities according to mechanism.
- Identify red flags for occult haemorrhage, compartment syndrome, open fracture, tendon/nerve injury, vascular injury and infection.
- Choose appropriate bedside tests and imaging, including when a normal examination is not reassuring.
- Use trauma-informed consent, chaperones, safeguarding and forensic documentation principles.
1. Before touching the patient
- Ensure scene and staff safety; use gloves, eye protection and sharps precautions.
- Introduce yourself, confirm identity, explain the purpose and likely discomfort, and obtain consent for examination, photographs, chaperone and specimens separately.
- Provide privacy, warmth and a chaperone according to patient preference and policy. Use a trained interpreter rather than a family member when possible.
- Look at the mechanism, time, first aid, contamination, anticoagulants, bleeding disorders, diabetes, immunosuppression, pregnancy and tetanus history.
- Control catastrophic bleeding and perform ABCDE before detailed wound inspection.
2. Primary survey: ABCDE
| Domain | Examination | Red flags |
|---|---|---|
| Airway/cervical spine | Talk to the patient, inspect mouth/face/neck, listen for voice change/stridor, palpate gently and protect the spine when indicated. | Obstruction, expanding haematoma, hoarseness, dysphagia, neck penetrating injury or facial burns. |
| Breathing | Respiratory rate/effort, oxygen saturation, chest expansion, percussion, breath sounds and open wounds. | Severe distress, absent breath sounds, tracheal deviation, sucking chest wound, cyanosis or shock. |
| Circulation | External bleeding, pulse/skin/mental status, capillary refill, blood pressure, pelvis and long bones; obtain IV/IO access as needed. | Uncontrolled haemorrhage, weak/absent pulses, cool clammy skin, altered mental state or disproportionate tachycardia. |
| Disability | GCS/AVPU, pupils, glucose, focal neurology, spinal tenderness and limb motor/sensory function. | GCS decline, seizure, unequal pupils, focal deficit or new paralysis. |
| Exposure | Undress systematically, inspect front/back/perineum and protect from hypothermia. | Missed wounds, pressure injury, hidden bleeding or unsafe environment. |
3. Secondary survey and SAMPLE history
Once immediate threats are treated, repeat vital signs and complete a head-to-toe examination. Use SAMPLE: Symptoms, Allergies, Medicines (including anticoagulants), Past history/pregnancy, Last meal/menstrual period, Events/environment/mechanism.
- Ask about pain location, severity, movement limitation, numbness, weakness, bleeding, foreign-body sensation and loss of consciousness.
- Clarify the object or surface, force, direction, distance, protective clothing, chemical/electrical source, animal/human bite and time since injury.
- Ask what the patient did after injury (washing, pressure, medication, removal of an object) and record it without blame.
- Assess psychosocial safety, violence, self-harm and safeguarding when the mechanism or history suggests assault, neglect or abuse.
4. Systematic local wound examination
| Element | How to examine and document |
|---|---|
| Site | Use anatomical landmarks, side, body region and distance from fixed points; avoid vague terms such as “near the arm.” |
| Number | Count and number wounds; examine surrounding skin and hidden surfaces. |
| Size | Measure length, width and visible depth in millimetres/centimetres; do not force a probe into a puncture. |
| Shape/orientation | Describe linear, curved, stellate, irregular, patterned, transverse/longitudinal and relation to skin tension lines. |
| Margins/base | Clean, ragged, abraded, inverted/everted, tissue bridges, devitalised tissue, fat/tendon/bone exposure and foreign material. |
| Colour/appearance | Redness, bruising, swelling, blister, eschar, discharge, granulation or necrosis; colour alone cannot date a bruise. |
| Bleeding | Active venous/arterial bleeding, oozing, haematoma, pulsatility and haemostasis after pressure. |
| Tenderness/function | Pain, sensation, movement, strength, range of motion and function before local anaesthetic when safe. |
| Associated findings | Fracture, dislocation, compartment signs, vascular deficit, infection, foreign body or cavity penetration. |
5. Neurovascular examination
Document before and after manipulation, anaesthesia, splinting or closure. Compare with the uninjured side when appropriate.
- Vascular: colour, temperature, capillary refill, pulses proximal/distal to injury, Doppler signal, active bleeding and signs of ischaemia.
- Motor: test each relevant tendon and nerve against resistance; record power and pain limitation separately.
- Sensory: light touch and two-point discrimination in named nerve territories; map numbness rather than writing “normal sensation.”
- Compartment: pain out of proportion, pain on passive stretch, tense swelling, paraesthesia, weakness and late pulselessness. Pulses may remain present.
| Region | Useful function checks |
|---|---|
| Hand/wrist | Finger flexion/extension, thumb opposition/abduction, wrist movement, radial/ulnar pulses, median/ulnar/radial sensory territories. |
| Forearm/elbow | Wrist/finger tendons, pronation/supination, elbow range, pulses and compartment signs. |
| Lower limb | Toe/ankle movement, knee/hip function, dorsalis pedis/posterior tibial pulses, peroneal/tibial sensation and compartment signs. |
| Neck | Airway/voice/swallowing, neurological exam, expanding haematoma, pulses and penetrating trajectory; avoid blind probing. |
6. Regional examination priorities
Head and face
Inspect scalp, ears, nose, mouth, teeth, eyes, facial symmetry and cranial nerves. Look for skull depression, CSF/blood from ear/nose, malocclusion, orbital injury, dental fracture and facial nerve deficit. Do not press on a suspected open globe; use a rigid shield and urgent ophthalmology.
Neck and strangulation
Ask about loss of consciousness, voice change, breathing/swallowing difficulty, neck pain, incontinence and neurological symptoms. Inspect petechiae, ligature marks, bruising and swelling, but absence of marks is not reassuring. Consider delayed airway/vascular injury and urgent imaging/ENT/vascular review.
Chest and back
Inspect all surfaces, palpate ribs/sternum/spine, assess expansion and breath sounds, and look for penetrating wounds. A small wound can conceal pneumothorax, haemothorax, cardiac or great-vessel injury.
Abdomen and pelvis
Inspect, auscultate as appropriate, palpate gently for tenderness/guarding/rigidity and assess pelvic stability only once. Check flank/perineum, urinary blood, pregnancy possibility and genital injury. Do not repeatedly rock an unstable pelvis.
Limbs and joints
Inspect alignment, swelling, open wounds and deformity. Palpate bone and compartments, test active/passive movement, tendon function, sensation and distal circulation. Examine the entire limb, not only the obvious wound.
Genital/anal examination
Use trauma-informed consent, a chaperone, appropriate lighting and a trained examiner. Document injuries, discharge, bleeding and normal findings. Avoid speculum or digital examination when contraindicated or not consented; children require specialist pathways.
7. Bedside tests and imaging
| Test | When useful | Limitations |
|---|---|---|
| Plain radiograph | Fracture, dislocation, radiopaque foreign body, gas or chest injury. | May miss radiolucent wood/plastic, tendon injury or early occult fracture. |
| Ultrasound/POCUS | Free fluid, pneumothorax, vascular flow, tendon, abscess or retained superficial foreign body. | Operator dependent; a negative scan does not exclude injury. |
| CT | Head, facial, cervical, chest/abdomen, complex fracture, deep foreign body or vascular injury in stable patients. | Radiation/contrast risks; do not delay surgery in an unstable patient. |
| CT angiography/Doppler | Hard/soft signs of arterial injury or uncertain perfusion. | Requires renal/contrast assessment and vascular expertise. |
| MRI | Selected tendon, ligament, spinal cord, soft-tissue and occult injury. | Time, availability, metal/foreign-body and instability limitations. |
| Laboratory | CBC, group/cross-match, renal/electrolytes, CK, coagulation, pregnancy, infection/toxicology according to case. | Do not let normal labs reassure against structural injury. |
8. Special mechanism examinations
| Mechanism | Exam priorities |
|---|---|
| Blunt impact/fall | Head/neck, spine, chest, abdomen, pelvis, long bones, hidden posterior injuries and anticoagulant use. |
| Sharp/penetrating | Count wounds, determine possible trajectory without probing, assess distal neurovascular status and signs of cavity penetration. |
| Firearm/blast | Entry/exit or fragment sites, burns/soot, multiple body surfaces, hearing/eye injury, secondary fragments and scene coordination. |
| Bite | Depth, tendon/joint involvement, teeth/foreign body, infection, tetanus/rabies risk and safeguarding. |
| Crush | Duration of compression, perfusion, compartments, CK, urine, potassium, renal function and systemic shock. |
| Thermal/chemical/electrical | Airway, burn depth/extent, circumferential injury, ocular exposure, entry/exit electrical burns, arrhythmia and associated trauma. |
9. Recognising hidden danger
- Small external wound with shock, expanding haematoma, severe pain or falling haemoglobin.
- Penetrating wound near neck, chest, abdomen, groin, axilla, eye or major joint.
- Delayed pain, swelling, fever, discharge, tissue necrosis or crepitus.
- Loss of active movement or sensation despite preserved skin; consider tendon or nerve injury.
- Pain out of proportion or pain on passive stretch; suspect compartment syndrome.
- Normal pulse but cool, pale or cyanotic limb; use Doppler/vascular consultation.
- Patient with diabetes, immunosuppression, vascular disease, anticoagulation or bleeding disorder.
10. Examination in suspected violence or SGBV
- Provide privacy, LIVES support and separate consent for medical examination, photographs and evidence samples.
- Record the survivor’s account without leading questions; do not equate absence of injury with absence of assault.
- Use a chaperone and trauma-informed pauses; stop if requested. Children require specialised, safeguarding-led examination.
- Describe bruises, abrasions, bite marks and genital/anal findings with measurements, sites and diagrams; colour cannot date a bruise accurately.
- Label, dry, seal and transfer specimens according to the local evidence kit and chain-of-custody procedure.
11. Examination of burns
| Feature | Assessment |
|---|---|
| Depth | Superficial erythema; partial-thickness blistering/moist painful skin; full-thickness leathery, pale/charred, insensate skin. |
| Extent | Estimate total body surface area using a validated method; do not count simple erythema in major-burn calculations. |
| Location | Face/neck, hands, feet, genitalia, major joints and circumferential limbs need specialist review. |
| Inhalation | Enclosed-space fire, facial burns, soot, hoarseness, cough, stridor, hypoxia or altered consciousness. |
| Associated trauma | Fall, blast, electrical arrhythmia, chemical exposure, fracture and safeguarding. |
12. Examination of bites and punctures
Measure, photograph with scale, map tooth/pressure patterns and assess depth, tendon, nerve, joint and foreign body. Ask about animal vaccination and exposure geography for rabies. Human bites require blood-borne infection risk assessment. Do not rely on a small skin mark to judge deep penetration.
13. Documentation essentials
- Record identity, date/time, examiner, chaperone/interpreter, consent and mechanism/history source.
- Use a body diagram and number every injury; measure in three dimensions and record side/anatomical landmark.
- Describe appearance objectively and record relevant normal findings and function.
- Document neurovascular status before and after treatment, anaesthetic, splint or closure.
- List investigations, photographs, specimens, treatment, referrals and follow-up.
- State limitations and distinguish observed fact from expert opinion.
14. Worked cases
Case 1: Knife wound to the forearm
After bleeding control and ABCDE, the patient cannot flex the ring finger and has reduced ulnar sensation. Document tendon/nerve tests, pulses and wound dimensions, cover and splint, provide analgesia/tetanus, obtain imaging if foreign body is suspected and refer for urgent hand surgery. Do not close a deep wound before specialist assessment.
Case 2: Neck wound after assault
A small lateral neck wound is accompanied by hoarseness and neck swelling. Treat as a potential airway/vascular emergency: airway readiness, monitoring, urgent trauma/ENT/vascular input and appropriate imaging. The skin size is not a measure of internal risk.
Case 3: Leg crush injury
Severe pain and a tense compartment with potassium 6.0 mmol/L indicate systemic crush risk and possible compartment syndrome. Perform repeated neurovascular checks, ECG/renal/CK testing, treat hyperkalaemia, resuscitate and obtain urgent surgical review.
15. Quick self-test
- What must be completed before the detailed wound examination?
- Name the four key components of a neurovascular exam.
- Why can a small puncture wound be dangerous?
- What symptoms after strangulation require urgent escalation?
- Why should a clinician document relevant normal findings?
Answers
- Scene safety, consent, catastrophic haemorrhage control and ABCDE primary survey.
- Perfusion/pulses, capillary refill/colour/temperature, motor function and sensory function, with compartment assessment.
- It may penetrate a joint, cavity, tendon, nerve or vessel and can conceal a foreign body or infection.
- Breathing/voice/swallowing change, syncope, neurological deficit, neck swelling/tenderness, petechiae or airway symptoms.
- They provide a complete, objective baseline, support clinical decisions and prevent the false inference that unrecorded findings were absent.
Key take-home points
- Examine in a consistent head-to-toe sequence and reassess after treatment or clinical change.
- Measure wounds, test function and document neurovascular status before and after intervention.
- Normal pulses, a small skin wound or normal initial imaging does not exclude deep injury.
- Mechanism guides examination, but the examination must remain objective and survivor-centred.
- Use specialist pathways early for airway/neck, eye, hand, genital, joint, vascular, compartment, burn and penetrating injuries.
References and further reading
- WHO: Improving care of the injured
- MSD Manual Professional: Approach to the trauma patient
- MSD Manual Professional: Skin lacerations
- NCBI Bookshelf: Wound classification
- MSD Manual Professional: Human and mammal bites
Educational note: This is a learning resource. Follow current trauma, surgical, burn, safeguarding and forensic protocols, and obtain senior help whenever depth or function is uncertain.
