moved,  all  suspected  or  known  fractures  should  be stabilized (with splints, traction splints, or the like). Step 21.—Check for a distal pulse and capillary refill.  To make sure there are no circulatory problems in the legs or feet, check the distal pulse and capillary refill.   The  distal pulse  is a pulse taken at the foot or wrist.  It is called distal because the pulse is located at the distal end of the limb.  The distal pulse of the foot, also referred to as pedal pulse, may be taken at either of two sites:  the posterior tibial pulse (located behind the medial ankle) or the dorsalis pedis pulse (located on the anterior surface of the foot, lateral to the large tendon of the great toe). You should compare the quality of the pulses in each  lower  limb.    Absence  of  a  distal  pulse  usually indicates  that  a  major  artery  supplying  the  limb  has been  pinched  or  severed. This  condition  may  be caused by a broken or displaced bone end or a blood clot.   An absent or weak distal pulse may also result from splints or bandages being applied too tightly. Check capillary refill by squeezing a toe (usually, the big toe) with your thumb and forefinger.  The skin and  nail  where  pressure  is  applied  should  blanch (lighten).    When  you  release  the  pressure,  the  color (blood)  should  return  immediately.    If  it  takes  more than 2 seconds for the color to return, capillary refill is considered delayed. NOTE:   After splints or bandages are applied, check capillary refill to make sure circulation has not been impaired. Step   22.—Check  for  nerve  function  and possible   paralysis   of   the   lower   extremities (conscious patient).   Check the lower extremities of conscious  patients  for  nerve  function  or  paralysis. First, touch a toe and ask the patient which toe it is.  Do this to both feet. If the patient cannot feel your touch or if the sensations in each foot are not the same, assume that nerve damage in the limb or a spinal injury has occurred. If  sensations  appear  normal  and  no  injuries  are present, have the patient wave his feet.  Finally, ask the patient to gently press the soles of his feet against your hand.   The inability of the patient to perform any of these tasks indicates the possibility of nerve damage. When nerve damage is suspected, assume the patient has a spinal injury. Step  23.—Examine  the  upper  extremities  for injury.   Check  for  signs  of  injury  to  the  upper extremities (arms and hands) by inspecting each limb, one at a time, from clavicle to fingertips.  Rearrange or remove  items  of  clothing  to  observe  the  entire examination  site.     Check  for  point  tenderness, swelling,  or  bruising.    Any  of  these  symptoms  may indicate  a  fracture.    Immobilize  any  limb  where  a fracture is suspected. Step 24.—Check for a distal pulse and capillary refill.   To  make  sure  the  circulation  to  the  upper extremities has not been compromised, confirm distal (radial)  pulse.     Initial  check  of  radial  pulse  was performed during the primary survey.  Check capillary refill  of  fingers  or  palm  of  hand  (see  step  21  for procedure).  If there is no pulse or if capillary refill is delayed, the patient may be in shock or a major artery supplying  the  limb  has  been  pinched,  severed,  or blocked. Step   25.—Check   for  nerve   function   and possible   paralysis   of   the   upper  extremities (conscious patient).   Check the upper extremities of conscious  patients  for  nerve  function  or  paralysis. Have the patient identify the finger you touch, wave his hand, and grasp your hand.   Do this to both hands.   If the patient cannot feel your touch or the sensations in each hand are not the same, assume nerve damage in the limb or a spinal injury has occurred. WARNING:   Be  alert  for  a  rapid  onset  of difficult  breathing  or  respiratory  arrest. These conditions may occur to patients who have sustained a cervical injury. Step  26.—Inspect  the  back  and  buttocks  for injury.   If there is no indication of injury to the skull, neck, spine, or extremities, and you have no evidence of severe injury to the chest or abdomen, gently roll the conscious  patient  as  a  unit  toward  your  knees  and inspect the surface of the back for bleeding or obvious injuries.   The back surface may be inspected prior to positioning the patient for transport or delayed until the patient   is   transferred   to   a   spineboard   or   other immobilization device. VITAL SIGNS.¾Vital signs (which generally are taken  after  primary,  secondary,  and  head-to-toe surveys  have  been  completed)  include  taking  the patient’s  pulse,  respiration,  blood  pressure,  and temperature.  Depending  on  local  protocols,  the patient’s level of consciousness as well as eye pupil size and reactivity may be recorded with vital signs. Skin  characteristics,  such  as  temperature,  color,  and 4-9