Trauma and Orthopedic Emergencies
What the board tests
Sequencing of the primary survey, control of catastrophic haemorrhage, damage-control resuscitation, and recognition of limb- and life-threatening orthopaedic injury.
Primary survey and haemorrhage
- Catastrophic external bleeding is controlled before airway in the exsanguinating patient (C-ABC).
- Apply a pelvic binder at the level of the greater trochanters; do not spring the pelvis to test it.
- Permissive hypotension targets a systolic near 90 mmHg until haemorrhage control, except in traumatic brain injury where SBP at least 110 mmHg (or MAP at least 80) is maintained.
- Massive transfusion in 1:1:1 ratio (red cells, plasma, platelets), with calcium replacement; tranexamic acid 1 g within 3 h of injury, then 1 g over 8 h.
- Unstable patient with a positive FAST goes to laparotomy, not to CT.
Limbs and secondary survey
- Hard signs of vascular injury: pulsatile bleeding, expanding haematoma, bruit or thrill, absent distal pulse, ischaemia. These need immediate exploration or CT angiography.
- Knee dislocation: reduce early, document pulses and sensation before and after, measure ankle-brachial index (under 0.9 is abnormal), splint and image the vessels.
- Compartment syndrome: pain out of proportion, pain on passive stretch, tense compartment. Pulses and pink skin persist late, so never wait for all five Ps.
- Open fracture: IV antibiotics within 1 h, tetanus cover, saline-soaked dressing, formal debridement; do not close primarily in the ED.
- Use Ottawa ankle and knee rules to justify or withhold imaging.
Worked example
A pedestrian struck by a car has BP 80/50, a tender unstable pelvis and no external bleeding. Place a pelvic binder, give tranexamic acid, activate the massive transfusion protocol, and run a FAST. If FAST is negative and the patient stays unstable after binder and blood products, the bleeding source is likely pelvic venous or arterial: proceed to angioembolisation, preperitoneal packing or REBOA depending on local capability rather than sending an unstable patient to CT.
Traps
Sending a responder to CT before resuscitation; missing a posterior hip dislocation; relying on crystalloid; missing a second fracture (femur with tibia, calcaneus with spine); failing to re-document neurovascular status after every reduction or splinting.