Orthopedics and Emergency Care
This domain covers the first hour of emergency care and musculoskeletal problems that present to the health unit: fractures, dislocations, back pain, anaphylaxis, chest pain, stroke and hypoglycaemia. The Board tests structured primary survey, safe splinting and indications for transfer.
Core rules
- Primary survey (ATLS): catastrophic haemorrhage control, Airway with cervical spine protection, Breathing, Circulation, Disability (GCS, pupils, glucose), Exposure with prevention of hypothermia. Treat threats as you find them.
- Describe every fracture by site, open or closed, pattern (transverse, oblique, spiral, comminuted), displacement, angulation and neurovascular status distally.
- Ottawa ankle rules: X-ray only if there is pain near the malleoli plus bone tenderness at the posterior edge of either malleolus or inability to bear weight four steps. Similar rules exist for the knee.
- Back pain red flags: age over 50 with new pain, trauma, weight loss, fever, night pain, history of cancer, intravenous drug use, neurological deficit, bladder or bowel dysfunction, saddle anaesthesia - the last three mean cauda equina syndrome, an emergency.
- Shoulder dislocation is usually anterior; check the axillary nerve (deltoid sensation) before and after reduction.
- Compartment syndrome: pain out of proportion, pain on passive stretch, paraesthesia, pallor, paralysis, pulselessness (late). Refer immediately; do not elevate above heart level.
- Anaphylaxis: intramuscular adrenaline 0.5 mg of 1:1000 solution into the anterolateral thigh for adults, repeated after five minutes; oxygen, fluids, then antihistamine and steroid as adjuncts.
Worked example
A 30-year-old develops stridor, urticaria and hypotension minutes after an intramuscular antibiotic. Reasoning: anaphylaxis, so adrenaline 0.5 mg IM immediately into the thigh, lie flat with legs raised, high-flow oxygen, rapid crystalloid bolus, repeat adrenaline at five minutes if no improvement, and observe for at least six hours because biphasic reactions occur.
Traps that cost marks
- Delaying adrenaline while giving antihistamines first.
- Missing cauda equina red flags in back pain.
- Diagnosing a sprain without applying the Ottawa rules and missing a fracture.