Orthopedic Surgery and Anesthesia
Orthopaedic Surgery and Anaesthesia tests fracture description, emergency management, and the airway, anaesthetic risk and analgesic decisions a surgical trainee must own.
Fracture principles
- Describe every fracture: bone and site, pattern (transverse, oblique, spiral, comminuted, greenstick), displacement, angulation, rotation, shortening, joint involvement, open or closed.
- Document neurovascular status before and after reduction and after plastering.
- Open fractures follow Gustilo-Anderson grading: IV antibiotics within 1 hour, tetanus cover, photograph the wound, saline dressing, then debridement and fixation - urgent in grade III.
- Compartment syndrome: pain out of proportion, pain on passive stretch, tense compartment. A delta pressure (diastolic minus compartment) under 30 mmHg or absolute pressure above 40 mmHg means fasciotomy. Pulses are usually present - do not wait for them to disappear.
- Hip fracture: surgery within 48 hours, VTE prophylaxis and early mobilisation reduce mortality. Fat embolism causes hypoxia, petechiae and confusion after long-bone fracture.
Anaesthesia
- ASA I-V classification; airway assessment with Mallampati, mouth opening, thyromental distance and the LEMON mnemonic.
- Malignant hyperthermia: masseter spasm, hypercapnia, rigidity, rising temperature - stop the volatile agent and give dantrolene 2.5 mg/kg.
- Local anaesthetic systemic toxicity: perioral tingling, seizures, arrhythmias - 20% lipid emulsion and airway support.
- Multimodal analgesia with paracetamol, NSAIDs where safe, opioid PCA and regional blocks to reduce opioid requirements.
Worked example
A 35-year-old has an open tibial shaft fracture with a 6 cm wound and periosteal stripping after a motorcycle crash. This is Gustilo IIIB: IV antibiotics and tetanus immediately, debridement and external fixation, and planning for flap coverage of the soft-tissue defect.
Traps
Waiting for absent pulses to diagnose compartment syndrome; delaying antibiotics to reach theatre in open fracture; failing to document distal neurovascular status after plaster; ignoring rising end-tidal CO2 in a febrile patient under anaesthesia.