Trauma and Fracture Management
What this domain tests
Physiologic triage, fracture classification, decision timing in polytrauma, and damage-control orthopedics (DCO) versus early total care (ETC).
Core rules
- The polytrauma patient is judged by physiology, not by the fracture list. A "borderline" patient has ISS roughly 20-40 with additional insults: lactate above 2.5 mmol/L, base deficit worse than -5, hypothermia under 35 °C, coagulopathy, or vasopressor requirement. These patients get DCO.
- DCO means hemorrhage control and temporary stabilization: pelvic binder, external fixator, packing, angioembolization. Definitive fixation waits for the "window of opportunity", typically days 5-10, once the systemic inflammatory response has settled.
- Open fractures: antibiotics within one hour, tetanus status, urgent debridement and irrigation, then Gustilo-Anderson grading after debridement. A grade III fracture is never downgraded; IIIC requires vascular repair.
- Compartment syndrome is a clinical diagnosis: pain out of proportion, pain on passive stretch, tense compartment. Pulselessness and paralysis are late and must not be awaited. Pressure above 30 mmHg, or within 30 mmHg of diastolic, supports fasciotomy.
Worked example
A 34-year-old unrestrained driver has an open femur shaft fracture, a lateral compression pelvic ring injury, ISS 29, lactate 4.2 mmol/L, and base deficit -6. Answer: DCO. Apply a pelvic binder, place an anterior external fixator, resuscitate with a balanced transfusion protocol, and consider angioembolization; delay intramedullary nailing until physiology normalizes. Immediate reamed nailing in this state risks fat embolism and acute respiratory distress syndrome.
Traps that cost marks
- Downgrading a Gustilo grade after debridement.
- Missing an associated posterior urethral injury when a pelvic fracture shows blood at the meatus; do not catheterize before retrograde urethrography.
- Treating a pulseless but perfused supracondylar fracture with immediate exploration instead of reduction and pinning.