Orthopaedics and Trauma: Limb Threats
What you must know
Trauma follows the primary survey with catastrophic haemorrhage control and spinal precautions, then the secondary survey. Orthopaedic assessment describes fractures by site, pattern, displacement, angulation, rotation, and whether the injury is open or closed. Know the Gustilo classification of open fractures, compartment syndrome, fat embolism, osteomyelitis, septic arthritis and the Salter-Harris classification in children.
Classic traps
- Compartment syndrome is a clinical diagnosis. The earliest reliable sign is pain out of proportion to the injury, especially on passive stretch. Pulses usually remain palpable; never wait for pulselessness.
- In open fractures, cover the wound, splint, give intravenous antibiotics and tetanus prophylaxis, and proceed to theatre for debridement. Do not repeatedly probe or inspect the wound.
- A pulseless supracondylar fracture in a child needs urgent reduction, not simply a cast.
- Always document distal neurovascular status before and after any manipulation.
Rule of thumb
Reduce dislocations and fracture-dislocations as soon as the patient is stable, then reassess neurovascular status and immobilise. An ischaemic limb is an emergency: the longer the delay, the greater the risk of irreversible injury. Remember the six Ps of compartment syndrome but rely on pain.