Emergency and Acute Care Management
Domain 10: Emergency and Acute Care Management
This domain tests rapid triage, limb salvage priorities, and recognition of time-critical orthopaedic emergencies.
Core rules
- Primary survey first: airway, breathing, circulation, disability, exposure. Control external hemorrhage with direct pressure or a tourniquet.
- Compartment syndrome: pain out of proportion, pain with passive stretch, tense swelling, and paresthesia. Pulses may be normal. Remove casts and dressings and arrange emergent fasciotomy.
- Open fracture: antibiotics, tetanus, sterile dressing, splint, and urgent debridement.
- Cauda equina syndrome: saddle anesthesia, bowel/bladder dysfunction, bilateral leg pain or weakness; obtain urgent MRI and decompress.
- Septic arthritis: hot swollen joint, fever, inability to bear weight; aspirate before antibiotics when feasible.
- Necrotizing fasciitis: pain out of proportion, rapidly spreading erythema, bullae, systemic toxicity; surgical emergency.
- Fat embolism: hypoxemia, confusion, petechiae after long-bone fracture; supportive care.
Worked example
A patient with a tibial shaft fracture in a cast reports escalating pain and numbness. Passive toe extension is agonizing, but the foot is pink with a palpable pulse. This is compartment syndrome until proven otherwise. Split the cast, call orthopaedics, and prepare for fasciotomy; do not wait for pulselessness.
Traps
Using pulses to exclude compartment syndrome; giving antibiotics before cultures in a stable septic joint; and delaying MRI in suspected cauda equina.