OR1.3 | Soft Tissue Injury Assessment — Summary & Reflection

KEY TAKEAWAYS

Soft tissue injury assessment encompasses a spectrum from contusion to compartment syndrome, open fractures, and crush injury with rhabdomyolysis.

Key points:
- Closed degloving (Morel-Lavallée lesion) is easily missed — skin is intact but detached from deep fascia; skin necrosis follows
- Compartment syndrome: 6 P's in order — Pain (out of proportion), Pain on passive stretch (earliest reliable sign), Paraesthesia, Pallor, Paralysis, Pulselessness (LATEST — present pulse does NOT exclude the diagnosis)
- Compartment pressure thresholds: >30 mmHg absolute, OR ΔP (diastolic BP minus compartment pressure) <30 mmHg = fasciotomy
- Open fracture: antibiotics within 1 hour (more time-critical than surgery); Gustilo-Anderson I/II: cephalosporin; Grade III: add gentamicin; farm/soil: add metronidazole; the 6-hour debridement rule is obsolete
- Gustilo-Anderson IIIC = arterial injury requiring vascular repair; IIIB = periosteal stripping requiring flap reconstruction
- Rhabdomyolysis: CK >5,000 + myoglobinuria = treat aggressively; IV fluids to achieve UO 200–300 mL/h; urinary alkalinisation; monitor K+ (hyperkalaemia is the acute killer)
- Dark 'cola' urine + dipstick 'blood' positive + no RBCs on microscopy = myoglobinuria (not haematuria)

REFLECT

Consider a scenario in which you are working as the duty doctor in a district hospital and a 30-year-old man is admitted with a tibial fracture after a motorcycle crash. He has a small open wound, 0.8 cm, over the fracture site. The orthopaedic surgeon is not available until the next morning, 8 hours away. What steps will you take in the first hour? How will you decide whether to administer antibiotics, and which ones? How will you monitor for compartment syndrome through the night, and at what threshold will you escalate or act? Write a brief management plan as if you were handing over to a colleague, using the framework from this module. This exercise prepares you for the most common scenario a general duty doctor faces in the Indian district hospital setting.