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OR13.1-2 | Orthopaedic Procedural Skills — Assignment
CLINICAL SCENARIO
This assignment asks you to apply your knowledge of orthopaedic procedural skills to a real-world clinical scenario involving polytrauma. You will work through the initial resuscitation priorities (ATLS ABCDE), describe the procedural steps for relevant interventions, and critically reflect on the rationale behind key safety rules — including cast application principles and the contraindication to urethral catheterisation.
Instructions
Read the following scenario carefully and answer all four sections:
Scenario: A 24-year-old male motorcyclist is brought to the emergency room after a high-speed road traffic accident. He is unconscious (GCS 9), BP 85/55 mmHg, HR 128/min, respiratory rate 28/min. On examination: trachea midline, diminished breath sounds at the right base, open tibial fracture (right leg, bone visible, heavily contaminated), and pelvic instability on gentle rocking. Blood is noted at the urethral meatus.
- ATLS ABCDE Resuscitation (approx. 200 words): Outline the ABCDE priorities for this patient's initial 15 minutes in the emergency room. For each step, state what you would do and why, including specific procedures relevant to polytrauma resuscitation.
- Procedural Skills Rationale (approx. 200 words): (a) Explain why urethral catheterisation is contraindicated in this patient and describe the safe alternative. (b) Describe how you would apply appropriate splintage to the open tibial fracture as a temporising measure, including the principle behind the 'joint above and below' rule.
- Cast Complication Recognition (approx. 200 words): After the patient is stabilised, a plaster slab is applied to the fractured tibia pending surgery. Describe the neurovascular observations you would perform and the specific signs that would prompt you to split the cast immediately. Include the physiological basis of compartment syndrome.
- Critical Reflection (approx. 100 words): Reflect on ONE potential error a junior doctor might make in this scenario (e.g., attempting urethral catheterisation, delayed antibiotics, or missing compartment syndrome signs) and describe what system-level safeguard or habit could prevent it.
Length: 600–900 words
What to Submit
Section 1: ATLS ABCDE Resuscitation
Guidance: Follow the structured ABCDE format. For A (Airway): mention GCS threshold for intubation (≤8). For B (Breathing): identify the diminished breath sounds (consider pneumothorax). For C (Circulation): address haemorrhagic shock — state IV access strategy, including contraindications to urethral catheter. For D (Disability): AVPU/GCS reassessment. For E (Exposure): log-roll, keep warm, analgesia.
Section 2: Procedural Skills Rationale
Guidance: Part (a): Clearly state blood at meatus = urethral injury = absolute contraindication. Describe retrograde urethrogram and suprapubic catheter as the safe alternative. Part (b): Describe the splint (posterior tibial slab or box-splint), immobilise the ankle and knee (joint above and below the tibia), cover the wound with saline-soaked gauze, and explain why IV antibiotics within 1 hour are also part of the procedural bundle.
Section 3: Cast Complication Recognition
Guidance: List the 5 Ps: Pain (especially on passive stretch — earliest sign), Pallor, Paraesthesia, Paralysis, Pulselessness (late sign). Explain that compartment pressure above 30 mmHg (or within 30 mmHg of diastolic BP = delta P < 30 mmHg) impairs perfusion. Describe cast splitting, bivalving, and cutting all padding as the immediate intervention, with fasciotomy if pressure does not normalise.
Section 4: Critical Reflection
Guidance: Focus on one realistic error: e.g., attempting urethral catheter despite blood at meatus (systemic fix: mandatory pre-catheter meatus check protocol); or delaying antibiotics >1 hour for open fracture (fix: antibiotic kit in the trauma bay with a checklist prompt). Reflection should be specific, not generic.
Grading Rubric — Orthopaedic Procedural Skills Assignment Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| ATLS ABCDE Application — Correct, structured application of ATLS priorities to this specific patient with appropriate procedural detail | 10 pts | All 5 ABCDE steps addressed with correct, patient-specific procedural detail; airway protection threshold (GCS ≤8) stated; breathing abnormality correctly identified; shock management including IV access plan described; urethral catheter contraindication acknowledged |
| Procedural Knowledge — Accurate description of urethral catheter contraindication, safe alternative, and splintage principles including the joint-above-and-below rule | 10 pts | Blood at meatus as absolute contraindication explicitly stated; retrograde urethrogram + suprapubic catheter described; splint correctly named with joints immobilised (ankle and knee for tibial fracture); antibiotic timing (within 1 hour) mentioned |
| Compartment Syndrome Recognition — Accurate description of neurovascular observations and trigger signs, with physiological basis explained | 10 pts | All 5 Ps listed; passive stretch pain identified as earliest sign; compartment pressure threshold stated (delta P <30 mmHg or absolute >30 mmHg); cast splitting/bivalving with padding release described; fasciotomy mentioned as next step |
| Critical Reflection Quality — Specificity, insight, and practical value of the reflection on one potential error and its prevention | 10 pts | Specific error identified with realistic mechanism of occurrence; systemic or habit-based prevention strategy described; reflection shows genuine insight rather than restating facts |
| Communication and Structure — Clarity, professional medical writing, logical organisation, and adherence to word guidance | 10 pts | Clear, logical structure with section headings used; professional medical writing; word count within 600–900 words; terminology correct throughout |
PEER REVIEW
You will review one peer's assignment anonymously. Read their response to each section and use the rubric criteria above to assign a score (0, 4, 6, 8, or 10) for each criterion. For each criterion, write 1–2 sentences explaining your score — focus on what was done well and what was missing or incorrect. Be constructive and specific. Total score is out of 50.