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OR13.1-2 | Orthopaedic Procedural Skills — PBL Case

CLINICAL SETTING

It is 3:00 AM on a Saturday. A 26-year-old male motorcyclist, Rajan, is brought to the emergency room of a district hospital by ambulance after a head-on collision with a truck on a national highway. The paramedic handover states: estimated speed 80 km/h, no helmet, 30-minute transport time. On arrival, Rajan is moaning but confused (GCS 10: E3V3M4), with BP 92/60 mmHg, HR 124/min, SpO2 87% on room air, RR 30/min. You are the senior intern on duty with the casualty medical officer. Quick inspection reveals: a visibly deformed right thigh with massive swelling and bruising; an open wound over the right tibial shaft with bone protruding (approximately 2 cm, heavily contaminated with road grit); a deep laceration over the right flank; and multiple abrasions. The trachea appears to be deviated slightly to the left. Before inserting a urinary catheter, your casualty officer pauses: 'Wait — look at this.' A drop of blood is visible at the urethral meatus.

Trigger 1: Airway, Breathing and the Deviated Trachea

The team secures the airway with a jaw thrust and oral airway adjunct while preparing for rapid sequence intubation (GCS ≤10 with RR 30 and SpO2 87%). Tracheal deviation to the LEFT is now confirmed with absent breath sounds over the RIGHT upper zone. There is hyper-resonance on percussion over the right chest.

DISCUSSION POINTS

  • What life-threatening condition does this triad (tracheal deviation away from a silent hemithorax, hyper-resonance) suggest, and what is the immediate intervention before confirming with imaging?
  • What is the correct anatomical landmark for needle decompression and why?
  • After needle decompression, what definitive 'B' step follows, and where is the chest drain inserted?
  • The SpO2 improved to 96% after needle decompression and intubation. What ATLS step comes next and why is sequence important?
Click to reveal Trigger 2: Circulation, IV Access, and the Urethral Dilemma (discuss previous trigger first!)

Trigger 2: Circulation, IV Access, and the Urethral Dilemma

With breathing stabilised, attention turns to circulation. BP remains 90/60 mmHg with HR 118/min. The femoral shaft fracture has caused a massively swollen right thigh. The open tibial fracture is bleeding moderately. Your CMO asks you to establish IV access and prepare for bladder catheterisation to monitor urine output. You notice the blood at the urethral meatus. A second look confirms bruising spreading across the perineum.

DISCUSSION POINTS

  • Why is blood at the urethral meatus an absolute contraindication to urethral catheterisation, and what specific injury does it indicate?
  • What investigation confirms urethral injury before proceeding with bladder drainage? If imaging is unavailable and bladder drainage is urgent, what is the safe procedural alternative?
  • With the femoral shaft fracture, up to how much blood can accumulate in the thigh, and why does the Thomas splint help with both pain and haemorrhage control?
  • The open tibial fracture has visible bone and road contamination. What is the most time-critical non-surgical intervention, and within what timeframe must it be given according to guidelines? What antibiotic would you choose and why?
Click to reveal Trigger 3: Post-Stabilisation: The Tight Plaster and a New Complaint (discuss previous trigger first!)

Trigger 3: Post-Stabilisation: The Tight Plaster and a New Complaint

Four hours later, Rajan has been taken to the operating theatre. The tibial fracture has been washed out and a posterior tibial slab (below-knee plaster slab) applied as a temporary measure pending formal fixation. The femoral shaft fracture has been placed in a Thomas splint with skin traction. Rajan is now in recovery, extubated and alert. He begins to complain of 6/10 aching in his right lower leg that is increasing despite IV analgesia. The nurse notices his toes are cool and there is no capillary return in the toenails.

DISCUSSION POINTS

  • What are the 5 Ps of compartment syndrome? Which of these signs is the earliest and most sensitive, and why is an intact pulse misleading?
  • What is the physiological threshold for compartment syndrome? Define delta-P and explain why a measured compartment pressure of 35 mmHg in a patient with a diastolic BP of 55 mmHg is dangerous.
  • Describe the immediate procedural steps you would take in response to Rajan's symptoms — in the correct order.
  • If cast splitting does not relieve the ischaemia, what definitive surgical procedure is required, and which four compartments of the leg must be decompressed?

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [OR13.2] What are the ATLS ABCDE priorities in polytrauma resuscitation, and what are the procedural skills required at each step (airway — ETT; breathing — needle decompression; circulation — IV access + catheter; disability — GCS; exposure — splintage)?
  2. [OR13.2] What are the signs of urethral injury in pelvic trauma, and what is the absolute contraindication to urethral catheterisation? What is the safe alternative procedure?
  3. [OR13.1] What is the joint-above-and-below rule in casting, and how does it apply to different fracture levels (tibial shaft, femoral shaft, distal radius)?
  4. [OR13.1] What are the clinical signs of compartment syndrome after cast application? What is the earliest sign? What is the delta-P threshold, and what procedural steps are taken to relieve it?
  5. [OR13.1] What is the role of the Thomas splint in femoral shaft fracture management, and how does traction reduce blood loss and fat embolism risk?