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OR2.10-13 | Lower Limb Fractures — Assignment

CLINICAL SCENARIO

This assignment develops your ability to apply the principles of lower limb fracture management to a real-world clinical scenario. You will work up a patient presenting with a femoral shaft fracture and develop a structured management plan covering initial resuscitation, operative decision-making, and complication recognition — with particular emphasis on fat embolism syndrome and damage control orthopaedics.

Instructions

Read the following clinical scenario carefully.

Scenario: A 30-year-old male motorcyclist is brought to the emergency department after a high-speed collision. He has a closed mid-shaft femur fracture with 4 cm shortening and a Glasgow Coma Scale score of 14/15. His blood pressure is 90/60 mmHg, heart rate is 118/min, SpO2 94% on room air. There is no other obvious injury.

2. Write a structured management plan with the following sections:
a. Initial assessment and resuscitation (ATLS-based approach)
b. Specific management of the femoral shaft fracture — justify your choice of definitive fixation method
c. Rationale for the timing of surgery (damage control orthopaedics vs early total care)
d. Recognition and prevention of fat embolism syndrome — pathophysiology, clinical features, and management
e. Rehabilitation plan and expected outcomes

Use clinical evidence and reference standard textbooks (Maheshwari's Essential Orthopaedics, Apley and Solomon's, ATLS guidelines).
Your response should be 600–900 words, well-structured with clear headings.
Submit your response by the deadline and complete a peer review of one classmate's submission.

Length: 600–900 words

What to Submit

Initial Assessment and Resuscitation

Guidance: Use the ATLS primary survey (ABCDE) framework. Address the haemodynamic instability — estimate blood loss from femoral shaft fracture (typically 1–2 L), IV access, fluid resuscitation targets. Note any airway or breathing concerns.

Fracture Management Plan

Guidance: Define your operative approach: closed antegrade intramedullary interlocking nailing. Justify why this is preferred over traction, plating, or external fixation for this closed fracture. Comment on entry point and distal locking.

Timing of Surgery: Damage Control vs Early Total Care

Guidance: Explain the concept of damage control orthopaedics (DCO) vs early total care (ETC). Discuss physiological thresholds (lactate, base deficit, temperature, pH). Argue whether DCO (temporary external fixator → definitive nail) or ETC is appropriate given this patient's haemodynamic instability.

Fat Embolism Syndrome

Guidance: Describe the pathophysiology (mechanical and biochemical theories). List the clinical triad: hypoxaemia, neurological dysfunction, petechiae. Discuss Gurd's criteria. Management: supportive — supplemental O2, respiratory support, prophylaxis role of early fracture stabilisation.

Rehabilitation and Outcomes

Guidance: Outline early physiotherapy, protected weight-bearing progression, timeline to full weight-bearing after IMN. Address expected complications (non-union, malrotation, knee stiffness) and their prevention.

Grading Rubric — Lower Limb Fractures Assignment Rubric

Criterion	Points	Full-marks descriptor
ATLS-Based Initial Resuscitation	10 pts	Complete ABCDE assessment with accurate blood loss estimation, appropriate IV access, fluid targets, and recognition of haemorrhagic shock class.
Fracture Fixation Choice and Justification	10 pts	Correctly identifies closed antegrade IMN as gold standard; provides detailed technical justification (load sharing, early mobilisation, periosteal preservation, distal locking) and explains why alternatives are inferior.
Damage Control Orthopaedics vs Early Total Care	10 pts	Accurately explains DCO vs ETC with correct physiological thresholds (lactate >4, pH <7.25, base deficit >8, temp <35°C); correctly recommends DCO for this haemodynamically unstable patient with a clear staged plan.
Fat Embolism Syndrome — Pathophysiology, Diagnosis, Management	10 pts	Covers both mechanical and biochemical theories; correctly lists the Gurd triad (hypoxaemia, CNS dysfunction, petechiae); management includes supplemental O2, respiratory support, and role of early fracture stabilisation in prevention.
Rehabilitation Plan and Complication Awareness	10 pts	Structured rehabilitation timeline (early physiotherapy, touchdown → partial → full weight-bearing); addresses key complications (non-union, malrotation, knee stiffness) with specific prevention strategies.

PEER REVIEW

Review your assigned classmate's management plan using the rubric criteria above. For each criterion: (1) award a score with a brief justification, (2) identify one clinical fact they stated correctly, and (3) suggest one specific improvement or factual correction. Be constructive and evidence-based. Submit your peer review within 48 hours of receiving the assignment.