Orthopaedics
Trauma and Polytrauma
Orthopaedic trauma for MBBS and NEET-PG: primary survey, haemorrhagic shock, open fractures, dislocations and polytrauma management, mapped to NMC codes OR1.1 to OR1.6.
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Trauma and Polytrauma
Orthopaedic trauma for MBBS and NEET-PG: primary survey, haemorrhagic shock, open fractures, dislocations and polytrauma management, mapped to NMC codes OR1.1 to OR1.6.
This chapter builds the systematic approach to the injured patient that the rest of orthopaedic trauma depends on. It covers the primary and secondary survey, the recognition and early management of shock, the emergency care of fractures and dislocations, and the principles of open fracture and polytrauma management.
High-yield: Trauma and Polytrauma
- The primary survey follows ABCDE: airway with cervical spine control, breathing, circulation, disability and exposure.
- The lethal triad in major trauma is hypothermia, acidosis and coagulopathy, and each one worsens the others.
- A tension pneumothorax is a clinical diagnosis treated by immediate needle decompression in the second intercostal space, not by waiting for an x-ray.
- Class III haemorrhagic shock, a loss of 30 to 40% of blood volume, is the point at which blood pressure begins to fall; tachycardia appears much earlier.
- Pelvic fractures can bleed massively into the retroperitoneum, so a binder is applied early to close the pelvic ring and tamponade bleeding.
- Damage control orthopaedics stabilises fractures temporarily with external fixation in the unstable patient and delays definitive fixation until the patient is resuscitated.
- Fat embolism syndrome typically appears 24 to 72 hours after a long bone fracture with breathlessness, confusion and a petechial rash over the chest and axilla.
- Compartment syndrome is diagnosed on pain out of proportion and pain on passive stretch; pulselessness is a very late and unreliable sign.
- The Gustilo-Anderson classification grades open fractures, and type IIIB and IIIC carry the highest infection and amputation risk.
- Open fractures need early antibiotics, tetanus cover, thorough debridement and skeletal stabilisation.
- The commonest cause of preventable death after trauma is uncontrolled haemorrhage.
- A dislocated hip in a young patient is an orthopaedic emergency because delayed reduction raises the risk of avascular necrosis of the femoral head.
- Posterior shoulder dislocation is easily missed and is classically associated with epileptic seizures and electrocution.
- Splints and traction reduce pain, limit further soft tissue and neurovascular injury, and control bleeding at the fracture site.
- A secondary survey is a head to toe examination performed only after the primary survey and resuscitation are complete.
Trauma emergencies at a glance
- **Primary survey:** ABCDE: airway with cervical control, breathing, circulation, disability, exposure. Treat as you find.
- **Haemorrhagic shock:** Tachycardia is early; falling blood pressure is a late sign from class III (30 to 40% loss).
- **Open fractures:** Gustilo-Anderson grading, early antibiotics, tetanus cover, debridement and stabilisation.
- **Time-critical joints:** Hip dislocation and open fractures need urgent reduction to protect blood supply and reduce infection.
NMC competencies in this chapter
- **OR1.1:** Principles of management of the polytrauma patient
- **OR1.2:** Recognition and management of haemorrhagic shock in trauma
- **OR1.3:** Splints, traction and emergency stabilisation of fractures
- **OR1.4:** General principles of fractures: types, clinical features and management
- **OR1.5:** Dislocations of major joints: shoulder, hip and knee
- **OR1.6:** Open fractures and the principles of their management
Frequently Asked Questions
What is the ABCDE approach in trauma?
It is the order of the primary survey: airway with cervical spine control, breathing, circulation with haemorrhage control, disability and exposure. Problems are treated as they are found before moving on.
Why is a falling blood pressure a late sign in shock?
The body compensates for early blood loss with vasoconstriction and tachycardia, so the pressure holds until about 30 to 40% of blood volume is lost, which is class III shock.
What is damage control orthopaedics?
It is a staged strategy for the unstable trauma patient in which fractures are stabilised quickly and temporarily, usually with external fixation, so definitive surgery can wait until the patient is resuscitated.
When should you suspect fat embolism syndrome?
In a patient 24 to 72 hours after a long bone or pelvic fracture who develops breathlessness, confusion and a petechial rash over the chest, axilla and conjunctiva.
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