"Orthopedic Trauma & Compartment Syndrome" — Practice

Question 1

Which is the most reliable early clinical sign of acute compartment syndrome of the leg?

Accepted Answer

B

Question 2

An open tibial fracture has a 2 cm wound but the popliteal artery is divided and requires repair. The Gustilo-Anderson grade is

Accepted Answer

D

Question 3

A 24-year-old with a closed tibial shaft fracture in a cast reports escalating pain 8 hours after admission, needing increasing morphine. The dorsalis pedis pulse is easily palpable and the foot is warm. What is the next step?

Accepted Answer

Treat this as compartment syndrome. A palpable pulse does not exclude it, and an escalating analgesic requirement is itself a warning sign.

Split the cast and all dressings down to skin immediately, since a bivalved cast still constricts. Keep the limb at heart level rather than elevating it, because elevation lowers arterial inflow pressure and worsens perfusion. Examine for pain on passive stretch of the toes, correct any hypotension, and proceed to fasciotomy without waiting for imaging.

Question 4

A farmer sustains an open tibial fracture with a 3 cm soil-contaminated wound and arrives 2 hours after injury. Theatre is available in 5 hours. What are the priorities?

Accepted Answer

Antibiotics immediately, since early administration is the single most effective measure against infection and matters more than the precise timing of surgery. Add Gram-negative cover for the agricultural contamination and check tetanus status.

Photograph and dress the wound with a saline-soaked dressing, splint the limb, and assess neurovascular status with a specific look for compartment syndrome. The old six-hour rule is not evidence-based, so a planned debridement by a skilled team within a reasonable window is preferable to an immediate operation by whoever is available. Grade the fracture definitively in theatre.

Question 5

A patient with a cervical spine injury is hypotensive at 80/50 with a heart rate of 52. The abdomen is soft and the pelvis is stable. What is the diagnosis and the trap?

Accepted Answer

Neurogenic shock from loss of sympathetic outflow in an injury above roughly T6. The combination of hypotension with bradycardia is the discriminator, since hypovolaemic shock produces tachycardia.

Treatment is fluid with vasopressor support rather than continued transfusion alone. The trap runs in both directions: attributing the hypotension to bleeding leads to over-transfusion, while accepting neurogenic shock too readily leads to a missed haemorrhage, so occult bleeding must still be actively excluded.

Question 6

A polytrauma patient has a femoral shaft fracture and a splenic injury, with lactate 6 mmol/L, base deficit −9 and temperature 34.5 degrees Celsius. Should the femur be nailed now?

Accepted Answer

No. The physiology decides, not the fracture. Raised lactate, a large base deficit and hypothermia all indicate incomplete resuscitation, and the patient is entering the lethal triad of hypothermia, acidosis and coagulopathy.

A long reamed nailing would deliver a second hit to an already primed inflammatory system, raising the risk of acute respiratory distress syndrome and multi-organ failure. Apply an external fixator as damage control, taking minutes rather than hours, continue resuscitation and active rewarming, and convert to definitive fixation once lactate, base deficit and temperature have corrected. The evidence that early nailing reduces pulmonary complications applies to the resuscitated patient, not this one.

Question 7

A man is rescued after 6 hours trapped under a collapsed wall. His legs are compressed but he is alert and haemodynamically stable. What is the greatest immediate danger and how is it managed?

Accepted Answer

Reperfusion, not compression. While the limb is compressed the damaged muscle is effectively isolated from the circulation. Lifting the weight releases potassium, myoglobin, phosphate and urate simultaneously, and hyperkalaemia can cause cardiac arrest within minutes of extrication.

Intravenous fluid should be started before the weight is lifted wherever feasible, so the circulation is loaded before the potassium arrives. Anticipate hyperkalaemia with cardiac monitoring and immediate treatment, give aggressive fluid resuscitation to limit myoglobin precipitation in the renal tubules, and monitor for acute kidney injury. Reserve fasciotomy for genuine compartment syndrome in salvageable muscle, since opening a limb of already necrotic muscle adds infection risk without benefit.

Question 8

An unstable patient has an open-book pelvic injury. A binder has been applied over the iliac crests without improvement, and the team is arranging angiography. Critique this management.

Accepted Answer

Two errors of sequence. The binder is in the wrong place: the mechanical lever that closes an open-book injury acts through the greater trochanters, so a binder over the iliac crests achieves nothing and the ring remains open.

And angiography is being reached for too early. Most pelvic haemorrhage is venous, from the presacral plexus, and from cancellous bone surfaces, both of which tamponade once the volume of the pelvis is reduced. Arterial bleeding is a minority of cases, though a majority of deaths. The correct order is to reposition the binder at trochanteric level, continue resuscitation including tranexamic acid if within three hours of injury, and only then move to preperitoneal packing or embolisation if instability persists.

Question 9

A polytrauma patient extubated on day 3 complains of wrist pain that was never documented. How could this have been prevented, and why does it matter?

Accepted Answer

By a tertiary survey. Roughly one in ten significant injuries is missed during the primary and secondary surveys, and the pattern is predictable: injuries cluster in hands, feet, the cervical and thoracic spine and the non-dominant limb, precisely because they are neither life-threatening nor obvious.

The patients at highest risk are those intubated, distracted by a dominant injury, or taken straight to theatre, all of which apply here. The tertiary survey is a complete head-to-toe re-examination with a review of every image, performed once the patient is awake and stable, conventionally within 24 hours. It matters because a missed scaphoid or Lisfranc injury rarely kills anyone but frequently determines whether a survivor returns to work.

Practice — "Orthopedic Trauma & Compartment Syndrome"

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