12.1 ATLS Principles

Question 1

A 35-year-old male is brought to the emergency department after a high-speed motor vehicle collision. On arrival, he is drowsy but opens his eyes to voice. His blood pressure is 80/50 mmHg, heart rate 128 beats/min, respiratory rate 28/min, and oxygen saturation 90% on room air. Pelvic instability is noted on examination, and there is no obvious external bleeding. FAST scan shows no intra-abdominal free fluid.

Which of the following is the most appropriate next step in his management?

A) Apply a pelvic binder and initiate massive transfusion protocol
B) Insert a urinary catheter to monitor urine output
C) Obtain an urgent CT scan of the abdomen and pelvis
D) Administer intravenous tranexamic acid and arrange orthopedic consultation
E) Perform an urgent laparotomy for suspected intra-abdominal hemorrhage

Correct Answer: A) Apply a pelvic binder and initiate massive transfusion protocol

In a hemodynamically unstable trauma patient with pelvic instability and no evidence of intra-abdominal bleeding on FAST, pelvic fracture-related hemorrhage is the most likely cause of shock. Immediate application of a pelvic binder reduces pelvic volume, stabilizes the fracture, and limits further bleeding. Concurrent activation of a massive transfusion protocol (balanced ratio of PRBCs, plasma, and platelets) is critical to correct hypovolemia and coagulopathy.

Urinary catheter insertion (B) should be avoided before excluding urethral injury, which is common in pelvic fractures. CT scan (C) is inappropriate in unstable patients as it delays resuscitation. Tranexamic acid and orthopedic review (D) are important but should follow initial hemorrhage control measures. Urgent laparotomy (E) is indicated for unstable patients with positive FAST, which is not the case here.

Question 2

A 22-year-old male motorcyclist presents to the emergency department after colliding with a car. He has an obvious deformity and open wound over the mid-shaft of the right tibia with bone protruding through the skin. The wound is contaminated with dirt. His vitals are: BP 110/70 mmHg, HR 104 beats/min, RR 18/min, SpO₂ 98% on room air. Distal pulses are palpable.

What is the most appropriate immediate next step in his management?

A) Urgent transfer to the operating theatre for fracture fixation
B) Irrigation of the wound with normal saline and wound closure in the ED
C) Application of sterile dressing, IV antibiotics, tetanus prophylaxis, and limb splinting
D) Arrange for urgent CT scan of the leg to assess fracture pattern
E) Perform aggressive wound debridement and leave wound open for secondary closure

Correct Answer: C) Application of sterile dressing, IV antibiotics, tetanus prophylaxis, and limb splinting

Open fractures are orthopedic emergencies due to the high risk of infection and neurovascular compromise. Immediate management in the emergency setting involves covering the wound with a sterile saline-soaked dressing, initiating broad-spectrum intravenous antibiotics as soon as possible (preferably within 1 hour of injury), providing tetanus prophylaxis, and immobilizing the limb to reduce pain and further tissue damage. These measures stabilize the patient and prevent infection before definitive surgical management.

Urgent fixation (A) is necessary but only after initial resuscitation, wound care, and antibiotics. Primary wound closure in the ED (B) is not recommended as contaminated wounds require thorough surgical debridement first. CT imaging (D) is unnecessary before urgent antibiotic administration. Aggressive debridement (E) should be performed in the operating theatre after the patient is stabilized.

Question 3

A 28-year-old man presents 6 hours after sustaining a closed tibial shaft fracture during a football game. His leg is in a splint. He complains of severe pain that is not relieved by intravenous opioids. On examination, the leg is tense and swollen, and pain increases markedly with passive stretching of the toes. Distal pulses are palpable, and capillary refill is normal.

What is the earliest and most reliable clinical sign of his condition?

A) Pallor of the skin distal to the injury
B) Absent distal pulses
C) Severe pain out of proportion to the injury
D) Numbness over the dorsum of the foot
E) Paralysis of the toes

Correct Answer: C) Severe pain out of proportion to the injury

The earliest and most reliable clinical sign of acute compartment syndrome is severe pain that is disproportionate to the apparent injury, often accompanied by pain on passive stretch of the affected muscles. This occurs due to rising intracompartmental pressure impairing tissue perfusion. Distal pulses (B) may remain intact until late because major arteries are relatively resistant to compression. Pallor (A), sensory deficits (D), and paralysis (E) are later findings that suggest advanced ischemia, at which point irreversible muscle and nerve damage may have occurred.

Early recognition is essential because compartment syndrome is a surgical emergency requiring urgent fasciotomy to prevent permanent disability.

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12. Orthopedics Module

12.1 ATLS Principles

12.2 Upper Limb Fractures

12.3 Lower Limb Fractures

12.4 Dislocations & Soft Tissue Injuries

12.5 Bone & Joint Infections

12.6 Bone Tumors