Trauma for FRCS (Tr & Orth)

This is an unstable, under-resuscitated polytrauma patient: hypothermic, coagulopathic and acidotic, with chest injury and bilateral femoral fractures, all markers of high risk for acute respiratory distress syndrome and multi-organ failure after prolonged surgery. Damage control orthopaedics applies: rapid external fixation to control pain, bleeding and ongoing soft-tissue injury while limiting the surgical second hit, with conversion to nails once physiology has recovered. Reamed or unreamed nailing and plating are definitive procedures that add blood loss and embolic load. Traction does not stabilise the fractures adequately, prevents upright nursing and prolongs the inflammatory stimulus. Reference: Pape HC et al., J Orthop Trauma 2005; Rockwood and Green's Fractures in Adults 9e.

Early antibiotic administration is the intervention most consistently shown to reduce infection after open fracture. The BOAST standard is that intravenous prophylactic antibiotics are given as soon as possible, ideally within one hour of injury, which in practice often means by the pre-hospital team; the agent follows local policy, commonly co-amoxiclav or a cephalosporin. A 3-hour threshold comes from older observational work and is no longer the standard. The 6-hour figure is the historical rule for debridement, which has not been supported by evidence, and 12 and 24 hours are the current BOAST limits for surgical debridement, not for antibiotics. Reference: BOAST, Open Fractures (2017); NICE NG37.

The type II odontoid fracture, through the waist of the dens, is the most common cervical fracture in the elderly and has a high non-union rate because of its small watershed surface. In a frail, low-demand patient the aim is comfort and safety, not bony union: a rigid collar is tolerated best, and a stable fibrous union gives an acceptable result in most. Halo vests are poorly tolerated in the elderly, with high rates of aspiration, pneumonia and death, and are avoided. Surgery improves union and may be offered to fit older patients, but the anaesthetic risk is not justified here, and osteoporotic bone holds an anterior screw poorly. Traction means prolonged recumbency. Reference: Rockwood and Green's Fractures in Adults 9e; Tashjian RZ et al., J Trauma 2006.

The concern is a Rockwood type IV acromioclavicular dislocation, in which the lateral clavicle is displaced posteriorly into or through trapezius. Because the displacement is in the axial plane, anteroposterior films can look almost normal, and the diagnosis is made on an axillary lateral view, which shows the clavicle lying posterior to the acromion. Type IV injuries are painful, usually irreducible and are treated surgically. The Zanca view, with 10–15° of cephalic tilt, improves the anteroposterior picture of the joint but shows only vertical displacement. The Stryker notch view profiles a Hill-Sachs lesion, the West Point view the anteroinferior glenoid rim, and the serendipity view the sternoclavicular joints. Reference: Rockwood and Green's Fractures in Adults 9e.