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OR1.1-6 | Skeletal Trauma and Polytrauma Principles — PBL Case

CLINICAL SETTING

It is 11:30 PM on a Saturday. You are the junior resident on call in the casualty of a district hospital. An ambulance crew wheels in Rajan Kumar, a 34-year-old construction labourer, who was a front-seat passenger in a bus that swerved off the highway and hit a barrier at high speed. The bystanders report he was trapped for approximately 30 minutes before extraction. He is conscious but confused, moaning loudly, and his clothes are soaked in blood from an obvious wound on his right thigh. On first look: he is pale and diaphoretic. His airway is clear but his neck has not been immobilised. Respiratory rate is 32/min, SpO2 is 91% on room air. You can barely feel a radial pulse — very rapid and thready. His GCS is 13/15 (E3V4M6). There is a gaping 6 cm wound on the right mid-thigh with bone visible and heavy contamination with road grit. The right lower limb is shortened and externally rotated, and there is marked swelling of the thigh. His left knee is grossly swollen and deformed. The first nurse asks you: 'Doctor, where do we start?'

Trigger 1: Primary Survey — What is Killing Him Now?

You apply a cervical collar, administer high-flow oxygen via non-rebreather mask, and establish two large-bore IV cannulas. Repeat vital signs: BP 80/56 mmHg, HR 148/min, RR 32/min, SpO2 97% (on O2), Temperature 36.2°C. Urine output from the catheter inserted 15 minutes ago: 6 mL over 15 minutes. GCS remains 13/15. Portable pelvic X-ray shows no pelvic ring disruption. Blood tests sent: Hb 7.2 g/dL, haematocrit 22%. Thromboelastography (TEG) is unavailable; the blood bank confirms 4 units packed red cells are available on-site.

DISCUSSION POINTS

Using the ATLS classification, what class of haemorrhagic shock is Rajan in? Justify your answer using all the clinical parameters provided.
What is your immediate resuscitation strategy — fluid type, volume, blood product triggers, and targets? Why should crystalloid volumes be restricted in haemorrhagic shock?
What are the likely sources of blood loss in this patient? Estimate the maximum potential internal haemorrhage from a closed femoral shaft fracture.
What additional investigations are essential in the primary survey phase, and in what order would you proceed?

Click to reveal Trigger 2: The Thigh Wound and the Knee — Injury Classification and Nerve Assessment (discuss previous trigger first!)

Trigger 2: The Thigh Wound and the Knee — Injury Classification and Nerve Assessment

After two units of packed red cells and 500 mL of crystalloid, BP improves to 94/66 mmHg, HR 122/min. The resuscitation team has now fully exposed Rajan. The right thigh wound is re-examined: 6 cm, with visible femoral shaft fragments, periosteum stripped at the wound edge, and extensive soil contamination — however, the right dorsalis pedis and posterior tibial pulses are palpable and equal bilaterally. The left knee is markedly swollen with a haemarthrosis; valgus stress test reveals significant medial instability; the anterior and posterior drawer tests are both positive; the left dorsalis pedis is weakened (1+/4+). Sensation is reduced over the dorsum of the left foot. Rajan reports 'I cannot lift my left foot up, Doctor.'

DISCUSSION POINTS

Classify the right thigh open fracture using the Gustilo-Anderson system. Which type is it, and what is the key distinguishing feature from a higher or lower grade?
State the recommended antibiotic regimen (drug names, dose, route, timing) for this fracture class, including cover for soil/faecal contamination. What is the evidence base for the 1-hour antibiotic rule?
What is the likely diagnosis in the left knee? Which neurovascular structure is most at risk, and how do the clinical findings support this? What is the most critical investigation and why must it precede MRI?
What nerve injury best explains the inability to dorsiflect the left foot, and which division of the sciatic nerve is most commonly injured in this pattern?

Click to reveal Trigger 3: Definitive Management and Recent Advances (discuss previous trigger first!)

Trigger 3: Definitive Management and Recent Advances

CT angiography of the left lower limb confirms a complete popliteal artery transection. The vascular surgery team performs emergency vascular reconstruction with a temporary intraluminal shunt, followed by external fixation of the knee. For the right femoral shaft fracture, the orthopaedic team plans locked intramedullary nailing using computer-assisted surgical navigation. Post-operatively on day 2, Rajan is transferred to HDU. You note that his right thigh wound has been covered with a negative pressure wound therapy (NPWT/VAC) device applied in theatre. The wound team plans a fasciocutaneous flap at day 5–7. On post-operative day 3, Rajan develops confusion, tachypnoea (RR 38/min), SpO2 84% on room air, and the nurse notices small petechial spots on his chest and in the subconjunctivae.

DISCUSSION POINTS

What complication has Rajan developed on post-operative day 3? What is the pathophysiology, and which specific clinical triad confirms the diagnosis?
Explain the role of NPWT (VAC therapy) in the management of this open fracture wound. What are its proven benefits over conventional dressings, and when is it contraindicated?
What is the advantage of computer-assisted surgical navigation over conventional intramedullary nailing? How does this represent a recent advance (OR1.6) in trauma orthopaedics?
How would you manage the newly developed complication — pharmacologically and supportively? What is the definitive prevention strategy for this complication in polytrauma patients?

Learning Issues

Research these questions and bring your findings to the discussion.

[OR1.1] What are the principles of ATLS primary and secondary survey in a polytrauma patient, and how does the ABCDE sequence prioritise life-threatening injuries?
[OR1.2] How is haemorrhagic shock classified using the ATLS system, and what are the physiological bases and treatment targets for each class?
[OR1.3] What is the Gustilo-Anderson classification of open fractures, and what antibiotic regimen and timing standard applies to each type?
[OR1.4] What are the clinical features of knee dislocation, which vascular structure is at risk, and why is CT angiography mandatory before MRI?
[OR1.5] What are the principles of closed and open reduction of major joint dislocations, and what pre- and post-reduction assessments are mandatory?
[OR1.6] What are the key recent advances in orthopaedic trauma management — including NPWT, computer-assisted navigation, and biological adjuncts — and what is the evidence supporting each?