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OR2.14-16 | Fracture Complications and Special Situations — Assignment

CLINICAL SCENARIO

This assignment develops your ability to clinically reason through fracture complications and special situations encountered in orthopaedic practice — the kind of diagnostic and management decisions you will face as a house officer. You will work through a structured clinical case involving an open fracture and its subsequent complications, demonstrating mastery of Gustilo-Anderson classification, antibiotic protocol, non-union workup, and paediatric injury principles.

Instructions

Read the following case scenario and answer each section in sequence.

Case: A 25-year-old male motorcyclist presents to casualty with a Grade IIIA open fracture of the tibial shaft following a road traffic accident. He is haemodynamically stable. The wound is 8 cm, moderately contaminated, with comminuted fracture fragments but soft tissue is adequate for coverage. He undergoes emergency surgery. Three months later he returns with persistent pain, absent callus on X-ray, and raised inflammatory markers.

Classify the fracture using Gustilo-Anderson and justify your choice (include what distinguishes IIIA from IIIB and IIIC).
Describe the immediate antibiotic protocol — drug, route, timing, and rationale for the 1-hour rule.
At 3-month follow-up with persistent pain and absent callus: outline the investigations you would order to determine whether this is non-union with or without infection, and explain what each investigation tells you.
If imaging and biopsy confirm infected non-union: outline the principles of management (antibiotic strategy + surgical options).
(Paediatric extension): A 7-year-old child is admitted alongside him with a supracondylar fracture. List the three most important neurovascular structures at risk and explain the immediate assessment you would perform.

Length: 600–900 words

What to Submit

Section 1: Gustilo-Anderson Classification

Guidance: State the grade and subtype clearly. List the specific criteria for each Grade III subtype (IIIA/B/C) with the defining feature of IIIC being arterial injury requiring repair. Justify why this case is IIIA and not IIIB or IIIC.

Section 2: Immediate Antibiotic Protocol

Guidance: Specify the antibiotic (co-amoxiclav or cefazolin ± metronidazole), route (IV), timing (within 1 hour of injury), duration, and the evidence-based rationale. Mention tetanus prophylaxis. Explain why delaying until theatre is unacceptable.

Section 3: Investigations for Suspected Non-union ± Infection

Guidance: Structure as: (a) radiological investigations — plain X-ray findings of non-union, CT for cortical bridging, MRI for medullary infection/soft tissue involvement, three-phase bone scan for vascularity; (b) laboratory investigations — ESR, CRP, WBC, blood culture; (c) tissue diagnosis — bone biopsy with histology and culture. Explain what each tells you.

Section 4: Principles of Management of Infected Non-union

Guidance: Cover: organism-directed antibiotics (IV then oral, minimum 6 weeks), surgical débridement (sequestrectomy, canal reaming), stability (exchange nailing / circular external fixator such as Ilizarov), bone grafting for the defect, and the role of soft-tissue flap coverage if needed.

Section 5: Paediatric Neurovascular Assessment — Supracondylar Fracture

Guidance: Name the three structures: (1) anterior interosseous nerve (AIN — median branch; test FDP index + FPL, the 'OK sign'); (2) median nerve (sensory pulp index finger); (3) brachial artery (palpate radial pulse, assess capillary refill, hand colour/temperature). Explain the significance of absent pulse — rule out compartment syndrome even if pulse present.

Grading Rubric — Fracture Complications and Special Situations Assignment Rubric

Criterion	Points	Full-marks descriptor
Gustilo-Anderson Classification Accuracy and Justification	10 pts	Correctly classifies as Grade IIIA with precise criteria for all subtypes including the defining feature of IIIC (arterial injury requiring repair); clearly justifies why IIIB and IIIC do not apply.
Antibiotic Protocol — Drug, Route, Timing, Rationale	10 pts	Specifies IV co-amoxiclav or cefazolin ± metronidazole, IV route, within 1 hour of injury, duration (Grade III: 72h or until coverage), and clearly explains the 1-hour rule rationale with tetanus prophylaxis mentioned.
Investigations for Non-union ± Infection — Selection and Interpretation	10 pts	Systematically lists radiological (X-ray, CT, MRI, bone scan) and laboratory investigations (ESR, CRP, WBC, cultures) and tissue diagnosis (biopsy + histology/culture); explains what each investigation contributes to diagnosis.
Management of Infected Non-union — Antibiotic and Surgical Principles	10 pts	Covers all four pillars: organism-directed antibiotics (IV then oral ≥6 weeks), débridement/sequestrectomy, stable fixation (exchange nail/Ilizarov), and bone grafting; soft-tissue coverage mentioned.
Paediatric Neurovascular Assessment — Supracondylar Fracture	10 pts	Names AIN (and its test — OK sign / FDP index + FPL), median nerve (sensory pulp index), and brachial artery (radial pulse + capillary refill + colour); explicitly notes that present pulse does NOT exclude compartment syndrome.

PEER REVIEW

Review your peer's assignment against the rubric. For each criterion: (1) assign a score, (2) write one specific strength, and (3) suggest one concrete improvement. Be factually specific — if the Gustilo-Anderson classification is incorrect, state the correct answer. For the antibiotic protocol, check whether the 1-hour rule and IV route are explicitly stated. Submit your peer review within 48 hours of receiving the assignment.