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OR2.1-6 | Upper Limb Fractures — Assignment
CLINICAL SCENARIO
This assignment develops your ability to integrate clinical history, examination findings, investigations, and evidence-based management for a patient with a complex upper limb fracture. You will produce a structured clinical workup and management plan that demonstrates mastery of OR2.1–OR2.6 competencies, with particular attention to neurovascular complications, fracture classification, and analgesic prescribing.
Instructions
- Read the clinical scenario below carefully.
- Answer each section heading in order, using evidence from standard orthopaedic references (Maheshwari, Apley & Solomon).
- For each management decision, state the specific indication and the evidence or classification that supports it.
- Address analgesic prescribing explicitly, considering comorbidities.
- Your response should be 600–900 words (excluding headings).
- After submission, you will peer-review one colleague's response using the provided rubric.
CLINICAL SCENARIO:
Mr Rajesh Kumar, 48 years old, is brought to the Emergency Department following a road traffic accident. He was the driver of a car that was struck on the left side at moderate speed. He complains of severe pain in his right forearm. On examination, there is visible deformity of the forearm, a 4 cm laceration with bone visible at the fracture site, and moderate contamination with soil. Radial pulse is present and strong. Sensation and movement of the fingers are intact. X-ray reveals a fracture of the distal third of the radius with disruption of the distal radio-ulnar joint (DRUJ). He has a history of type 2 diabetes (on metformin) and hypertension (on amlodipine). His creatinine is 1.2 mg/dL (eGFR 58 mL/min).
Length: 600–900 words
What to Submit
1. Fracture Classification
Guidance: Identify the fracture type (name the specific fracture pattern from the X-ray description). Classify the open wound using the Gustilo-Anderson system, identifying the grade. State which grade criteria are met and which features would upgrade it to the next grade.
2. Immediate Emergency Management
Guidance: Outline the first-hour management steps: wound care, splinting, antibiotic timing and drug choice (per Gustilo grade), tetanus prophylaxis. State the rationale for each intervention.
3. Neurovascular Assessment
Guidance: Describe the complete neurovascular assessment you would perform. Identify which nerve and vessel are at specific risk in this fracture pattern, and what clinical signs would indicate their injury.
4. Definitive Surgical Management
Guidance: Outline the definitive operative plan: timing, approach, implant choice, and DRUJ management. Justify your choice of implant with reference to fracture characteristics.
5. Analgesic Prescribing
Guidance: Prescribe an appropriate analgesic regimen for this patient in the acute post-operative period. Account for his eGFR (58 mL/min), diabetes, and risk of NSAID-related complications. Explain why specific agents are chosen or avoided.
Grading Rubric — Upper Limb Fractures Assignment Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Fracture classification accuracy (Galeazzi + Gustilo-Anderson grade, criteria stated) | 10 pts | Correctly identifies Galeazzi fracture AND correct Gustilo grade (II or IIIA based on wound size and contamination) with all defining criteria explicitly stated and no errors |
| Emergency management (antibiotics within 1 hour, correct drug choice, wound care, splinting) | 10 pts | All four elements addressed correctly: antibiotics within 1 hour, appropriate drug choice for Gustilo grade, wound irrigation/dressing, and above-elbow splinting with rationale |
| Neurovascular assessment (correct nerve and vessel at risk, clinical signs of injury) | 10 pts | Correct identification of both the posterior interosseous nerve and the anterior interosseous artery/radial artery as structures at risk; accurate clinical signs for each; systematic assessment described |
| Operative plan (timing, implant choice for Galeazzi, DRUJ management justified) | 10 pts | Correct: urgent debridement and stabilisation within 6 hours; volar locking plate for radius; DRUJ repair/stabilisation with K-wire if unstable after radius fixation; all justified with fracture characteristics |
| Analgesic prescribing (appropriate agents for eGFR 58, diabetes; NSAIDs discussed with rationale) | 10 pts | Recommends paracetamol ± opioid (short-term); explicitly avoids NSAIDs with correct rationale (eGFR borderline at 58, diabetic nephropathy risk, post-op renal hypoperfusion); no unsafe drug choices |
PEER REVIEW
Review your peer's assignment against the rubric criteria above. For each criterion, assign a score with a 2–3 sentence justification explaining why you gave that score and what was done well or could be improved. Focus on accuracy of classification, completeness of emergency management, specificity of neurovascular assessment, operative rationale, and safety of analgesic prescribing. Write respectfully and constructively.