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ATLS Primary Survey: ABCDE

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A — Airway (with C-spine protection)

• Vocal response (talking = patent airway)
• Auscultation
• Look for obstruction: blood, secretions, foreign bodies, facial/mandibular/neck trauma, altered consciousness

• Direct injury to face, mandible, or neck
• Hemorrhage in nasopharynx, sinuses, or mouth
• Diminished consciousness (TBI, intoxication, analgesia)
• Aspiration of gastric contents, blood, or foreign body (dentures, broken teeth)
• Esophageal intubation

1. Chin lift / jaw thrust
2. Suction + oral/nasal airway
3. Bag-valve-mask with 100% O₂
4. Endotracheal intubation (confirm with capnography immediately — esophageal intubation is common and devastating)
5. Surgical cricothyroidotomy if all else fails — this takes absolute priority over all other procedures

C-spine immobilization is maintained throughout unless injury has been excluded.

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B — Breathing & Ventilation

• Pulse oximetry
• Arterial blood gas
• Chest X-ray
• Inspect: respiratory rate, symmetry of chest rise, tracheal deviation, crepitus, subcutaneous emphysema

• Tension pneumothorax
• Open pneumothorax
• Hemothorax
• Flail chest / pulmonary contusion
• Direct tracheobronchial injury
• Cervical spine injury (phrenic nerve)
• Bronchospasm (smoke / toxic gas inhalation)

• Supplemental O₂ for all trauma patients
• Mechanical ventilation if needed
• Needle decompression + tube thoracostomy for pneumo/hemothorax
• Seal open chest wounds (three-sided dressing)

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C — Circulation & Hemorrhage Control

• Vital signs: HR, BP, pulse pressure (narrowed = early shock)
• Capillary refill
• Skin: pallor, diaphoresis
• Response to fluid bolus
• Labs: CBC, coagulation studies, type & crossmatch
• FAST (Focused Assessment with Sonography in Trauma)
• Pelvic plain films

• Large-bore IV access × 2 (or IO/central if needed)
• Uncrossmatched blood (O-negative) if in extremis
• Activate Massive Transfusion Protocol (MTP) early — target 1:1:1 ratio (pRBC:FFP:platelets)
• Direct pressure on wounds
• Tourniquet for extremity hemorrhage
• Pelvic binder for open-book pelvic fractures
• REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) at trauma centers
• ED thoracotomy if indicated
• Emergent OR for hemorrhage control

Avoid the lethal triad: Hypothermia + Acidosis + Coagulopathy (Trauma-Associated Coagulopathy, TAC)

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D — Disability (Neurological Status)

• GCS (Glasgow Coma Scale) — Eye (1–4) + Verbal (1–5) + Motor (1–6) = 3–15
• Pupil size, reactivity, and symmetry
• Sensation and motor function in all four extremities
• Pressure stimuli: fingertip pressure, trapezius pinch, or supraorbital notch pressure

• Abnormal flexion (decorticate): Slow stereotyped arm across chest, forearm rotating, thumb clenched, leg extended
• Normal flexion: Rapid, variable, arm moves away from body

• Any significant neurological deficit → immediate head CT
• Support oxygenation and perfusion (secondary brain injury prevention)
• Cervical spine films / CT
• Neurosurgery for operative lesions (epidural/subdural hematoma)
• ICP monitoring if indicated

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E — Exposure & Environment

• Completely undress the patient (cut off clothing)
• Full log-roll to examine the back
• Look for: wounds, deformities, bruising, burns, signs of penetrating injury

• Warm blankets and IV fluids to prevent hypothermia
• Laboratory studies
• ECG
• Plain films and CT as indicated
• Detailed history (AMPLE: Allergies, Medications, Past medical history, Last meal, Events/mechanism)

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After the Primary Survey: Secondary Survey

1. The primary survey is complete
2. Resuscitation is underway
3. Vital functions are improving

The ABCDE survey must be reassessed continuously throughout care. Any deterioration restarts the sequence from A.

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Fracture Basics

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1. Fracture Description Framework

By convention, the distal fragment is described relative to the proximal fragment.

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2. Fracture Line Types

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3. Open vs. Closed

• Closed: Skin and soft tissue overlying fracture are intact
• Open (compound): Fracture communicates with external environment — may not be immediately obvious
  • If a wound is near the fracture and doubt exists, treat as open
  • Do NOT probe with blunt swabs to determine communication — unreliable and potentially harmful
  • Open fractures require urgent surgical debridement and IV antibiotics

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4. Displacement & Angulation

• Displacement: Fragments deviate from their normal position (described in mm or % bone width)
• Angulation: Deviation of the long axis; described by the direction the apex points
  • Valgus: Apex toward midline
  • Varus: Apex away from midline
• Rotation: Distal fragment rotated along the bone axis — may only be apparent clinically (e.g., finger scissoring on flexion)
• Shortening: Overlap or impaction of fragments

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5. Fracture Healing

Phases of Secondary Bone Healing

Primary vs. Secondary Healing

Key Factors Affecting Healing

• Pro-healing: Good vascularity, periosteum intact, stable fixation, BMPs (BMP-2, BMP-7)
• Impair healing: NSAIDs (inhibit COX-2, impair endochondral ossification), smoking, corticosteroids, infection, diabetes, poor nutrition
• Bone grafts:
  • Osteoconductive — scaffold (e.g., demineralized bone matrix)
  • Osteoinductive — stimulate bone formation (e.g., BMP)
  • Osteogenic — contain living bone-forming cells (e.g., autograft)

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6. Complications

Early

Late

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7. Principles of Fracture Management

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Shoulder Dislocation

Anatomy & Why the Shoulder Dislocates So Easily

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Types of Dislocation

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Anterior Dislocation

Clinical Features

• Posterior sulcus visible (loss of normal rounded contour)
• Arm held in slight abduction and external rotation
• Inability to place palm of affected hand on contralateral shoulder
• Palpable fullness anteriorly (humeral head)

Imaging

• AP view — humeral head not in glenoid fossa
• Axillary (glenoid) view — gold standard; confirms direction
• Y-view (scapular lateral) — useful when axillary view not tolerated

Associated Injuries

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Posterior Dislocation

Clinical Features (Easily Missed!)

• Arm in internal rotation + adduction ("sling position")
• Loss of external rotation and forward flexion
• No obvious deformity — diagnosis commonly delayed
• Causes: seizures, electrocution, direct posterior blow

Imaging

• Often missed on AP view alone — the humeral head may appear falsely normal
• Axillary view is mandatory — shows posterior displacement
• Trough sign on AP — dense sclerotic line on humeral head (reverse Hill-Sachs impaction)
• Fracture of the lesser tuberosity = posterior dislocation until proven otherwise

Associated Injuries

• Reverse Bankart fracture (posterior glenoid rim)
• Reverse Hill-Sachs lesion (anterior humeral head)
• Posterior capsule and labrum tear
• 65% have an associated injury overall

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Inferior Dislocation — Luxatio Erecta

• Arm locked in marked hyperabduction with forearm lying on or behind the head
• Associated with neurovascular injury (brachial plexus, axillary vessels) and rotator cuff tears
• Reduction: Overhead traction in abduction with cephalad pressure on the humeral head; assistant applies countertraction caudally via sheet over the shoulder

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Reduction Techniques (Anterior Dislocation)

• Audible/palpable "clunk"
• Immediate pain relief
• Restoration of round shoulder contour
• Patient can place palm of affected hand on contralateral shoulder

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Posterior Dislocation Reduction

• Traction on internally rotated and adducted arm + anteriorly directed pressure on posterior humeral head
• Generous premedication + countertraction via axillary sheet
• If head locked on posterior glenoid → add lateral traction on upper humerus
• Impression defect >20% of articular surface → open reduction required
• Post-reduction: Check patient can place palm on opposite shoulder; orthopedic consultation for all posterior dislocations

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Post-Reduction Management

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Recurrent Instability & Surgery

• Arthroscopic Bankart repair — gold standard for most cases (anteroinferior capsulolabral complex)
• Latarjet procedure — coracoid transfer to anterior glenoid rim; for large bony glenoid defects (>25% glenoid bone loss) or engaging Hill-Sachs lesions
• Remplissage — arthroscopic infraspinatus tenodesis into Hill-Sachs defect; reduces engagement
• Open Bankart repair — reserved for revision or complex cases

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Fractures of the Humerus

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1. Proximal Humerus Fractures

Epidemiology

• Most common in elderly women after low-energy falls onto the shoulder
• Also occur in young patients after high-energy trauma
• Account for ~5% of all fractures; 3rd most common fragility fracture after hip and distal radius

Anatomy — The Neer 4-Part System

1. Humeral head (articular segment)
2. Greater tuberosity (supraspinatus, infraspinatus, teres minor insertions)
3. Lesser tuberosity (subscapularis insertion)
4. Humeral shaft

Despite wide use, inter-observer reliability of the Neer system is moderate. CT is recommended for complex patterns.

Blood Supply & AVN Risk

• The humeral head blood supply comes predominantly via the anterior humeral circumflex artery (arcuate artery) and posterior circumflex artery
• 4-part fractures and fracture-dislocations carry >30% risk of avascular necrosis (AVN) of the humeral head

Treatment

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2. Humeral Shaft (Diaphyseal) Fractures

Mechanisms

• Direct blow, fall, high-energy trauma
• Torsional force (spiral fracture pattern)
• Pathologic fracture (metastasis is common here)

Key Nerve at Risk: Radial Nerve

• The radial nerve runs in the spiral (radial) groove on the posterior surface of the humerus
• Incidence of radial nerve palsy: ~11–18% of all humeral shaft fractures
• Holstein-Lewis fracture: Spiral fracture of the distal third of the shaft — highest risk of radial nerve entrapment/injury
• The vast majority of radial nerve palsies are neuropraxias (stretch/contusion) → spontaneous recovery expected within 3–4 months
• EMG at 6–8 weeks helps assess recovery; if no recovery by 3–4 months → surgical exploration

Acceptable Alignment for Non-Operative Treatment

Radial nerve palsy is NOT a contraindication to conservative management (except in open fractures, where nerve must be explored)

Treatment

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3. Distal Humerus Fractures

Types

Nerve Injuries at the Distal Humerus

Vascular Injury

• Supracondylar fractures can injure or tether the brachial artery
• Check: radial pulse, capillary refill, and "pink pulseless hand" (pulseless but perfused via collaterals) vs. true ischaemia

Treatment

Elbow fractures are notorious for stiffness — early range of motion is critical to a good outcome.

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Summary Table

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Hip Fracture

Epidemiology & Public Health Impact

• Bimodal distribution: rare high-energy fractures in the young; overwhelmingly common fragility fractures in the elderly (mean age ~80 years, female:male ~3:1)
• 15–20% mortality within 3 months; 20–25% mortality at 1 year for trochanteric fractures
• 30–50% lose a degree of functional independence
• ~4.5 million fractures/year worldwide projected by 2050 (up from 1.3 million in 1990)
• Strongly associated with osteoporosis, falls, sarcopenia, polypharmacy, and frailty

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Classification by Anatomical Location

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1. Intracapsular (Femoral Neck) Fractures

Blood Supply

Garden Classification

Clinically simplified as: Undisplaced (I + II) vs. Displaced (III + IV)

Treatment

Key principle: Displaced intracapsular fractures in the elderly are generally best treated with arthroplasty rather than fixation (high failure and revision rate with fixation due to AVN and non-union).

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2. Extracapsular — Trochanteric Fractures

OTA/AO Classification

Treatment

Key point for DHS: Screw tip must be close to the articular surface (tip-apex distance <25 mm) to prevent cut-out.

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3. Subtrochanteric Fractures

• Region of highest mechanical stress in the skeleton (bending + compressive forces)
• Occur at medial calcar — area of cortical stress concentration
• Associated with bisphosphonate therapy (atypical subtrochanteric fractures with prodromal thigh pain and a "banana" lateral bow on plain X-ray)
• Treatment: Intramedullary nail (long, to the knee, to avoid stress risers)

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Clinical Presentation

~15% of hip fractures are occult on plain X-ray — use MRI (gold standard) or CT if high clinical suspicion with normal X-ray.

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Perioperative Management

Timing of Surgery

• Target: within 24–48 hours of admission (once medically optimised)
• Delay >48 hours associated with higher mortality, increased pressure sores, DVT, pneumonia
• Brief delay acceptable for reversing anticoagulation or optimising significant cardiorespiratory comorbidity

Anaesthesia

• Spinal vs. general: No significant difference in 60-day mortality or delirium in large prospective studies; slightly shorter hospital stay with regional anaesthesia
• Regional analgesia: Fascia iliaca block or 3-in-1 femoral nerve block — effective pre- and post-operative pain control; avoids respiratory depression of intrathecal opioids

Perioperative Considerations

• Thromboprophylaxis: LMWH or direct oral anticoagulants post-op; mechanical prophylaxis (TED stockings, pneumatic compression) pre-op
• Delirium prevention: Avoid anticholinergics, benzodiazepines; early mobilisation; adequate analgesia; sleep hygiene
• Orthogeriatric co-management: Geriatrician involvement from admission reduces mortality and complications
• Bone health: Osteoporosis treatment (bisphosphonates, denosumab) must be initiated prior to discharge — a hip fracture is a sentinel event for future fractures

Falls Risk Factors to Address

• Polypharmacy review (antihypertensives, tranquillisers, alcohol)
• Visual correction
• Balance and strength physiotherapy
• Home hazard assessment

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Complications

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Summary Decision Framework

Hip Fracture
│
├── Intracapsular (femoral neck)
│   ├── Undisplaced (Garden I/II)
│   │   ├── Young → Internal fixation (cannulated screws)
│   │   └── Elderly / poor bone → Hemiarthroplasty
│   └── Displaced (Garden III/IV)
│       ├── Young → Urgent ORIF (or hemi if irreducible)
│       ├── Active elderly → THA
│       └── Frail elderly → Hemiarthroplasty (cemented)
│
└── Extracapsular
    ├── Trochanteric (A1/A2, intact lateral wall) → DHS
    ├── Trochanteric (A3 / reverse oblique) → IM nail
    └── Subtrochanteric → Long IM nail

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Femur Fractures

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Overview: Regions of the Femur

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Part 1: Femoral Shaft (Diaphyseal) Fractures

Epidemiology & Mechanism

• Young males (15–25 years): High-energy trauma — MVA, motorcycle accidents, falls from height, pedestrian injuries, gunshot wounds
• Elderly females (>75 years): Low-energy falls on osteoporotic bone
• Atypical femur fractures (50–70 years): Bisphosphonate-associated; transverse subtrochanteric or midshaft fractures with prodromal thigh pain and lateral cortical thickening ("beaking")

• Bending force → transverse ± butterfly fragment
• Rotational force → spiral or oblique
• Axial force → associated hip/knee injuries
• Higher energy → comminution ↑

Haemorrhage

Associated Injuries

• Lung injury: 18.9%
• Intracranial injury: 13.5%
• Liver: 6.2%
• Tibia/fibula fractures: 20.5%
• Ribs/sternum: 19.1%
• Ipsilateral femoral neck fracture: 5.8% — missed in 20–50% of cases initially

Always image the full femur, including the hip and knee. Protocol: internal rotation AP hip view + fine-cut CT of the hip (2 mm axial/sagittal) + post-op radiographs → 91% reduction in missed femoral neck fractures.

Classification — Winquist & Hansen (Comminution)

Higher grade = requires statically locked nail to prevent shortening and rotation.

Treatment

1. Temporary Stabilisation

• Distal femur pin: placed medial → lateral (avoids femoral artery at adductor hiatus)
• Proximal tibia pin: placed lateral → medial (avoids peroneal nerve)
• Weight: ~15% of body weight (15–20 lb)

2. Definitive Fixation

• Most closed and open femoral shaft fractures
• Segmental and comminuted fractures
• Multiple trauma (within 24 hours when stable)

• Canal too narrow (unable to ream)
• Pre-existing implant filling the canal (e.g., THA)
• Associated ipsilateral femoral neck fracture (use separate fixation)
• Open growth plates (piriformis entry avoided; trochanteric entry used)
• Severe polytrauma with chest/head injury → temporary external fixation first

• Used when IMN is contraindicated or in certain fracture patterns
• Open approach (lateral): extensive dissection → higher blood loss, infection risk
• MIPO (minimally invasive plate osteosynthesis): smaller incisions, preserves blood supply, but higher risk of malreduction
• Plate is not load-bearing → immediate weight-bearing carries implant failure risk

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Part 2: Distal Femur (Supracondylar/Condylar) Fractures

Definition

Epidemiology

• Bimodal: Young (high-energy) and elderly (fragility fracture)
• Elderly distal femur fracture = analogous to hip fracture in terms of morbidity; 5-year mortality >50%
• Often complicates total knee arthroplasty (periprosthetic fracture)

OTA/AO Classification

Hoffa fracture: Coronal plane fracture through a single condyle — found in 40% of intercondylar fractures; frequently missed on plain X-ray — CT mandatory.

Key Anatomy

• Distal femur is trapezoidal on end — implants placed anteriorly on AP view may protrude posteriorly and cause pain
• Popliteal artery lies posterior to the distal femur — at risk in displaced fractures
• Peroneal and tibial nerves in the popliteal fossa — check neurovascular status

Deforming Force

Treatment

Stiffness is the most common complication of distal femur fractures — early range of motion is critical.

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Complications Summary

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Osteoarthritis (OA)

OA is primarily a degenerative disorder; inflammation is a secondary contributor, not the primary driver (unlike rheumatoid arthritis).

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Epidemiology & Risk Factors

• Age (most important)
• Obesity (mechanical loading + metabolic effects)
• Female sex (especially post-menopausal)
• Previous joint injury (trauma, meniscectomy, ACL tear)
• Joint deformity (varus/valgus malalignment, hip dysplasia, FAI)
• Repetitive occupational loading
• Genetic predisposition (polymorphisms in matrix components and signalling molecules)
• Systemic diseases: diabetes, haemochromatosis, acromegaly, Wilson's disease

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OA vs. Rheumatoid Arthritis — Key Differences

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Pathogenesis

Stage 1 — Chondrocyte Injury

• Biomechanical stress + genetic predisposition → chondrocyte injury
• Type II collagen and proteoglycan matrix alterations begin

Stage 2 — Early OA

• Chondrocytes proliferate (attempt at repair) and secrete:
  • MMPs (matrix metalloproteinases) → degrade type II collagen and proteoglycans
  • PGE₂, NO, TNF → pro-inflammatory mediators
  • TGF-β, BMP → attempted repair signals
• Degradation exceeds repair → net cartilage loss
• Water content of cartilage ↑ initially (proteoglycan loss) → softening, fibrillation

Stage 3 — Late OA

• Progressive chondrocyte apoptosis and dropout
• Loss of articular cartilage (exposed subchondral bone)
• Subchondral bone changes:
  • Sclerosis (eburnation — ivory-like polished bone surface)
  • Subchondral cysts (fluid forced through micro-fractures)
  • Osteophyte (bone spur) formation at joint margins
• Cartilage fragments → loose bodies in joint
• Secondary synovitis from debris phagocytosis

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Gross & Microscopic Pathology

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Joints Affected

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Clinical Features

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Investigations

Radiograph (Plain X-ray) — Cornerstone of Diagnosis

X-ray correlates poorly with symptoms — many radiologically severe cases are asymptomatic, and symptomatic patients may have mild radiographic changes.

• MRI: Cartilage thickness, bone marrow oedema, meniscal pathology — useful for pre-surgical planning and diagnosing early OA
• Bloods: Normal CRP/ESR, RF, ANA — used to exclude inflammatory arthritis
• Joint aspiration: Clear, viscous fluid; WBC <2000/µL (cf. septic arthritis >50,000/µL)

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Management

Non-Pharmacological (First-Line for All)

Pharmacological

Surgical

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Osteomyelitis

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Classification by Route of Infection

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Microbiology

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Pathogenesis & Morphology

Acute Osteomyelitis (first days–weeks)

1. Bacteria proliferate → neutrophilic reaction → necrosis of bone and marrow within 48 hours
2. Bacteria spread through Haversian canals → reach periosteum
3. In children, periosteum loosely attached → subperiosteal abscess forms, dissects along bone
4. Periosteal lifting → further impairs blood supply → extends necrosis
5. Soft tissue abscess → can channel to skin as draining sinus

Chronic Osteomyelitis (weeks → years)

• Chronic inflammatory cells recruited → cytokines stimulate bone resorption + fibrous ingrowth
• Sequestrum: Dead, devascularised infected bone (fails to resorb)
• Involucrum: Shell of reactive new bone laid down around the infected/necrotic bone (periosteal new bone formation)
• Sinus tracts may fistulise to skin

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Age-Specific Distribution

Children — Acute Haematogenous Osteomyelitis (AHO)

• Ages 3 months to 16 years; male:female = 2–3:1
• Long bones in ~80%: distal femoral metaphysis most common
• Metaphysis targeted due to sluggish blood flow in metaphyseal sinusoids (terminal capillaries loop, allowing bacteria to settle)
• In neonates: Metaphyseal vessels penetrate the growth plate → epiphysis and metaphysis both involved; septic arthritis frequently coexists (~50% have multifocal disease)
• In older children (after growth plate closure): Vessels anastomose → epiphysis and subchondral regions more susceptible

Adults

• Usually post-surgical, post-traumatic, or from contiguous spread
• Vertebral osteomyelitis common (haematogenous spread to vertebral body endplates)

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Cierny-Mader Classification (Chronic Osteomyelitis)

• Class A: Healthy host
• Class B: Compromised host (local or systemic)
• Class C: Treatment worse than disease

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Clinical Features

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Investigations

Bloods

Imaging

Microbiological Diagnosis

• Bone biopsy / culture — gold standard for organism identification
• Culture positive in ~50% of cases (PCR assays improving this)
• Blood cultures before antibiotics
• Do NOT start antibiotics before cultures in stable patients

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Specific Subtypes

Vertebral Osteomyelitis (Spondylodiscitis)

• Often haematogenous (urinary tract, skin, dental source)
• Lumbar > thoracic > cervical
• Disk avascular → bacteria proliferate → diskitis often coexists
• Complications: psoas abscess (lumbar), retropharyngeal abscess (cervical), epidural abscess (<15% but can cause paraplegia)
• MRI whole spine with contrast is the investigation of choice
• Treatment: IV antibiotics ± CT-guided biopsy; surgery for cord compression, abscess, instability, or failure of antibiotics

Diabetic Foot Osteomyelitis

• Contiguous spread from neuropathic/ischaemic ulcers
• Probe-to-bone test: if bone palpated through ulcer → osteomyelitis very likely (positive predictive value ~90%)
• Polymicrobial; MRI most sensitive; treatment often requires prolonged antibiotics ± surgical debridement

Posttraumatic / Implant-Associated

• Open fractures: Gustilo classification guides antibiotic cover
• Implant-associated: hardware left in place if stable and fracture not yet healed; remove if unstable or fracture healed
• Biofilm on implants makes eradication difficult without hardware removal

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Treatment

Antibiotics

Surgical Indications

Dead Space Management

• Local antibiotic beads (PMMA + gentamicin/vancomycin)
• Calcium sulphate beads
• Vascularised muscle flap
• Bone transport (Ilizarov) for large defects

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Complications

Mycobacterial (TB) Osteomyelitis — Special Mention

• Pott's disease: TB osteomyelitis of the spine (thoracolumbar most common)
• Bloodborne from pulmonary/extrapulmonary focus
• Presents with localised pain, low-grade fever, weight loss; cold abscess may track (paravertebral, psoas)
• More destructive and resistant than pyogenic; diagnosis often delayed (present for years)
• Treat with standard anti-TB regimen (6–9 months); surgery for cord compression or instability

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