Trauma Management: Bike Accident with Left Hand and Leg Injuries

1. Initial Emergency Assessment (ABCDE Approach)

• A - Airway: Ensure patent airway
• B - Breathing: Check respiratory rate, oxygen saturation
• C - Circulation: Check BP, pulse, signs of haemorrhage (tibial/fibula fractures alone can cause 500 mL blood loss; femur fracture up to 1,000 mL - Rosen's Emergency Medicine)
• D - Disability: GCS, pupillary response (rule out head injury from bike accident)
• E - Exposure: Full skin survey for road rash, open wounds, deformity

2. X-Ray Imaging - What to Order

For the Left Hand/Wrist

"Almost every hand evaluation should include plain X-rays of the injured or affected part. A standard, anteroposterior, lateral, and oblique view of the hand or wrist is rapid, inexpensive, and usually provides sufficient information about the bony structures to achieve a diagnosis." - Schwartz's Principles of Surgery, 11th Ed.

• Fracture lines (lucencies in bone)
• Congruency of MP and IP joints (rotation of finger = incongruency)
• Gilula's arcs at the wrist (disruption = ligament injury or dislocation)
• Commonly missed: scaphoid fracture (may appear normal on initial X-ray)

AP (A) and lateral (B) views of the wrist showing distal radius fracture - Tintinalli's Emergency Medicine

• Repeat X-ray at 14 days (scaphoid fracture classically appears late)
• CT scan for suspected scaphoid fracture, CMC fractures, or comminuted distal radius
• MRI for suspected ligament or tendon injury

For the Left Leg

• Tibia/fibula: AP + lateral (include BOTH knee AND ankle joints in the same film)
• If knee pain: AP, lateral, and skyline (patella) views of the knee
• If ankle involvement: AP, lateral, mortise view of ankle

AP view of lower leg showing tibial shaft fracture - Rockwood & Green's Fractures in Adults, 10th Ed.

3. Treatment Plan

A. Closed Fractures (Skin Intact)

Hand/Wrist Fractures

Leg Fractures

• Non-displaced, non-comminuted: closed reduction + above-knee cast for 4-6 weeks, then functional brace
• Comminuted or angulated: intramedullary (IM) nailing is preferred - allows early weight bearing
• Fibula shaft fracture (often accompanies tibial fracture): usually heals without surgery
• Plate and screw fixation used for fractures at diaphyseal-metaphyseal junction

"Most tibial shaft fractures, especially comminuted and angulated fractures, are treated with an intramedullary nail placed down the tibial canal, with interlocking screws placed proximally and distally. Weight-bearing can begin soon after surgery." - Schwartz's Principles of Surgery, 11th Ed.

• Single column injury (stable): cast or splint 6-8 weeks
• Two or three column injury (unstable)/talar shift: ORIF

B. Open Fractures (Skin Wound Over Fracture)

1. Control bleeding with sterile pressure dressing - remove gross debris only
2. Splint without reduction (unless vascular compromise)
3. Irrigate with saline; cover with saline-soaked dressings
4. IV antibiotics as early as possible (ideally within 1 hour)
5. Tetanus prophylaxis (tetanus toxoid + immune globulin for large crush wounds)
6. Wound debridement and irrigation within 24 hours

4. Compartment Syndrome - Must Not Miss

• Pain out of proportion to the injury
• Pain on passive stretch of muscles
• Tense/taut leg swelling
• Paresthesia or weakness (late signs)

5. Analgesia and Supportive Care

6. Orthopaedic Referral Indications

• Open fractures of any kind
• Vascular or nerve compromise
• Displaced intra-articular fractures
• Compartment syndrome
• Barton's fracture (>50% articular involvement or carpal subluxation)
• Unstable ankle fractures with talar shift

7. Follow-Up Imaging

• If initial X-ray is negative but scaphoid tenderness is present: CT or MRI within 48-72 hours, or repeat X-ray in 2 weeks
• Post-reduction X-rays for all manipulated fractures to confirm alignment
• CT scan for pilon fractures after initial external fixation (to plan ORIF)

Disclaimer: This is a clinical reference guide. All treatment decisions must be made by the treating physician after direct patient assessment.