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Fractures and dislocations in the emergency department
In every fracture or dislocation, first check nerves and vessels beyond the injury, recognise the urgent situations — open fracture, vascular injury, hip or knee dislocation, compartment syndrome — and reduce dislocations early to prevent necrosis and nerve damage.
Why it matters in the exam
Questions describe a routine skeletal injury with a "twist": an open fracture that needs IV antibiotics within one hour, a knee dislocation that requires a pulse check and an ankle-brachial index (ABI) because of the risk to the popliteal artery, or a posterior hip dislocation that should be reduced within about 6 hours to reduce avascular necrosis of the femoral head. A common distractor is discharging a patient with a normal X-ray after a fall on an outstretched hand with tenderness in the "anatomical snuffbox".
Shoulder dislocations are also tested: the common anterior dislocation, with a risk to the axillary nerve (sensation over the lateral shoulder), and the posterior dislocation, which follows a seizure or electric shock and is easily missed on an anteroposterior view alone. In children, a supracondylar humeral fracture can injure the brachial artery and the anterior interosseous nerve, so the pulse and the "OK sign" of the fingers are checked.
General principles are asked in every question: X-rays in at least two planes and of the joint above and below the fracture; temporary splinting and early analgesia; and suspicion of compartment syndrome when pain is out of proportion and worse on passive stretch. In an open fracture give antibiotics (usually cefazolin) within one hour, cover the wound with a moist dressing, check tetanus status and refer for debridement in theatre. In an older patient with hip pain after a fall and a normal X-ray, think of an occult fracture and obtain MRI or CT.
Key points
- Check nerves, vessels and skin before and after every procedure.
- Open fracture — antibiotics within one hour and surgery.
- Knee dislocation — ABI; hip dislocation — reduction within about 6 hours.
- Snuffbox tenderness — splint even with a normal X-ray.
- Pain out of proportion — think of compartment syndrome.
Summary table
| Situation | Danger | Test | Action |
|---|---|---|---|
| Open fracture | Deep infection | Wound inspection, tetanus | IV antibiotics within one hour, moist dressing, surgery |
| Knee dislocation | Popliteal artery injury | Pulse, ABI; below 0.9 — CT angiography | Immediate reduction, vascular assessment |
| Posterior hip dislocation | Femoral head necrosis, sciatic nerve injury | Pelvic X-ray | Reduction within about 6 hours |
| Anterior shoulder dislocation | Axillary nerve injury | Sensation over the lateral shoulder before and after | Reduction under light sedation, post-reduction X-ray |
| Snuffbox tenderness | Occult scaphoid fracture, necrosis | X-ray; if normal — splint and MRI | Thumb splint even with a normal X-ray |
| Supracondylar fracture in a child | Brachial artery, anterior interosseous nerve | Pulse, OK sign | Urgent orthopaedic assessment |
A free exam question
באירוע שריפה אותרו 4 נפגעים במרכז כוויות 3 מקומות. את מי ניתן לפנות לבית החולים האזורי? (the question as examined, in Hebrew)
- א. בן 15 כויות בגב עליון חבלה ושינוי צורה בפמור
- ב. בת 78 מונשמת כוויות בפנים
- ג. בן 45 עם כויות דרגה 3 באזור שוק שמאל
- ד. בן 36 כוויה דרגה שניה בטן תחתונה
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Sources
- Rockwood and Green's Fractures in Adults, 9th edition (2019) — Open fractures; Dislocations
- ATLS Advanced Trauma Life Support, Student Course Manual (American College of Surgeons), 10th edition (2018) — Musculoskeletal trauma
- BOAST/BAPRAS Standards for the management of open fractures, 2020 — Antibiotics and timing
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.