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The bigger picture

Not overlooking the basics in complex trauma

A patient was admitted late at night following an MVC with right-sided femoral and tibial fractures and a left sided open talus fracture.

They were taken to the Operating theatre around 11pm where the on call Registrar attempted (unsuccessfully) to reduce the talus. The on call consultant was called and she too struggled to reduce it. A senior foot & ankle consultant (long off the on rota...) was called who performed a medial maleolar osteotomy and managed to get it back in.

At around 5am the patient left the operating theatre for ICU. Colleagues were highly critical that the femur had not been fixed or at least stabilized at the same sitting and the patient returned to theatre several hours later for Ex-Fix

Learning points:

- Polytrauma can be very difficult to manage requires experience. A 15 minute delay to theatre while you discuss the plans and the 'what ifs' would - in this instance - have been time well spent.

- Ask someone to set a timer so you don't loose track of time.

- Do not be embarrassed to phone a friend if you are struggling.

- All injuries were identified in the secondary survey but all 3 operating surgeons failed to attend to the femur at the time of the first operation. This is a type of 'group think'. It might have helped to write the injuries on the white board at the beginning of the case.

- Beware of distracting injuries (like the extruded talus) and make sure you are not missing other common or serious problems which require attention.


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