Orthopaedic Surgery - Hammer Toes

Basics

A hammer toe is a lesser-toe deformity characterized primarily by flexion at the proximal interphalangeal (PIP) joint.

The distal interphalangeal (DIP) joint is usually extended, while the metatarsophalangeal (MTP) joint may remain neutral or become mildly extended.

The deformity may be flexible or rigid.

Epidemiology

Hammer toes are common and may be present in up to approximately 20% of patients presenting with foot disorders.

They occur more frequently in females than males.

Prevention

Because constrictive footwear is a major contributing factor, prevention focuses on wearing shoes with a wide, deep toe box that allows adequate room for the lesser toes.

Shoes that compress the forefoot or force the toes into a flexed position should be avoided.

Etiology

The most common cause is poorly fitting footwear, particularly shoes with a narrow or shallow toe box.

Other associated causes include:

Neuromuscular disease, diabetes mellitus, inflammatory arthropathy, and previous compartment syndrome.

Pathophysiology

Hammer toe develops from an imbalance between the intrinsic and extrinsic muscles and tendons controlling the lesser toes.

Abnormal forces progressively alter PIP and MTP alignment.

Initially, the deformity may remain flexible, but chronic imbalance can lead to capsular contracture and a fixed rigid deformity.

Associated Conditions

Hammer toes frequently coexist with other forefoot abnormalities.

Hallux Valgus

A bunion or hallux valgus deformity may crowd the lesser toes and contribute to development or progression of hammer toe.

MTP Hyperextension

When substantial MTP dorsiflexion accompanies the deformity, the clinical pattern may overlap with a claw toe.

Diagnosis

Diagnosis is primarily clinical.

The examination should define the location of deformity, degree of flexibility, associated MTP instability, and the source of pain.

Signs and Symptoms

Dorsal PIP Prominence

A prominent PIP joint is usually visible over the dorsum of the affected toe.

This prominence may rub against footwear.

Erythema

Repeated shoe pressure may produce localized redness over the prominent joint.

Callus Formation

A painful dorsal callus or corn may develop because of chronic pressure between the PIP prominence and the shoe.

History

Patients commonly report pain over the dorsal PIP prominence, particularly when wearing closed shoes.

Symptoms often improve with wider footwear or removal of the shoe.

Metatarsalgia

Some patients also develop pain beneath the metatarsal heads because altered toe mechanics transfer pressure to the plantar forefoot.

Physical Examination

Flexibility

The examiner should determine whether the deformity is flexible or rigid.

A flexible hammer toe can be passively corrected toward normal alignment, whereas a rigid deformity cannot.

MTP Joint

The MTP joint should be examined for dorsal subluxation, instability, or fixed hyperextension.

MTP instability may influence both treatment and prognosis.

Hallux Valgus

The foot should be inspected for an associated bunion deformity because hallux valgus can worsen crowding of the lesser toes.

Skin

The dorsal PIP joint and plantar forefoot should be examined for calluses, corns, ulceration, erythema, and pressure-related skin breakdown.

This is particularly important in patients with diabetes or neuropathy.

Imaging

Plain radiographs may confirm the PIP flexion deformity and demonstrate associated abnormalities such as MTP subluxation, hallux valgus, or degenerative change.

Weight-bearing views are generally most useful when overall forefoot alignment is being assessed.

Differential Diagnosis

Claw Toe

A claw toe usually demonstrates MTP hyperextension with flexion of both the PIP and DIP joints.

The MTP abnormality is typically more pronounced than in an isolated hammer toe.

Mallet Toe

A mallet toe consists primarily of flexion at the DIP joint.

The PIP joint is usually relatively neutral.

Treatment

General Principles

Treatment is directed toward symptoms rather than appearance alone.

Initial management is usually nonoperative and aims to reduce pressure on the prominent toe, accommodate the deformity, and improve comfort.

Footwear Modification

Shoes with a wide and high toe box should be used to minimize pressure over the dorsal PIP joint.

Avoidance of tight or pointed shoes is an important part of treatment.

Flexible Hammer Toe

A flexible deformity may improve symptomatically with a Budin splint or similar toe-straightening device.

The splint helps hold the toe in a more extended position and decreases dorsal pressure.

Rigid Hammer Toe

When the deformity is rigid, correction with a splint is less effective.

Treatment focuses on reducing local pressure.

Padding

Doughnut-shaped pads, silicone gel sleeves, and other protective devices may decrease friction and pressure over the dorsal prominence.

Geriatric Considerations

Hammer toes are particularly common in older women.

Many elderly patients also have medical conditions that increase operative risk or impair wound healing.

Diabetes and Vascular Disease

In patients with diabetes mellitus, peripheral neuropathy, or peripheral vascular disease, nonoperative treatment should be maximized whenever possible.

Skin integrity must be monitored closely because pressure points can progress to ulceration.

Surgery

Surgery is considered when persistent pain, shoe intolerance, ulceration, or progressive deformity continues despite appropriate nonoperative treatment.

The procedure depends largely on whether the toe remains flexible or has become rigid.

Flexible Hammer Toe Surgery

A flexor-to-extensor tendon transfer may be used for selected flexible deformities.

The procedure redirects flexor force to help extend the PIP joint and rebalance the toe.

Rigid Hammer Toe Surgery

Rigid deformities usually require a bony procedure.

Resection Arthroplasty

One of the most commonly performed operations is resection arthroplasty of the distal portion of the proximal phalanx.

The toe may then be temporarily stabilized with a pin while the soft tissues heal in corrected alignment.

Intramedullary Implants

Intramedullary fixation devices have increasingly been used as alternatives to external pins.

Potential advantages include avoidance of an exposed pin and improved patient convenience, although implant-related complications can still occur.

PIP Arthrodesis

Fusion of the PIP joint is another common option for painful rigid hammer toe.

It can be used both for primary correction and for revision of recurrent deformity.

Referral

Patients whose symptoms persist despite shoe modification, padding, or splinting may benefit from surgical consultation.

Diabetes

Patients with diabetes, neuropathy, or threatened skin breakdown should be assessed early because progressive pressure may lead to neuropathic ulceration or infection.

Prognosis

Hammer toe deformities commonly progress gradually over time.

Flexible deformities may become rigid as soft tissues contract.

Pain, callus formation, and difficulty wearing shoes may increase as the deformity worsens.

Complications

Potential postoperative complications include:

Stiffness, wound infection, persistent pain, incomplete correction, implant irritation, and recurrence of deformity.

Patient Monitoring

Follow-up should assess pain, shoe tolerance, skin condition, callus formation, flexibility of the toe, MTP stability, and progression of deformity.

Patients with diabetes or neuropathy require particularly careful surveillance for pressure-related skin breakdown and ulceration.

Surgery - Advanced Trauma Life Support (ATLS)

Principles of ATLS

Advanced Trauma Life Support (ATLS) provides a systematic and reliable approach to the assessment and initial resuscitation of trauma patients.

The aim is to rapidly identify and immediately treat potentially life-threatening injuries.

Once immediate threats to life have been managed, a more detailed assessment of the entire patient is performed to identify other injuries and establish definitive care.

The ATLS assessment is therefore divided into the primary survey and secondary survey.

Primary Survey

The primary survey is the initial systematic assessment of a trauma patient designed to identify and treat immediately life-threatening injuries.

Assessment and resuscitation occur simultaneously, with problems treated as soon as they are identified.

The primary survey follows the ABCDE approach.

A – Airway with cervical spine protection: Assess and secure the airway while maintaining appropriate cervical spine protection.

B – Breathing: Assess ventilation, oxygenation, and the respiratory system, and immediately treat life-threatening thoracic injuries.

C – Circulation with haemorrhage control: Assess the cardiovascular system, identify shock, and rapidly control significant haemorrhage.

D – Disability: Perform a rapid neurological assessment, including level of consciousness, pupils, and neurological status.

E – Exposure and environmental control: Fully expose the patient to identify injuries while actively preventing hypothermia.

Life-Threatening Injuries in the Primary Survey

The mnemonic ATOMIC can be used to remember important immediately life-threatening injuries.

A – Airway compromise: Airway obstruction may result in inadequate ventilation and oxygenation.

T – Tension pneumothorax: Increasing intrapleural pressure compromises ventilation and venous return and can rapidly cause cardiovascular collapse.

O – Open pneumothorax: A large open chest wall defect allows air to enter the pleural cavity and may severely compromise ventilation.

M – Massive haemothorax: A large accumulation of blood within the pleural cavity causes both respiratory compromise and haemorrhagic shock.

I – Incipient flail chest: Multiple rib fractures can produce an unstable chest wall segment, often associated with significant pulmonary contusion and respiratory compromise.

C – Cardiac tamponade: Accumulation of blood within the pericardial sac restricts cardiac filling and may cause obstructive shock.

Secondary Survey

The secondary survey is a thorough head-to-toe assessment performed after the primary survey and initial resuscitation have addressed immediate life-threatening problems.

Its purpose is to identify other injuries caused by the trauma that may not have been apparent during the primary survey.

It includes a detailed history, complete physical examination, appropriate investigations, and repeated reassessment of the patient.

The findings are then used to formulate a plan for definitive treatment and ongoing care.

If the patient deteriorates at any stage during the secondary survey, assessment should immediately return to the ABCDE primary survey.

Trauma Imaging

Traditionally, the standard trauma radiographic series consisted of cervical spine, chest, and pelvic X-rays.

A chest X-ray (CXR) may rapidly identify important thoracic injuries such as pneumothorax, haemothorax, and other chest pathology.

A pelvic X-ray may identify major pelvic fractures associated with significant haemorrhage.

Dedicated cervical spine X-rays have largely been replaced in many modern major-trauma pathways by CT when cervical spine imaging is indicated.

Imaging should never delay the treatment of an immediately life-threatening injury identified during the primary survey.

Surgery - Breathing

Timing of Breathing Assessment

Breathing should be assessed only after the airway has been cleared and secured.

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Mechanisms of Injury Affecting Breathing

Blunt trauma may compromise breathing through direct impact to the chest.

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Shear forces may also cause thoracic injury, such as when a patient is run over by a motor vehicle.

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Deceleration injuries may occur following high-speed road traffic collisions or falls from height.

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Penetrating trauma may result from stab wounds.

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Gunshot wounds can also cause severe penetrating thoracic injury.

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Blast injuries may follow a nearby explosion and can cause pulmonary damage secondary to capillary haemorrhage and alveolar rupture.

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Assessment of Breathing

Breathing should be assessed systematically using inspection, auscultation, palpation, and percussion.

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Inspection

Cyanosis may indicate significant hypoxia.

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An increased respiratory rate may be an early sign of respiratory compromise.

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Asymmetrical chest expansion may indicate unilateral thoracic injury.

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Use of accessory muscles, tracheal tug, or visibly increased work of breathing suggests respiratory distress.

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Paradoxical chest wall movement occurs when a segment of the chest moves inward during inspiration and outward during expiration, usually because of multiple rib fractures.

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The chest should be inspected for superficial signs of trauma such as bruising, gunshot wounds, stab wounds, and seatbelt marks.

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Auscultation

All lung zones should be auscultated for areas of reduced or absent air entry.

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Bronchial breathing may indicate underlying pulmonary pathology.

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Wheeze may occur because of bronchospasm associated with intrathoracic injury.

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Palpation and Percussion

Air movement should be assessed to confirm that the patient is breathing spontaneously.

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The trachea should be palpated for deviation.

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The chest should be percussed for areas of dullness or hyperresonance.

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Subcutaneous emphysema may indicate an underlying pneumothorax or other air leak associated with thoracic injury.

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Immediately Life-Threatening Thoracic Injuries

Four important life-threatening thoracic injuries must be identified during the primary survey.

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These are tension pneumothorax, open pneumothorax, massive haemothorax, and flail chest.

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Tension Pneumothorax

A tension pneumothorax occurs when air accumulates under pressure within the pleural cavity.

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The rising intrathoracic pressure compresses the ipsilateral lung and may displace the mediastinum and compromise the contralateral lung and venous return.

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It usually develops through a one-way valve mechanism in which air enters the pleural cavity but cannot escape effectively.

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Clinical Features of Tension Pneumothorax

Ipsilateral chest expansion may be reduced.

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The trachea may deviate away from the affected side, although this is usually a late sign.

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Percussion over the affected side may be hyperresonant.

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Air entry may be markedly reduced or absent on the affected side.

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The patient may develop tachycardia, tachypnoea, severe respiratory distress, and hypoxia.

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Distended neck veins may occur because of impaired venous return, although they may be absent if the patient is also hypovolaemic.

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Open Pneumothorax

An open pneumothorax occurs when there is a chest wall defect that communicates directly with the pleural cavity.

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If the defect is sufficiently large, air preferentially enters through the chest wall wound rather than through the trachea.

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It is traditionally called a sucking chest wound because air may be heard moving through the wound during respiration.

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Clinical Features of Open Pneumothorax

There may be an obvious chest wall defect with a sucking sound during inspiration.

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Air entry is reduced on the affected side.

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Chest expansion is reduced on the affected side.

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Tachycardia and tachypnoea are common.

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Massive Haemothorax

A massive haemothorax is traditionally defined as accumulation of more than 1500 mL of blood within the pleural cavity.

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It may result from injury to intercostal vessels, pulmonary vessels, or major intrathoracic vessels.

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Clinical Features of Massive Haemothorax

Ipsilateral chest expansion is reduced.

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Percussion over the affected side is dull.

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Air entry is reduced on the affected side.

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The patient may develop tachypnoea, tachycardia, and signs of hypovolaemic shock.

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Flail Chest

Flail chest occurs when multiple adjacent ribs are fractured in multiple places, creating a free-floating segment of chest wall.

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The unstable segment may move paradoxically inwards during inspiration and outwards during expiration.

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Clinical Features of Flail Chest

Paradoxical chest wall movement may be visible.

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Crepitus may be felt on palpation of the injured area.

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Air entry may be reduced on the affected side.

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Tachypnoea and tachycardia are common.

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Associated pulmonary contusion is often an important contributor to respiratory compromise.

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Immediate Management of Tension Pneumothorax

Tension pneumothorax is a clinical diagnosis and should be treated immediately without waiting for imaging.

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Emergency decompression should be performed promptly, followed by definitive chest drain insertion.

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Needle decompression has traditionally been used, although finger thoracostomy may be preferred in some trauma systems where expertise is available.

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Landmarks for Emergency Thoracic Decompression

A traditional site for needle decompression is the second intercostal space in the mid-clavicular line.

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Many current trauma protocols also accept or prefer the fourth or fifth intercostal space in the anterior to mid-axillary line, particularly because chest wall thickness may make the anterior approach less reliable.

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Landmarks for Chest Drain Insertion

A chest drain is usually inserted within the safe triangle, commonly around the fourth or fifth intercostal space between the anterior and mid-axillary lines.

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The tube should be inserted just above the upper border of the rib to reduce the risk of injury to the intercostal neurovascular bundle.

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Management of Open Pneumothorax

The open chest wound should be covered promptly with an appropriate occlusive or vented dressing.

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A traditional temporary technique is to secure an occlusive dressing on three sides, creating a flutter-valve effect that limits air entry while allowing air to escape.

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A chest drain should then be inserted on the affected side at a separate clean site away from the wound.

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Definitive surgical closure of the chest wall defect may subsequently be required.

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Blood Investigations

A group and cross-match should be performed if significant bleeding or transfusion is anticipated.

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An arterial blood gas may provide information about oxygenation, ventilation, acid-base status, lactate, and haemoglobin concentration.

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Co-oximetry can be used to measure carboxyhaemoglobin when smoke inhalation or carbon monoxide exposure is suspected.

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Chest X-Ray

A chest X-ray remains an important investigation in thoracic trauma, although treatment of immediately life-threatening conditions should not be delayed for imaging.

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A pneumothorax may appear as a visible pleural line with loss of peripheral lung markings beyond it.

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The size of a pneumothorax should not be estimated using the old assumption that a 1 cm rim equals 10% lung-volume loss, as this is unreliable.

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A haemothorax may produce blunting of the costophrenic angle on an erect chest X-ray.

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Several hundred millilitres of pleural blood may be required before costophrenic angle blunting becomes visible on an erect film.

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Chest X-ray may also assist in identifying pulmonary contusion, parenchymal injury, rib fractures, mediastinal abnormalities, and other thoracic pathology.

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CT Imaging

CT scanning can provide more detailed information about thoracic injuries.

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It should generally be reserved for patients who are sufficiently stable for transfer to the scanner.

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CT is usually performed after immediate life-threatening problems have been addressed and often as part of the secondary survey or definitive trauma imaging pathway.

Surgery - Circulation: Classification of Haemorrhagic Shock

Class 1 Shock

Blood pressure: Systolic blood pressure is unchanged and diastolic blood pressure is unchanged.

Pulse: The pulse is high-normal in rate and normal in volume.

Capillary refill time: Capillary refill time is normal.

Respiratory rate: Respiratory rate is normal.

Urine output: Urine output remains greater than 30 mL/hour.

Extremities: The extremities retain a normal colour.

Complexion: The complexion remains normal.

Mental state: The patient remains alert.

Blood loss: Blood loss is less than 15%, approximately 750 mL.

A useful tennis analogy is “love-fifteen.”

Class 2 Shock

Blood pressure: Systolic blood pressure is usually normal, while diastolic blood pressure may be raised.

Pulse: The pulse rate is approximately 100–120 beats/minute, with a generally normal pulse volume.

Capillary refill time: Capillary refill is slow, usually taking more than 2 seconds.

Respiratory rate: Tachypnoea develops.

Urine output: Urine output falls to approximately 20–30 mL/hour.

Extremities: The extremities become pale.

Complexion: The patient appears pale.

Mental state: The patient may become anxious.

Blood loss: Blood loss is approximately 15–30%, corresponding to around 800–1500 mL.

A useful tennis analogy is “fifteen-thirty.”

Class 3 Shock

Blood pressure: Both systolic and diastolic blood pressure are reduced.

Pulse: The pulse is greater than 120 beats/minute and becomes thready.

Capillary refill time: Capillary refill remains slow, usually more than 2 seconds.

Respiratory rate: The respiratory rate is greater than 20 breaths/minute.

Urine output: Urine output falls to approximately 10–20 mL/hour.

Extremities: The extremities are pale.

Complexion: The patient appears pale.

Mental state: The patient may become aggressive or drowsy.

Blood loss: Blood loss is approximately 30–40%, corresponding to around 1500–2000 mL.

A useful tennis analogy is “thirty-forty.”

Class 4 Shock

Blood pressure: Systolic blood pressure is very low, while diastolic blood pressure is very low or may be unrecordable.

Pulse: The pulse is greater than 120 beats/minute and is very thready.

Capillary refill time: Capillary refill may be undetectable.

Respiratory rate: The respiratory rate is greater than 20 breaths/minute.

Urine output: Urine output falls to approximately 0–10 mL/hour.

Extremities: The extremities are pale and clammy.

Complexion: The patient may appear ashen.

Mental state: The patient becomes drowsy or confused.

Blood loss: Blood loss exceeds 40%, corresponding to more than 2000 mL.

A useful tennis analogy is “game over.”

Surgery - Circulation

Shock

Shock is a clinical state in which the circulation is inadequate to maintain sufficient tissue perfusion.

As a result, the metabolic demands of the body are not met, oxygen delivery to tissues becomes inadequate, and abnormal cellular and organ physiology develops.

Types of Shock

Hypovolaemic shock occurs when there is a reduction in intravascular volume, most commonly due to haemorrhage.

Cardiogenic shock occurs when the heart fails as an effective pumping mechanism. This may result from primary cardiac damage or secondary causes such as cardiac tamponade.

Septic shock results from infection and the release of inflammatory mediators, causing vasodilatation and abnormal distribution of intravascular volume.

Neurogenic shock results from loss of sympathetic vascular tone due to disruption of neurological pathways, such as following spinal cord injury.

Anaphylactic shock results from a severe allergic reaction with mediator release, causing vasodilatation, increased vascular permeability, and maldistribution of circulating volume.

Common Feature of Shock

All forms of shock ultimately result in inadequate effective circulation and insufficient delivery of oxygen to tissues for cellular uptake and aerobic metabolism.

Shock in Trauma

In a shocked trauma patient, hypovolaemic shock secondary to haemorrhage should be assumed until proven otherwise.

Obvious Haemorrhage

Obvious external haemorrhage may occur with open or compound fractures.

Digital or limb amputation may cause severe visible blood loss.

Arterial puncture wounds may also produce rapid and potentially life-threatening haemorrhage.

Hidden Haemorrhage

Closed long-bone fractures may conceal a considerable volume of blood within the surrounding tissues.

Thoracic trauma may result in blood accumulating within the pleural or thoracic cavity.

Abdominal trauma may produce significant intraperitoneal or retroperitoneal haemorrhage.

Closed pelvic fractures can cause massive concealed haemorrhage within the pelvis and retroperitoneum.

Penetrating Wounds

Penetrating wounds involving the neck or mediastinum should be treated with a high index of suspicion.

These injuries may damage major blood vessels or penetrate the heart, potentially producing severe haemorrhage, cardiac tamponade, or cardiogenic shock.

Clinical Assessment of Shock

Clinical assessment of shock should be systematic and include inspection, auscultation, palpation, and bedside monitoring.

Inspection

Peripheral or central cyanosis may indicate inadequate oxygenation or poor tissue perfusion.

A shocked patient may appear cold and clammy because sympathetic activation causes peripheral vasoconstriction and reduced skin perfusion.

Distended jugular veins may suggest an obstructive or cardiogenic cause of shock, such as cardiac tamponade.

Visible trauma should be assessed for evidence of active or previous haemorrhage.

Respiratory rate should be assessed. A normal adult respiratory rate is approximately 12–20 breaths per minute, and tachypnoea may be an early feature of shock.

Confusion, agitation, aggression, drowsiness, or coma may develop as a result of reduced cerebral perfusion or hypoxia.

The jugular venous pressure may provide additional information, although it may be difficult to assess reliably during the rapid evaluation of a trauma patient.

Auscultation

Muffled heart sounds may suggest cardiac tamponade in the appropriate clinical setting.

Pulse Assessment

The pulse should be assessed for rate, rhythm, and volume.

A normal resting adult pulse is approximately 60–100 beats per minute.

The pulse may be bounding, weak or thready, irregular, or absent depending on the patient’s condition.

If a radial pulse cannot be palpated, the carotid and femoral pulses should be assessed.

If no central pulse is present, cardiac arrest should be recognised and appropriate resuscitation commenced immediately.

Capillary Refill Time

Capillary refill time provides a rapid estimate of peripheral perfusion.

Pressure may be applied to the sternum or another appropriate site until the area blanches.

Normal colour should generally return within approximately 2 seconds.

A prolonged capillary refill time may suggest impaired peripheral perfusion and shock.

Bedside Investigations and Monitoring

Blood pressure should be measured and monitored.

Oxygen saturation should be assessed using pulse oximetry.

Continuous cardiac monitoring and an ECG rhythm trace should be obtained where appropriate.

Urine output should be monitored as an important marker of organ perfusion, usually after urinary catheterisation when appropriate during the subsequent trauma assessment.

Estimation of Blood Loss

The clinical findings of pulse, blood pressure, respiratory rate, mental status, and urine output can be used together to estimate the severity of haemorrhagic shock.

Traditional haemorrhagic shock classifications are based on an average 70-kg adult with an estimated circulating blood volume of approximately 5 litres.

Initial Management of Shock

In trauma, shock should initially be treated as haemorrhagic hypovolaemia until another cause has been established.

Management focuses on restoring effective circulation while identifying and controlling the source of bleeding.

Intravenous Access

Two large-bore peripheral intravenous cannulae should be inserted, preferably into the antecubital veins.

Large-bore access, such as 14–16G cannulae, allows rapid administration of fluids and blood products.

If antecubital access cannot be obtained, other accessible peripheral veins should be cannulated using the largest practical bore.

If peripheral venous access is unsuccessful, alternative access such as intraosseous access or central venous access may be required depending on the patient’s age, condition, and available expertise.

A surgical venous cut-down involves direct surgical exposure and cannulation of a vein, traditionally the great saphenous vein, although this is now much less commonly required.

Intraosseous access can provide rapid vascular access in both children and adults when conventional intravenous access cannot be established promptly.

Central venous access using a large-bore catheter or the Seldinger technique may be used by experienced clinicians when indicated.

Initial Fluid Resuscitation

Initial fluid resuscitation should use warmed fluids when appropriate, while avoiding unnecessary large-volume crystalloid administration in actively bleeding trauma patients.

Fluid or blood products may be administered rapidly using pressure-assisted systems when clinically indicated.

Balanced crystalloid solutions such as Hartmann’s solution, also known as Ringer’s lactate, may be used when crystalloid resuscitation is required.

Seldinger Technique

The Seldinger technique is used to insert a catheter into a blood vessel.

A needle is inserted into the desired vessel, and a guidewire is passed through the needle.

The needle is then removed while the guidewire remains in place.

A dilator and catheter are subsequently passed over the guidewire into the vessel, after which the wire is removed and the catheter is secured.

Blood Sampling During Cannulation

Blood should ideally be collected when intravenous access is obtained and before large-volume fluid administration.

A sample should be sent for group and save or group and cross-match, depending on the severity of bleeding and anticipated transfusion requirements.

A full blood count should be obtained to provide baseline haemoglobin, haematocrit, platelet count, and other haematological information.

Urea, electrolytes, and creatinine should be measured as baseline investigations.

Blood glucose should also be checked, either using a bedside glucose meter or laboratory testing.

Additional serum samples may be stored if further investigations are likely to be required.

Adjunctive Measures

Adequate oxygenation and ventilation must be ensured because restoring circulation alone will not correct tissue hypoxia if oxygenation remains inadequate.

Supplemental oxygen should be provided when indicated, and airway protection with intubation may be necessary in severely injured or unconscious patients.

External haemorrhage should be controlled promptly using direct pressure over the bleeding site.

Elevation of an injured limb may occasionally help reduce venous bleeding where appropriate, although direct pressure and definitive haemorrhage control remain more important.

Fluids and Blood Products

Hartmann’s solution or Ringer’s lactate is a balanced crystalloid that may be used for volume replacement.

Other crystalloids, such as normal saline, are also available, although large-volume administration may have disadvantages.

Colloid solutions have historically been used for intravascular volume expansion, but they have a limited role in modern trauma resuscitation.

Blood products provide both circulating volume and, in the case of red blood cells, oxygen-carrying capacity.

Indications for Blood Transfusion

Blood products are indicated when there is significant or ongoing haemorrhage, particularly when the patient shows evidence of severe haemorrhagic shock.

Patients with substantial blood loss may require activation of a major haemorrhage or massive transfusion protocol.

Emergency Blood

When blood is required immediately and the patient’s blood group is unknown, group O red blood cells may be used.

Group O negative red cells are traditionally regarded as universal donor red cells and are commonly prioritised for certain patients, although institutional emergency transfusion protocols may also use group O positive blood in selected circumstances.

Emergency uncross-matched blood can be given without waiting for full compatibility testing when life-threatening haemorrhage is present.

Type-Specific Blood

Type-specific blood can usually be provided once the patient’s ABO and Rh blood group has been determined.

This blood is matched to the recipient’s major blood group but may be issued before full cross-matching is complete when urgent transfusion is required.

Fully Cross-Matched Blood

Fully cross-matched blood undergoes ABO typing, antibody screening, and compatibility testing to maximise compatibility with the recipient.

A patient blood sample must be sent to the laboratory before fully cross-matched blood can be prepared.

Definitive Treatment of Shock

Once initial resuscitation has begun, management should focus on identifying and treating the specific underlying cause of shock.

In haemorrhagic shock, definitive haemorrhage control may require surgery, interventional radiology, endoscopy, fracture stabilisation, or other targeted treatment.

Cardiac Tamponade

Cardiac tamponade is a life-threatening circulatory problem that must be recognised during the primary survey.

It occurs when blood or other fluid accumulates within the pericardial sac and exerts pressure on the heart.

This pressure interferes with diastolic filling, reduces stroke volume, and may result in obstructive shock and cardiovascular collapse.

Traumatic cardiac tamponade most commonly follows penetrating or blunt cardiac injury.

Recognition of Cardiac Tamponade

Beck’s triad consists of hypotension, muffled heart sounds, and raised jugular venous pressure.

These classical findings may not all be present in a trauma patient, particularly in the presence of significant blood loss.

Bedside ultrasound, particularly the FAST or eFAST examination, can rapidly identify pericardial fluid in an unstable trauma patient.

Kussmaul’s Sign

Kussmaul’s sign refers to a paradoxical rise or failure of the jugular venous pressure to fall during inspiration.

Although it may occur in disorders that impair right ventricular filling, it is not a reliable classical sign of acute traumatic cardiac tamponade.

Management of Cardiac Tamponade

Management begins with the ABCDE approach and simultaneous resuscitation.

Definitive treatment requires urgent relief of pericardial pressure and control of the underlying cardiac injury.

Pericardiocentesis may be used as a temporary emergency measure in selected situations when definitive surgical treatment is not immediately available.

In traumatic tamponade, emergency thoracotomy or operative pericardial decompression may be required, particularly when penetrating cardiac injury is suspected.

Emergency Department Thoracotomy

Emergency department thoracotomy may be considered in selected patients with penetrating thoracic trauma who initially had signs of life and then deteriorate into profound shock or cardiac arrest.

It may also be used in exceptional circumstances to control catastrophic intrathoracic haemorrhage, relieve cardiac tamponade, perform open cardiac massage, or temporarily cross-clamp the descending thoracic aorta.

The procedure should only be undertaken in appropriately selected patients by teams with the necessary trauma and surgical expertise.

Situations Where Emergency Thoracotomy Is Unlikely to Be Beneficial

Emergency thoracotomy has a very poor outcome after prolonged cardiac arrest without signs of life.

Outcomes are particularly poor following severe blunt trauma with prolonged absence of vital signs.

The decision depends on the mechanism of injury, duration of resuscitation, presence or absence of signs of life, available expertise, and local trauma protocols.

Surgery - Disability

Immediate Neurological Assessment

Neurological status should initially be assessed rapidly using the AVPU system, followed by a more definitive assessment using the Glasgow Coma Scale (GCS).

AVPU System

A – Alert: The patient is spontaneously alert and responsive. This is approximately equivalent to a GCS of 14–15.

V – Voice: The patient responds to verbal stimuli. This is approximately equivalent to a GCS of 9–10.

P – Pain: The patient responds only to painful stimuli. This is approximately equivalent to a GCS of 7–8.

U – Unresponsive: The patient does not respond to verbal or painful stimuli. This may correspond to a GCS as low as 3.

Glasgow Coma Scale

The Glasgow Coma Scale (GCS) provides a more detailed assessment of the patient’s level of consciousness.

It consists of three components: eye response, verbal response, and motor response.

The patient’s best response in each category is recorded, giving a maximum total score of 15.

Best Eye Response

No eye opening – 1 point.

Eye opening to painful stimuli – 2 points.

Eye opening to verbal stimuli – 3 points.

Spontaneous eye opening – 4 points.

Best Verbal Response

No verbal response – 1 point.

Incomprehensible sounds or noises – 2 points.

Inappropriate words – 3 points.

Confused conversation – 4 points.

Orientated and lucid response – 5 points.

Best Motor Response

No motor response – 1 point.

Abnormal extension to pain (decerebrate response) – 2 points.

Abnormal flexion to pain (decorticate response) – 3 points.

Withdrawal from pain – 4 points.

Localising to pain – 5 points.

Following commands – 6 points.

Highest GCS Score

The highest possible GCS score is 15.

A patient with a GCS of 15 is fully alert, awake, orientated, and appropriately responsive.

Lowest GCS Score

The lowest possible GCS score is 3, not zero.

A patient with a GCS of 3 is deeply unconscious and demonstrates no eye, verbal, or motor response.

GCS and Intubation

A GCS of 8 or less indicates severe impairment of consciousness and should prompt assessment of the patient’s ability to protect their airway.

In trauma, the traditional principle is “GCS 8, intubate,” although the decision to intubate should also take into account the patient’s airway, ventilation, oxygenation, clinical trajectory, and other injuries.

Reassessment of GCS in Trauma

The GCS should be reassessed frequently in a trauma patient, traditionally every 15 minutes during the acute phase.

Every GCS assessment should be clearly documented so that any improvement or deterioration in neurological status can be identified.

Surgery - Exposure

Patient Exposure

The patient should be fully exposed from head to toe so that injuries anywhere on the body can be identified. Clothing may need to be removed using shears when necessary.

Full exposure is important because visual clues may reveal otherwise unsuspected injuries. For example, seatbelt marks may indicate significant underlying chest or abdominal trauma, including possible sternal injury.

Log-Roll

Following exposure, a log-roll should be performed when indicated. The patient is rolled onto their side while maintaining spinal alignment and immobilisation throughout the manoeuvre.

A coordinated team is required to perform the log-roll safely, traditionally involving up to five people, particularly when spinal injury is suspected.

Assessment During Log-Roll

During the log-roll, the back, buttocks, posterior thighs, posterior legs, and spine should be carefully examined.

The spine should be assessed for deformity, focal tenderness, bruising or ecchymosis, wounds, and other evidence of injury.

A digital rectal examination (DRE) may be performed when clinically indicated, particularly when pelvic, rectal, urethral, or spinal injury is suspected.

Digital Rectal Examination

Anal tone may be assessed during DRE. Reduced anal tone can occur with spinal cord or neurological injury.

The examination should assess for blood, which may indicate anorectal or pelvic trauma.

The prostate may be assessed in male patients. A high-riding or non-palpable prostate has traditionally been associated with urethral injury.

Palpable bony fragments or spicules may suggest an associated pelvic fracture.

Prevention of Hypothermia

Hypothermia must be avoided once the patient has been exposed.

Following examination and log-roll, the patient should be covered and appropriately insulated as soon as possible while still allowing access for continued assessment and treatment.

Core Body Temperature

Core body temperature should be monitored using an appropriate core-temperature measurement method. Rectal temperature is one method of assessing core temperature, although other core sites may be used depending on the clinical situation.

Raising Core Temperature in Hypothermia

In mild hypothermia, external warming can be provided using forced-air warming devices such as Bair Hugger® systems, together with blankets and appropriate covering.

Warmed intravenous fluids may be administered to prevent further heat loss and assist rewarming when fluid resuscitation is required.

In more significant hypothermia, active internal rewarming techniques may be considered depending on severity and available expertise.

These techniques can include warmed lavage or irrigation through appropriate routes, such as gastric, bladder, peritoneal, or other body cavities, although their use depends on the clinical circumstances and current trauma protocols.

Surgery - Secondary Survey

Objectives of the Secondary Survey

The secondary survey begins after immediate life-threatening injuries have been identified and treated.

Its purpose is to obtain a definitive history, perform a thorough examination, assimilate relevant investigations, and formulate an appropriate management plan.

The patient should be examined systematically from head to toe, including both the front and back of the body.

A thorough assessment includes examination of all relevant orifices where indicated, traditionally summarized by the phrase “fingers and tubes in every orifice.”

A detailed history of the incident should be obtained, including collateral information from witnesses, paramedics, or accompanying persons when available.

A complete medical history should also be obtained.

All directed investigations should be reviewed and incorporated into the overall clinical assessment.

The secondary survey should conclude with the formulation of a definitive management plan.

Investigations

Any investigations relevant to the patient’s injuries and clinical condition should be performed.

At the very least, a trauma imaging series should be obtained or considered as appropriate, together with basic blood investigations and an electrocardiogram (ECG).

Further investigations should be directed by the mechanism of injury, examination findings, and the patient’s clinical condition.

History

A paramedic handover should be obtained to establish the mechanism of injury, events at the scene, pre-hospital findings, and any treatment already given.

A collateral history should be obtained from witnesses or accompanying persons whenever possible.

The patient’s own history should be obtained whenever their clinical condition allows.

An AMPLE medical history should also be obtained.

A – Allergies: Any known drug, food, or other relevant allergies should be identified.

M – Medications: Current medications should be documented.

P – Past Medical History: Relevant previous medical conditions, operations, and comorbidities should be established.

L – Last Meal: The timing of the patient’s last meal or oral intake should be determined.

E – Events Leading to the Situation: The events and circumstances leading to the injury or current situation should be clarified.

Deterioration During the Secondary Survey

If there is any change or deterioration in the patient’s clinical condition during the secondary survey, assessment should immediately return to the ABCDE approach.

Any newly identified life-threatening problem should be evaluated and treated as necessary.

The secondary survey should only be resumed once the patient has been sufficiently stabilized.

Surgery - Pelvis

Clinical Findings Suggesting Pelvic Injury

Obvious deformity or an open injury may indicate significant pelvic trauma.

Localised pelvic pain or limb paraesthesia may suggest associated bony or neurological injury.

Signs of retroperitoneal haemorrhage include bruising of the scrotum, buttocks, or along the line of the inguinal ligament, known as Fox’s sign.

Signs of urethral injury include blood at the urethral meatus, a high-riding prostate, and an inability to void urine.

Rectal examination may reveal blood or palpable bony fragments.

Reduced anal tone may indicate associated neurological or lumbosacral injury.

Abnormal pelvic stability on clinical assessment may also suggest disruption of the pelvic ring.

Types of Pelvic Injury

External rotation of the hemipelvis occurs with disruption of the pubic symphysis and is typically associated with anteroposterior compression.

This injury pattern may be caused by a direct anteroposterior compression force.

It may also result from a direct posterior blow to the iliac spines.

Forced external rotation of the lower limb can also produce this pattern of pelvic injury.

Internal rotation of the hemipelvis is associated with compression fractures of the pubic rami and usually results from lateral compression.

This pattern is typically caused by a lateral impact producing medial compression of the pelvis.

Vertical shear injury involves fracture-dislocation of the hemipelvis with superior and posterior displacement.

It is caused by a vertical loading force that fractures the pubic rami and disrupts the sacroiliac joint, resulting in displacement of the affected hemipelvis.

Pelvic Springing

Pelvic springing is a clinical test used to assess the stability and integrity of the pelvic ring.

It involves gentle compression of the iliac wings.

The aim is to identify pelvic instability that may suggest a fracture before imaging is obtained.

Main Concern in Pelvic Fracture

The major concern in pelvic fracture is uncontrolled haemorrhage into the pelvic cavity.

The pelvis can accommodate several litres of blood, so significant haemorrhage may occur before it becomes externally apparent.

Interim Management of Unstable Pelvic Fractures

A sheet may be placed beneath the buttocks and wrapped anteriorly around the pelvis, with the ends secured to provide a basic temporary splint.

Anterior external fixation may be used by inserting two pins into the anterior border of the ilium on each side and connecting them with a rigid external frame.

Posterior external fixation may involve pin insertion along the line between the anterior superior iliac spine and posterior superior iliac spine, with the pins connected using a reduction clamp.

External fixation should be performed by an experienced orthopaedic surgeon because of the risk of iatrogenic neurovascular injury.

Surgery - Musculoskeletal

Musculoskeletal Injuries Contributing to Shock

Several musculoskeletal injuries can result in significant blood loss and contribute to haemorrhagic shock. These include arterial bleeding, pelvic fractures, large vessel puncture, limb amputation, and long bone fractures. Long bone fractures can conceal substantial amounts of blood loss. A humeral fracture may be associated with approximately 0.5–1.5 litres of blood loss, a tibial fracture with approximately 0.5–1.5 litres, and a femoral fracture with approximately 1.0–2.5 litres.

Musculoskeletal Assessment in the Secondary Survey

The primary survey and ABCs should always be addressed first. Once the patient is stable, the musculoskeletal system can be assessed systematically during the secondary survey. This includes taking a focused history and examining the patient using the principles of look, feel, and move.

History

The history should include the position of the patient when first found or on arrival, any obvious or suspected trauma, and the mechanism of injury. In road traffic accidents, important details include seatbelt use, airbag deployment, whether the patient was able to mobilise after the accident, and the direction of impact. It is also useful to determine whether the patient was found close to or away from the accident site.

An AMPLE history should be taken, including allergies, medications, past medical history, last meal, and events surrounding the injury. Previous joint or limb pathology should also be identified. Osteoporosis and osteopenia are especially important because they increase susceptibility to fractures following relatively minor trauma.

Inspection

The patient should be appropriately exposed and both sides of the body compared. Look for open fractures, which may involve exposed bone but are not always immediately obvious. Other important features include swelling, deformity, bruising, wounds, and changes in the colour of the limb distal to the injury.

Palpation

Both sides should be compared while assessing the temperature of the distal limb, the presence of crepitus, joint effusions, haemarthroses, and capillary refill time. In a conscious patient, pain and tenderness should also be assessed. Neurological integrity should be checked by assessing fine touch sensation, motor function, and sweating of the skin, or hidrosis.

Movement

Range of active movement should be assessed in a conscious patient. Passive movement may be considered in an unconscious patient where appropriate. However, an obvious or suspected fracture should not be manipulated before X-ray imaging, as this does not add significantly to the diagnosis and may worsen the injury. Joint dislocations should generally be reduced as soon as clinically appropriate. Weight-bearing may be assessed as tolerated when relevant.

Investigations

Plain X-rays are the standard initial investigation for uncomplicated musculoskeletal trauma. Imaging should be selected according to the suspected site and type of injury.

Rule of Twos

The rule of twos is a useful principle when assessing fractures radiologically. Two joints should be considered, meaning the joint above and the joint below the injury should be assessed where appropriate. Two views, usually an anteroposterior and lateral view, should be obtained to assess displacement and angulation accurately. If doubt remains, the opposite side may occasionally be imaged for comparison, although this is rarely required.