A young man has an anterior shoulder dislocation. What must be examined and recorded BEFORE reduction? ANSWER: the NEUROVASCULAR status — pulse, sensation and movement — and in particular the AXILLARY NERVE. AXILLARY NERVE TEST: sensation over the DELTOID (the "regimental badge" area). WHY BEFORE, AND WHY WRITTEN DOWN: if a deficit is found after reduction and there is no pre-reduction record, nobody can say whether the injury caused it or the reduction did. That matters clinically for the patient, and medicolegally for you — the forensic chapter makes the same point about records in general. AND AFTERWARDS: repeat the same examination and record it again.

Why is a posterior hip dislocation reduced urgently? ANSWER: because delay increases the risk of AVASCULAR NECROSIS of the femoral head. 1. The femoral head's blood supply is precarious by anatomy. 2. Dislocation disrupts it. 3. The longer the hip stays dislocated, the higher the risk that the head dies — destroying the joint, often in a young patient. ALSO AT RISK: the SCIATIC NERVE. Test and document it before and after. CONTEXT WORTH ADDING: posterior hip dislocation is classically a DASHBOARD injury in a road crash, so look for the other injuries that accompany that mechanism rather than treating the hip in isolation.

A knee dislocation reduced spontaneously before arrival. The pedal pulses are present and the foot is warm. Can the patient be discharged? ANSWER: No. A palpable pulse early does NOT exclude popliteal artery injury. 1. Knee dislocation carries a high risk of POPLITEAL ARTERY injury. 2. An INTIMAL TEAR may not obstruct flow initially. 3. It can THROMBOSE over the following hours. 4. So a limb that felt normal on arrival can become ischaemic later. MANAGEMENT: vascular assessment and a period of observation, not reassurance from a single normal examination. AND NOTE THE TRAP IN THIS STEM: knee dislocations often reduce spontaneously before arrival, so the joint may look normal. The HISTORY of gross deformity is what tells you this was a dislocation.

A fracture has failed to unite after several months. Give the reasons this happens. ANSWER: healing needs THREE things, and non-union means one was missing. BLOOD SUPPLY Bone without it cannot heal and eventually dies. STABILITY A little movement stimulates healing; too much prevents it. APPOSITION The ends must be close enough to bridge. SO NON-UNION FOLLOWS FROM: - excessive movement at the fracture site - a gap between the ends, or soft tissue caught between them - dead bone - INFECTION - SMOKING, which impairs blood supply and is one of the strongest MODIFIABLE risk factors ANATOMICALLY VULNERABLE SITES: scaphoid, femoral head and talus — the classic sites of avascular necrosis, because a fracture can interrupt a blood supply that was always precarious.

A patient in a below-knee cast returns with pain that has been increasing since yesterday, worse than at the time of injury. What is the correct action? A. Prescribe stronger analgesia and review in two days B. Split or remove the cast and assess for compartment syndrome C. Reassure — pain is expected after a fracture D. Arrange an outpatient X-ray ANSWER: B — split or remove the cast. WHY: INCREASING pain under a cast is never normal. A rigid cast around a swelling limb is a classic cause of COMPARTMENT SYNDROME. WHY A IS DANGEROUS: giving stronger analgesia removes the only warning sign while the limb is being lost. Pain out of proportion is the earliest and most important feature — masking it is actively harmful. WHAT EVERY PATIENT SHOULD BE TOLD AT DISCHARGE: return immediately for increasing pain, numbness, tingling, colour change, or inability to move the fingers or toes. Elevate the limb.

A 40-year-old has had low back pain for three days after lifting. No fever, no weight loss, no trauma, normal power. Should an X-ray be arranged? ANSWER: No. Without red flags, early imaging does not help and can harm. WHY IT HARMS: 1. Age-related degenerative changes are present in large numbers of people with NO pain at all. 2. So a scan frequently finds "something". 3. That worries the patient, invites intervention, and correlates poorly with their actual symptoms. WHAT TO DO INSTEAD: analgesia, and advice to KEEP MOVING and stay at work if possible. Bed rest was standard advice for decades and makes outcomes WORSE. BUT FIRST, ASK THE RED FLAG QUESTIONS — including bladder, bowel and saddle sensation, which patients do not volunteer.

Which symptoms in a patient with back pain suggest cauda equina syndrome, and why must they be asked about directly? ANSWER: BLADDER or BOWEL disturbance — retention, incontinence, or loss of the sensation of needing to go SADDLE ANAESTHESIA — numbness in the area contacting a saddle BILATERAL leg symptoms, or progressive weakness WHY YOU MUST ASK: patients do NOT volunteer these. They are embarrassing, and the patient does not connect them to their back. A back pain assessment that omits those questions has not excluded cauda equina — it has simply not looked. WHY IT MATTERS: delay causes PERMANENT loss of bladder, bowel and sexual function. This is one of the few back pain presentations where hours change the outcome.