In this episode of CoROM Conversations, Bill Vasios is joined by Dr Bob Dichiera, a retired US Army veteran with experience in operational medicine, primary care and orthopaedic surgery, and an associate professor at East Carolina University's PA programme.
Bob introduces a practical approach to remote orthopaedics built around four questions: Is the patient dying? Is a limb dying? Can I stabilise it? Does the patient need evacuation?
The discussion examines the orthopaedic emergencies that clinicians cannot afford to miss, including open fractures and dislocations, neurovascular compromise, compartment syndrome, vascular injuries, pelvic fractures and traumatic amputations. Throughout the session, Bob emphasises repeated pulse, motor and sensory (PMS) assessment before and after interventions.
Using clinical cases, the conversation explores closed and open tibial fractures, field-expedient fracture assessment, compartment syndrome, irrigation and antibiotics, splinting, shoulder dislocations and reduction decisions. The discussion considers when reduction may be appropriate in a remote environment, particularly when prolonged transport is combined with neurovascular compromise.
The later discussion examines pelvic and hip injuries, field assessment, ultrasound and the difficult question of whether procedures such as fasciotomy have a role in genuinely remote care. Bob also considers how telemedicine and remote specialist support may extend what clinicians can safely accomplish in austere environments.
00:00 – Tuning-fork fracture diagnosis cold open
00:18 – Introduction to Remote Orthopaedics
01:58 – Why MSK injuries matter in remote medicine
03:00 – Orthopaedic emergencies you cannot miss
04:18 – Damage-control orthopaedics
05:00 – Is the patient dying? Is the limb dying?
06:42 – Closed tibial fractures
07:40 – Diagnosing fractures with a tuning fork
09:06 – Splinting and traction decisions
11:31 – Compartment syndrome
14:00 – Pain with passive stretch
15:30 – Open fractures
16:20 – Irrigation
17:00 – Antibiotics for open fractures
21:06 – Field splinting and improvised splints
23:30 – Shoulder dislocations
25:55 – Shoulder reduction techniques
28:21 – Immobilisation and rehabilitation
30:45 – When should remote clinicians reduce a dislocation?
33:07 – PMS and neurovascular assessment
34:00 – Knee dislocations
35:35 – The easily missed vascular injury
37:56 – Reduction, ABI and evacuation
38:45 – Ankle injuries and Ottawa Ankle Rules
40:20 – Why weight-bearing does not exclude fracture
42:00 – Hand and wrist injuries
42:43 – Pelvic fractures
44:00 – Pelvic binders and avoiding repeated pelvic assessment
45:30 – Haemorrhage and pelvic trauma
46:00 – Pelvis versus femoral neck fracture
47:30 – Ultrasound in remote orthopaedics
47:50 – Should remote clinicians perform fasciotomies?
48:30 – Telemedicine and remote procedural guidance
49:53 – Closing
