A 28-year-old male with bilateral femoral and tibial fractures and a chest wound presents with unstable blood pressure and tachycardia. After initial stabilization, what is the most appropriate initial management of his long bone fractures?

Appeared in: INI-CET EXAM -2026

Explanation

The patient is hemodynamically unstable with multiple injuries (polytrauma), making Damage Control Orthopedics (DCO) the correct approach.
The primary goal of DCO is rapid, temporary stabilization to allow for patient resuscitation and to avoid the 'second hit' of a major surgery.
External fixation is the standard procedure for DCO in long bone fractures because it is quick, minimally invasive, and effectively stabilizes the fracture to control bleeding and pain.
This approach allows the medical team to focus on life-saving measures for the chest wound and overall instability before performing definitive fracture repair later.

Option A: This involves definitive internal fixation of the femur, which is a prolonged and physiologically demanding procedure. It is contraindicated in a hemodynamically unstable patient as it would constitute a dangerous 'second hit'.
Option B: Similar to option A, this includes definitive internal fixation (nailing of the tibia). This is inappropriate for the initial management of an unstable polytrauma patient.
Option D: The choice of surgical procedure is dictated by the patient's physiological status and evidence-based trauma protocols, not the surgeon's skill or preference. Patient safety and stability are the primary determinants.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Damage Control Orthopedics (DCO) in Polytrauma Management in the correct sequence, documenting the action clearly, and monitoring for the expected response.
Nurses play a critical role in monitoring polytrauma patients for signs of hemodynamic instability and the 'lethal triad of death': hypothermia, acidosis, and coagulopathy. Prompt recognition and reporting are vital.
When caring for a patient with an external fixator, the nurse's responsibilities include frequent neurovascular checks, pin site care to prevent infection (osteomyelitis), and pain management.
What if the patient was hemodynamically stable and had only an isolated femoral fracture? In that case, the approach would likely be Early Total Care (ETC), and the most appropriate management would be definitive internal fixation with an intramedullary nail, not external fixation.

How to Approach the Question

First, analyze the patient's overall condition from the clinical scenario. Identify key indicators of stability or instability. Here, 'unstable blood pressure' and 'tachycardia' are critical clues for instability.
Next, note the extent of the injuries. 'Bilateral femoral and tibial fractures' plus a 'chest wound' indicates polytrauma.
Connect the patient's status (unstable) with the injury pattern (polytrauma). This combination should immediately trigger the concept of 'Damage Control Orthopedics' (DCO).
Recall the core principle of DCO: prioritize life-saving resuscitation and use rapid, temporary fracture stabilization. The standard method for this is external fixation.
Evaluate the options based on this principle. Eliminate any options that suggest immediate definitive or complex internal fixation (e.g., nailing, plating, screws), as these are part of 'Early Total Care' (ETC) for stable patients.
Select the option that aligns with DCO, which is temporary stabilization of all major fractures with external fixators.

Concept Tested & Keywords

Concept Tested: Damage Control Orthopedics (DCO) in Polytrauma Management
Stem keywords: bilateral femoral and tibial fractures, chest wound, unstable blood pressure, tachycardia, initial management
Lead-in keywords: most appropriate
Clinical cues: The combination of multiple long bone fractures, a chest wound, and hemodynamic instability (unstable BP, tachycardia) is the classic indication for Damage Control Orthopedics.

QWT1Mu8d9rYLkqT_u9RQyc

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 4 p. 123-125

E6 Nelson Textbook of Pediatrics(2024) — Volume 2 p. 2093-2095

Practise the full INI-CET EXAM -2026

Attempt every question from this paper in a timed mock, then review the full solution for each one.