Training

How to present an orthopedic consult

The orthobro · 2026-08-26 · 6 min read

The most common way a consult presentation goes wrong is not missing information. It is ordering.

You start at the beginning — 54-year-old gentleman with a background of — and the person listening has no idea yet whether they are deciding about theatre tonight, a cast, or a clinic appointment. So they cannot sort anything you say. They are holding it all in suspension waiting to find out what it is for.

Fix the order and most of the rest fixes itself.

Start with the question

First sentence: who, where, and what is being asked.

"ED wants us to see a 54-year-old with a closed, displaced distal radius fracture. It's neurovascularly intact. They're asking whether it needs reduction tonight."

That is the whole opening. Now the listener knows the shape of the decision, and everything you say next lands in a slot.

Compare it to the version that starts with the past medical history. Same facts, completely different cognitive load on the person you woke up.

The four fields that set urgency

Before any history, any imaging detail, any social background — these four. They are what determines whether this is a tonight problem.

Open or closed. If open, say it immediately, and say when it happened, what the wound looks like, whether antibiotics and tetanus have been given, and whether it is grossly contaminated.

Neurovascular status. Be specific and be honest about what you actually tested. "Neurovascularly intact" is a claim. If you did not check the individual nerves, do not say it — say what you did check. A named deficit changes the plan; a vague reassurance that turns out to be wrong destroys your credibility for the rest of the year.

Skin and compartment. Tenting, blistering, threatened skin, tense compartments, pain out of proportion, pain on passive stretch. If you are worried about compartment syndrome, that is the second sentence of the call, not the last.

Reducible / already reduced. What has been tried, what happened, what it looks like now.

If those four are clean, the rest of the presentation can proceed at a normal pace. If any one of them is not, say it in the first fifteen seconds and expect the conversation to change direction.

Describe the fracture the same way every time

Use a fixed order. Not because it is elegant, but because a fixed order is what stops you dropping a field at 3am.

Say them in that order every single time and you will stop losing the articular involvement, which is the field that most often changes the plan and the one most commonly forgotten.

Two habits inside this:

Say the imaging you actually have. "AP and lateral of the wrist" is different from "AP, lateral, and a CT." What you do not have is often the next thing the senior asks for.

Use classification only when you know it. A correctly applied classification is efficient. A confidently misapplied one sends someone in the wrong direction. If you are unsure, describe the fracture — the description is always safe and always sufficient.

Then the patient, briefly

Now the context, and now it can be short, because the listener knows what they are deciding.

• Age, and functional status. Not age alone. "82 and independent, walks to the shops" and "82 and hoists" are different patients with different operations.
• Hand dominance for upper limb, weight-bearing status for lower.
• Mechanism, and whether it fits the injury. A low-energy mechanism with a high-energy pattern is a flag.
• Comorbidities that change anaesthesia or fixation. Not the full list — the ones that matter here.
• Anticoagulation. Say the drug and the last dose.
• Last ate and drank.
• Relevant occupation or activity, if it changes the goal.

That is thirty to forty seconds. Anything longer and you are reading a chart at someone.

Finish with a plan

End with what you think should happen. Even as an intern. Especially as an intern.

"My plan would be a haematoma block and reduction in the department now, back-slab, repeat films, and fracture clinic in a week — unless you think this needs fixing."

Two things happen when you do this. You get corrected precisely, which is the fastest way to learn. And you signal that you were thinking rather than transcribing, which changes how much rope you get given over the following months.

Being wrong here costs nothing. Having no plan costs a lot.

Things that damage a presentation

Hedging on an exam you did not do. Say "I did not check that" and go check it. Everybody respects this. Nobody respects a guess that unravels.

Reading the whole chart. The listener wants the decision-relevant subset, and choosing that subset is the skill being assessed.

Burying the lede. Open fracture, vascular compromise, or suspected compartment syndrome mentioned at the end of a two-minute presentation is the single worst thing you can do on a consult call.

Not knowing where the patient is. Department, bay, and whether they are still in the scanner. You will be asked.

No films up. Have the imaging open before you dial. You will be asked to describe something you cannot see otherwise.

The version to keep in your pocket

1. Question first — who, what, what's being asked.
2. Open/closed, neurovascular, skin and compartment, reducible.
3. Fracture description in fixed order.
4. Patient in thirty seconds.
5. Your plan.

Write down the corrections you get on the first few, the same way you would keep notes on an attending's operative preferences. Every senior has a field they always ask about that nobody else does, and after four consults with the same person you can simply have it ready — which is the entire trick to looking competent faster than you actually are.