18 yo male involved in a head on MVC. Patient was the unrestrained driver. The patient was initially unconscious but is now combative. Per EMS there is an obvious deformity to the right lower leg with “bone sticking out.” Patient is slightly tachycardic on arrival with a HR of 102 with a blood pressure of 132/90 and has a GCS of 15. 

The primary survey is unremarkable and the patient continues to maintain stable vital signs. During the secondary survey a 3 cm laceration with what appears to be protruding bone is noted 20 cm distal to the R knee. Patient has intact sensation distal to the injury with strong DP and PT pulses with good capillary refill. Steady dark bleeding is noted from the wound.  The motor exam is limited by pain and uncooperative patient. 

IMAGING:

1.       First priority is trauma resuscitation
2.       Thorough neurovascular examination
3.       Irrigation and debridement of the site
4.       Application of a splint to the affected limb for temporary stabilization
5.       In addition to standard trauma resuscitation tetanus prophylaxis and early administration of antibiotics is indicated

• 1st or 2nd generation cephalosporin nearly always indicated
  
• Gentamycin traditionally recommended for Gustilo III and above (larger soft tissue defect, segmental fracture and/or neurovascular compromise); however, no definitive evidence shows any benefit at this time
  
• Add fluoroquinolone when fresh or salt water is involved. 
  
• Evidence shows that if antibiotic administration is delayed > 3 hours there is an INCREASED risk of infection.
  

DISCUSSION:

-          Patients will need operative debridement and fixation of their fractures
-          Copious irrigation in the OR is key for preventing infection
-          Direct pressure, NOT blind clamping is the best way to control bleeding
-          Open fractures can often wait until the following day for operative repair. At one time it was thought every open fracture required operative repair within 6 hours to lower the risk of infection. This is NOT true.

-          Tetanus and early antibiotic administration a MUST.
-          Thorough neurovascular examination prior to splinting
-          Remove gross debris from fracture site and cover with moist gauze.
-          Does not require immediate operative repair
-          Apply temporary splint to stabilize fracture

(Credits: South Florida Institute of Sports Medicine)

Bohler’s angle (normal):

Bohler’s angle (reduced):

Management:
#Initial ED
-       Obtain AP, Lateral, oblique foot plain film images at minimum.
-       Often Broden, Harris views will be requested for complete visualization.
#Non-operative
-       Extra-articular fractures with minimal displacement and intact Achilles tendon.
-       Sanders Type I fractures
-       Bulky cast with extra padding around the heel and ankle.
-       Requires EXTENDED non-weightbearing status. Often approaches 12 weeks.
-       All require referral to orthopedic surgery
#Operative
-       Prompt recognition of Tongue-type fractures as illustrated above.
-       Orthopedic EMERGENCY as skin overlying the fracture has a high instance of compromised vascularity and death/necrosis.
-       Displaced intraarticular fractures
-       Sanders type II-IV

Discussion:
-       Common in males aged 35-45, often work related
-       Due to extended non-weightbearing requirement these injuries have large socioeconomic impact on patients
-       High complication rate if not recognised early
-       Contralateral calcaneus and spine have a 10% concomitant injury rate.
-       Look for reduced Bohler angle and increased angle of Gissane

Key Points:
-       Be vigilant as secondary injuries very common
-       Most commonly the spine and contralateral calcaneus
-       Recognise tongue-type fractures early and prompt notification of orthopedic surgery
-       Don’t forget the spine in axial load type injuries

References:
http://www.orthobullets.com/trauma/1051/calcaneus-fractures

HPI:
Approximately 5 y/o male presents with right elbow pain and refusal to move the right arm after falling from a chair on an outstretched arm.

EXAM:
Gross deformity present on the distal humerus, just proximal to the elbow with mild skin tenting and tenderness. Refusal to move the elbow joint. Unable to extend the wrist and digits. Remainder of exam normal.

IMAGES:
Obtain AP and lateral elbow views

Garland Type III: Completely displaced

MANAGEMENT:
#Non-operative
- Posterior long arm splint with less than 90 degrees of flexion
- Type I and some Type II fractures.
- Consult Ortho for Type II fractures to determine if operative management is needed

#Operative
- All Type III fractures, some Type II fractures
- “floating elbow” : ipsilateral supracondylar and forearm fractures
- Immediate operative management if vascular compromise is present
- Reduce in ER if any vascular compromise is present
- Most are admissions with next day operative fixation

DISCUSSION:
- Incredibly common in 5-7 year olds with a fall on an outstretched arm.
- Radial, ulnar, anterior interosseous nerve neurapraxia all very common and resolve with reduction without long term effects but require expedited management
- Very easy to miss a type I fracture, use the anterior humerus line and fat pad sign
- Garland classification above, determines management
- Can be associated with vascular injury (~1%), this requires immediate reduction

KEY POINTS:
- Use the anterior humerus line and fat pad sign to help find subtle fractures
- High suspicion in any fall on an outstretched arm
- Remember the Garland Classifications
- Most Type II and all Type III will require operative management and admission
- A posterior long arm splint for Type I fractures
- Always assess for neurovascular compromise

By Dr. Mohamed El-Kara