HPI:  Middle age man s/p MCC with open fracture of right leg.  Tourniquet applied in the field.

Physical Exam:  Completely shattered tibia and fibula with 10cm open wound.  Weak but palpable DP after taking tourniquet down.  Intact sensation to light touch in superficial peroneal, deep peroneal, and tibial distributions.  Able to wiggle toes and slight dorsiflexion.

Management:  Basic Management of Open Fractures

• Fracture management starts after initial trauma survey
  
• First generation cephalosporin (we use Ancef 2 gm here) and update tetanus
  
• Control bleeding with direct pressure. Do not blindly clamp or place tourniquets on damaged extremity
  
• Assess soft tissue damage and perform neurovascular exam
  
• Remove large debris and place sterile saline soaked gauze on wound
  
• Splint Fracture

Key Points:  

• Ortho versus Vascular taking to operating room all depends on your detailed neurovascular exam
  
• Early antibiotic administration is the  most important factor in reducing infection
  
• Most important predictor of eventual amputation is the severity of extremity soft tissue injury
  

HPI:  Patient presents with a grossly deformed right upper extremity.

PE:  Gross deformity of humerus, no open fracture.  Unable to extend wrist. Unable to hyper-extend MP joints of fingers and unable to flex IP joint of thumb.  Radial and ulnar pulses intact.

IMAGING:  Multi-factorial fracture along the mid third of humerus along the expected course of the radial nerve.

DISPO (if at free standing ED):  Transfer patient to ED with on-call orthopedics for definitive fixation.  Reduce and splint prior to transfer.

TREATMENT:  Nonoperative managment.  Splinted and cast at bedside.  Follow radial nerve palsy clinically for improvement.