emDocs - December 31, 2015 - Authors: Moleno R and Venezia M
Edited by: Koyfman A and Long B
"Open fractures are something ED physicians deal with quite frequently. They can range from a tiny break in the skin to limbs hanging by a small piece of skin and tissue. Some common mechanisms by which these injuries occur include falls, motor vehicle collisions, motor vehicle versus pedestrian, and crush injuries. A thorough physical exam should be performed on all of these patients, paying special attention to mechanism of injury, examining the wound to look for contamination, and confirming intact neurovascular status. Following the primary survey, make sure to complete the secondary survey so that additional injuries are not missed. Plain films should be obtained of all injured areas, and tetanus status should be updated if indicated.
Diagnoses that cannot be missed include vascular compromise and compartment syndrome. Compartment syndrome teachings classically recite the 5 P’s; however, these perform poorly when studied with inadequate sensitivities. The most important clinical exam finding in these patients is pain out of proportion and pain with passive stretch of the affected area. Decreased two point discrimination in the affected limb can be beneficial in evaluating for compartment syndrome. A compartment pressure >30 mm Hg raises concern, and a pressure within 30 mm Hg of the diastolic blood pressure (ΔP) indicates compartment syndrome. Immediate involvement of an orthopaedic or general surgeon should be obtained so that fasciotomies can be performed. If vascular compromise is suspected, an ankle-brachial index (ABI) should be obtained. A normal ABI is > 0.9. Abnormal ABIs with suspected vascular compromise should be investigated with angiography.
Traditional teachings state that all patients should receive antibiotics and go to the operating room within 6 hours for washout and/or open reduction internal fixation (ORIF). To better understand treatment principles, we will first review how to classify open fractures.
http://www.emdocs.net/open-fractures-pearls-and-pitfalls/