Block 5A Gabatino, Gauiran, Go, Gomez, Gonzales E, Gonzales L, Granada

 OR  54/M  RC  Sta Ana, Manila  Right handed  c/c injuries secondary to vehicular crash

 DOI: 12/14/09 (3 days post injury)  TOI: 6pm  POI: Carmona complex, Makati  MOI: VC jeep vs tricycle (side of the tricycle and front of jeep)

 Brought to Ospital ng Makati, wounds dressed, X ray done, ATS, TeANA given, THOC to PGH secondary to lack of funds

 (-) loss of consciousness  (-) fever  (-) nausea  (-) vomiting  (-) dizziness  (-) cough and colds  (-) chest pain  (-) abdominal pain  (-) bowel changes  (+) polyuria, polydipsia, polyphagia  (+) numbness of bilateral peripheral extramities ( glove and stocking distribution)

 (-) Diabetes  (-) Hypertension but had episodes of hypertension since 2 years ago, highest Bpof 160/80 usual BP of 150/80  (+) hospitalization due to head injury (2008)  (-) PTB, BA  (-) food and drug allergies

 No known medical illness in the family

 Smoker >30 pack year  Heavy alcoholic beverage drinker 1-2 bottles of 500ml redhorse daily since 25 years old  Denies illicit drug use  Denies promiscuity  Works as a tricycle driver

 Awake, coherent, NICRD, ambulatory  Vital Signs: BP 150/90, HR 82, RR 20, T afebrile  HEENT: AS, PC, pupils 3 mm EBRTL, (-) CLAD/TPC/NVE/ANM  Chest/Lungs: ECE, Clear Breath Sounds, (-) crackles/wheezes

 Heart: AP, DHS, NRRR, (-) murmurs  Abdomen: soft, flabby abdomen, NABS, (-) tenderness, (-) masses/organomegaly  Extremities (both upper extremities and left lower extremity): Pink nail beds, Full and equal pulses, (-) cyanosis, (-) clubbing, (-) gross deformities

 Grossly deformed thigh (distal 1/3 of the thigh slightly angulated medially)  (+) swelling, tenderness, warmth, redness over distal thigh and knee  Intact sensation over (L) thigh, leg and foot  Able to wiggle toes and dorsi/plantar flex ankle  Intact and full popliteal, dorsalis pedis and post tibial pulses, pink nailbeds, (-) cyanosis  1.5x 1.5 cm wound over the anterior distal thigh with no bone protrusion and adequate tissue coverage, no gross contamination with debris

Fx: Open complete comminuted distal third femur (L) secondary to VC

 Therapeutics: - Cefazolin 1g IV LD then 1g q8 - Gentamycin 240mg IV OD - Long leg posterior splint  Surgical Plan: - Debridement - Skeletal traction

 Seen at the ER 12/17/2009 (3 days post injury)  12/19/09 – debridement of anterior thigh wound, arthrotomy of the L knee joint and skeletal traction inserted on proximal tibia – 15kg  12/26/09 – diagnosed with hypertension stage II fairly controlled with HHD, DM type II newly diagnosed with nephropathy, neuropathy, t/c retinopathy, T/c Alcoholic liver disease  12/29/09 – scheduled for OR, deferred due to lack of funds for IM nail

18 th hospital day, 21 days post injury  Awake, coherent, NICRD, ambulatory  Vital Signs: BP, HR, RR, T afebrile  HEENT: AS, PC, pupils 3 mm EBRTL, (-) CLAD/TPC/NVE/ANM  Chest/Lungs: ECE, Clear Breath Sounds, (-) crackles/wheezes

 Heart: AP, DHS, NRRR, (-) murmurs  Abdomen: soft, flabby abdomen, NABS, (-) tenderness, (-) masses/organomegaly  Extremities (both upper extremities and left lower extremity): Pink nail beds, Full and equal pulses, (-) cyanosis, (-) clubbing, (-) gross deformities

 Left lower extremity on skeletal traction inserted in the proximal tibia  (-) erythema, warmth, discharge, swelling, pain around pintracts.  (+) surgical incision over the anterior knee and thigh, good healing, no discharge, no redness, no necrotic tissue at incision site  (+) warmth over the periphery of the (L) knee, (+) mild swelling, (+) mild erythema  Intact popliteal, dorsalis pedis and post tibial pulses  Intact sensation on thigh, leg, toes and feet

 Osseous disruption in which a break in the skin and underlying soft tissue communicates directly with the fracture and its hematoma  Any wound occurring on the same limb segment as a fracture must be suspected to be a consequence of an open fracture until proven otherwise

 Contamination of the wound and fracture by exposure to the external environment  Crushing, stripping, and devascularization that results in soft tissue compromise and increased susceptibility to infection  Destruction or loss of the soft tissue envelope may affect the method of fracture immobilization, compromise the contribution of the overlying soft tissues to fracture healing and result in loss of function from muscle, tendon, nerve, vascular, ligament, or skin damage.

 Results from application of violent force which is dissipated by soft tissues and osseous structures  The applied force is directly proportional to resulting osseous displacement, comminution and degree of soft tissue injury

 ABCDE  Resuscitation and attention to life-threatening injuries  Evaluate injuries to head, chest, abdomen, pelvis, spine and all extremities  Assess neurovascular status of affected limbs  Assess skin and soft tissue involvement  Removal of obvious foreign bodies  Irrigation with pNSS  Radiographic evaluation

TypeWoundLevel of Contamination Soft Tissue InjuryBone Injury I < 1 cm long CleanMinimal Simple, minimal comminution II > 1 cm long Moderate Moderate, some muscle damage Moderate communition III A Usually > 10 cm long High Severe with crushing Usually comminuted, soft tissue coverage of bone possible B Very severe loss of coverage, usually requires reconstructive surgery Bone coverage poor, may be moderate to severe comminution C Very severe loss of coverage plus vascular injury requiring repair, may require soft tissue injury

 Contamination  Exposure to soil, water, fecal matter, oral flora  Gross contamination on PE  Delay in treatment > 12 hrs  Signs of high-energy mechanism  Segmental fracture  Bone loss  Compartment syndrome  Crush mechanism  Extensive degloving of SQ fat and skin  Requires flap coverage

 Perform a careful clinical and radiographic evaluation  Wound hemorrhage should be addressed with direct pressure rather than limb tourniquets or blind clamping  Initiate parenteral antibiosis  Assess skin and soft tissue damage; place a saline- soaked sterile dressing on the wound

 Perform provisional reduction of fracture and place a splint  Operative intervention: open fractures constitute orthopaedic emergencies, because intervention less than 8 hours after injury has been reported to result in a lower incidence of wound infection and osteomyelitis  Do not irrigate, debride, or probe the wound in the emergency room if immediate operative intervention is planned  Bone fragments should not be removed in the emergency room, no matter how seemingly nonviable they may be

 Gustilo I: Cefazolin 1 g IV q8h  Gustilo II: Cefazolin 1 g IV q8h  Gustilo III: Cefazolin 1 g IV q8h + Aminoglycoside 3-5 mg/kg/day  Organic contamination: Penicillin 2,000,000 units q4h or Metronidazole 500 mg q6h

 Incomplete (<3 doses) or unknown: (+) dT, (+/-) TIG  Complete and > 10 years since last dose: (+) dT, (-) TIG  Complete and < 10 years since last dose: (-) dT, (-) TIG

 Irrigation and debridement  Removal of foreign bodies  Fracture stabilization  Soft tissue coverage and bone grafting  Limb salvage

EXTERNAL FIXATION  Severe contamination: any site  Periarticular fractures  Definitive ▪ Distal radius ▪ Elbow dislocation ▪ Selected other sites  Temporizing ▪ Knee ▪ Ankle ▪ Elbow ▪ Wrist ▪ Pelvis  Distraction osteogenesis  In combination with screw fixation for severe soft tissue injury INTERNAL FIXATION  Periarticular fractures  Distal/proximal tibia  Distal/proximal femur  Distal/proximal humerus  Proximal ulnar radius  Selected distal radius/ulna  Acetabulum/pelvis  Diaphyseal fractures  Femur  Tibia  Humerus  Radius/ulna