1. Case Report Jonathan Kneib PGY-2

2.  19 yo male wth no significant PMH comes in to ED s/p texting while on a pogo stick and sustaining a fall. Patient has an obvious ankle deformity.

3. Vitals  Temperature 37  HR 82  BP 125/82  O2 99% on RA

4. Secondary Survey  1. check distal pulses, capillary refill  2. sensation  3. ROM

5. Ankle Inspection  Palpate base of 5th metatarsal (Jones, Dancers)  Palpate navicular  Palpate Achilles tendon and do Thompson test (Achilles rupture)  Palpate bony prominences (medial and lateral malleoli)  Palpate proximal fibula (Maisonneuve) Think referred pain  -see reference 1

6. Things to Do  Antibiotics and tetanus  XR  Remove gross contamination and apply moist sterile dressing  Photograph  Reduce/Splint the limb  Arrange for urgent surgical debridement/washout and stabilization of the fracture

7. Gustillo Type I  - less than 1 cm and relatively clean, no crushing injury

8. Gustillo Type I

9. Gustillo Type II  - longer than 1 cm with moderate contamination, slight to moderate crushing

10. Gustillo Type II

11. Gustillo Type III  - extensive damage to soft tissue and high degree of contamination and a great deal of communtion and instability

12. Gustillo IIIA  - IIIA: soft tissue can cover bone

13. Gustillo Type III A

14. Gustillo IIIB  IIIB: loss of soft tissue and will require flap

15. Gustillo Type IIIB

16. Gustillo III C  IIIC: arterial injury, regardless of degree of soft tissue loss

17. Gustillo Type III C

18. Antibiotics  Gustillo I and II  - 1st generation cephalosporin (Ancef)  - if allergy: clindamycin or vancomycin  Gustillo III  - in addition to above add an aminoglycoside (Gentamycin)  If a farm injury or open bowel contamination  - add penicillin (to cover clostridium)

19. Pearls  When covering an open fracture use pads soaked in saline

20. Pearls  Six Hour Golden Rule  Orthopedic goal to have operative repair of open fracture within 6 hours

21. Work Cited  Here?, -Why Are You, -General Tips, -Pearls And Pitfalls From Head To Toe, and -Summary Of Really Important Stuff. ORTHOPEDIC PEARLS & PITFALLS (n.d.): n. pag. Web.  "Gustilo Classification." - Trauma. N.p., n.d. Web. 03 Aug. 2015.