Open Fracture Approach

– Primary Survey –

PPE: goggles, mask, gown, gloves

AIRWAY + C-SPINE:

  • Talk to the patient (patent airway, conscious, in pain?)
  • Ask pt to open their mouth (inspect for foreign bodies)
  • Look, listen, and feel (hoarseness, cough, stridor)
  • Oxygen mask
  • Apply C-collar

BREATHING:

  • Inspect neck + palpate trachea (edema, distended neck veins, subcutaneous emphysema)
  • Expose chest: inspect, palpate, percuss, auscultate (circumferential burns, symmetrical breathing)
  • Pulse oximetry
  • CXR + pelvic X-ray

CIRCULATION:

  • BP, pulses, capillary refill
  • Insert 2 large-bore Iv cannula in ante-cubital fossa
  • Draw blood for CBC, cross match, coagulation, electrolytes, chemistry, pregnancy, tox, ABGs
  • Run warmed 2L crystalloids
  • Examine pelvis, abdomen, limbs (for circumferential burns, swelling, fractures)
  • External bleeding
  • FAST

DISABILITY:

  • Pupils
  • GCS

EXPOSURE:

  • Check temperature
  • Remove clothes and fully expose the patient
  • Cover the pt w\ blankets to prevent hypothermia

LOG ROLL + PR EXAM

ADJUNCTS:

  • ECG
  • Decompression: NGT + foley cath

 

– Secondary Survey –

  1. AMPLE history:
    • Allergies
    • Medications
    • Past medical hx
    • Last meal
    • Event \ Environment:
      • Time
      • Location (closed vs open space)
      • Cause (thermal, chemical, electrical, …)
      • Associated injuries
      • What first aid did the pt get?
  2. Complete head-to-toe physical examination
  3. Re-evaluation of the pt
  4. Specific tests (CO level > 10%)
  5. Definitive treatment

 


– Open Fracture Management –

(If at the beginning of the station the examiner says, “you’ve already done your primary and secondary surveys” -> jump straight to here!)

  1. Assessment: describe what you see
    • Location, size, depth
    • Soft tissue, muscle, bone
    • Gustillo staging
    • Active bleeding? Stop it
    • Compartment syndrome? Fasciotomy
  2. Neurovascular examination (including; pulses, pulse oximetry, doppler US)
  3. Remove any obvious foreign bodies (irrigate w\ saline only if grossly contaminated)
  4. Cover it w\ sterile dressing
  5. Reduce + splint
  6. Reassess neurovascular status
    • Know how to examine pulses and nerves in upper and lower limbs
    •  If persistently diminished pulses even after attempted realignment -> call vascular for arteriographic evaluation
  7. Analgesia
  8. Tetanus
  9. Abx:
    • Grade I: cefazolin
    • Grade II: cefazolin + gentamicin
    • Grade III: cefazolin + gentamicin + penicillin
  10. X-ray
  11. Take to OR w\in 6 hrs: I&D + Ex Fix + leave wound open (cover w\ sterile dressing)
  12. Take back to OR w\in 2-7 days: permanent fixation + soft tissue coverage
    • Soft tissue coverage:
      • Grades I> secondary intention
      • Grades II + IIIA –> delayed primary (w\out tension) or split thickness skin graft
      • Grades IIIB + IIIC -> call plastic for flap coverage

 


Download the PDF version: here

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