Rosen & Barkin's 5-Minute Emergency Medicine Consult (284 page)

• Cefazolin: 1–2 g (peds: 20 mg/kg IM/IV)
  
• Add gentamicin: 1.5–2 mg/kg IV for more extensive injuries and highly contaminated wounds (peds: 2–2.5 mg/kg IV)
  
• Add penicillin G: 4–5 million U IV in farmyard injuries, vascular injuries, and in wounds at risk of contamination with Clostridium (peds: 50,000 U/kg IV)
  
• Tetanus booster: 0.5 mL IM
  
• Tetanus immunoglobulin: 250 IU IM if not previously immunized against tetanus
  
• Morphine sulfate: 2–10 mg (peds: 0.05–0.1 mg/kg per dose IV or equivalent analgesic)
  

DTaP booster for children <7 yr of age

FOLLOW-UP

Most patients will be admitted for irrigation, débridement, IV antibiotics, and possibly operative fixation.

Simple open fractures may be washed out and immobilized in the ED after consultation with an orthopedic surgeon. The patient should be discharged with oral antibiotics.

Most open fractures will require emergent orthopedic consultation and may require trauma team evaluation for other injuries.

Patients discharged from the emergency department should be followed up with an orthopedic surgeon in 1–2 days.

• Open fractures are surgical urgencies requiring prompt orthopedic consultation.
  
• 40–70% of patients with open fractures have other traumatic injuries.
  
• Prompt and thorough ED assessment and treatment can significantly decrease morbidity in patients with open fractures.
  

• Bucholz RW, Heckman JD, Court-Brown CM, Tornetta P.
  Rockwood and Green’s Fractures in Adults
  , 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
  
• HauserCJ,AdamsCA Jr,Eachempati SR, etal. Surgical Infection Society guideline:Prophylactic antibiotic use in open fractures: An evidence-basedguideline.
  Surg Infect(Larchmt).
  2006;7(4):379–405.
  
• Okike K,Bhattacharyya T. Trends in the management of openfractures. A critical analysis.
  J Bone Joint Surg Am
  .2006;88(12):2739–2748.
  
• Schenker ML, Yannascoli S, Baldwin KD, et al. Does timing to operative debridement affect infectious complications in open long-bone fractures? A systematic review.
  J Bone Joint Surg Am
  . 2012;94(12):1057–1064.
  

CODES

• 818.1 Ill-defined open fractures of upper limb
  
• 827.1 Other, multiple and ill-defined fractures of lower limb, open
  
• 829.1 Fracture of unspecified bone, open
  

BASICS

• 20% of pediatric patients with acute traumatic injuries will have a fracture
  
• Boys have fractures more commonly than girls
  
• Anatomy:
  
  • Diaphysis: Physis to physis; bone shaft
    
  • Epiphysis: Cartilaginous center at or near end of bone that is site of bone growth
    
  • Epiphyseal (growth) plate: Radiolucent line between epiphysis and metaphysis; cartilaginous
    
  • Metaphysis: Region of rapidly growing trabecular bone underlying base of cartilaginous growth plate; between diaphysis and epiphysis
    
  • Most long bones are ossified by the end of puberty
    
• Bones are highly resilient, elastic, and springy
  
• Allow for fractures not seen in adults:
  
  • Greenstick fracture:
    
    • Incomplete fracture through cortex on opposite side of impact
      
  • Torus (buckle) fracture:
    
    • Usually at junction of metaphysis and diaphysis
      
    • Compression of bone of 1 cortex
      
  • Plastic deformity:
    
    • Bowing without disruption of cortex
      
  • Fractures involving the physis
    
• Cartilaginous growth plates are potential areas of injury.
  
• Ligaments more resistant to injury than growth plates
  
• Salter–Harris classification:
  
  • Risk of growth disturbance increases from type I to type V.
    
  • Type I:
    
    • Separation of epiphysis from metaphysis without displacement or injury to the growth plate
      
    • Tenderness and pain at point of growth plate
      
    • Radiograph typically normal
      
    • Growth disturbance is rare.
      
  • Type II:
    
    • Metaphyseal fracture extending to physis
      
    • Most common
      
    • Growth disturbance is rare.
      
  • Type III:
    
    • Intra-articular fracture extending through the epiphysis into the physis
      
    • Most common site is distal tibial epiphysis.
      
    • Growth disturbance possible
      
  • Type IV:
    
    • Epiphyseal, physeal, and metaphyseal fracture
      
    • Lateral condyle of humerus is the most common site.
      
    • Growth disturbance highly likely
      
  • Type V:
    
    • Crush injury to epiphyseal plate, producing growth arrest
      
    • Usually occurs in joints that move in only 1 plane such as knee
      
• Fractures often accompany dislocations.
  
• Nonaccidental trauma (NAT) if history inconsistent with findings
  

• Mechanism is useful in defining the potential and type of injury
  
• Obesity and rapid growth spurts are risk factors.
  
• NAT:
  
  • Any fracture in a child younger than 1 yr of age in whom history is not consistent with injury
    
  • Metaphyseal “corner” fractures are pathognomonic.
    
  • Posterior rib fractures
    
  • Spiral femur fracture
    
  • Fractures at different stages of healing
    
  • Skull fractures crossing suture lines, especially in children younger than 1 yr
    
  • Unusual behavior in child or parent
    

DIAGNOSIS

• Decreased limb movement, unwilling to use
  
• Swelling
  
• Tenderness
  
• Deformity
  
• Ecchymosis
  
• Crepitus
  
• Limp
  
• Abnormal neurovascular status of extremity
  
• Compartment syndrome:
  
  • Severe pain, especially in forearm, calf, foot
    
  • Pain with passive stretching of fingers or toes
    
  • Sensory deficit in the distal extremity
    
  • Cool extremity
    
  • Pulseless extremity
    
• Open fracture may be obvious or subtle (collection of blood with fat globules under skin)
  

• Mechanism of injury:
  
  • Velocity of car, bike, etc.
    
  • Height of fall
    
• Neurologic compromise
  
• Events surrounding injury
  
• Other injuries
  

• Thorough secondary survey looking for deformities, bruising, other injuries
  
• Assess neurovascular status:
  
  • Motor/sensation
    
  • Distal pulses
    
  • Capillary refill
    
• Range of motion of all joints involved
  
• Exclude concurrent injuries
  
• Ensure that history is consistent with injury
  

• Prompt immobilization
  
• Imaging as below
  

• Required only if concomitant injuries, surgery anticipated, or multiple/major bone involvement
  
• CBC, ESR if infection suspected
  

• Anteroposterior (AP), lateral, and oblique radiographs as necessary, including the joint above and below the fracture
  
• Comparison views may be useful if growth plates are involved.
  
• Follow-up radiographs at 7–10 days may be required to exclude avascular necrosis or Salter I fractures.
  
• Bone scan/CT/MRI may be useful to exclude fractures if plain radiographs are unhelpful or to evaluate for infection.
  

Arthrocentesis if infection is suspected

• Sprain or strain
  
• Contusion
  
• Infection
  
• Tumor
  
• Neurologic deficits
  
• Subtle dislocations such as radial head subluxation (nursemaid’s elbow)
  
• NAT
  

TREATMENT