Trauma: Orthopedic Fractures

Gustilo Classification of Open Fractures

• Type I: Wound ≤ 1 cm & Minimal Soft Tissue Damage/Contamination
• Type II: Wound 1-10 cm or Moderate Soft Tissue Damage
• Type III:
  • A: Wound > 10 cm, Extensive Soft Tissue Damage or Contaminated
    • Includes All Farm Injuries
  • B: Extensive Periosteal Stripping or Requiring Soft Tissue Coverage
  • C: Vascular Injury Requiring Repair

Initial Management

• Evaluation:
  • Always Evaluate Neurovascular Status First
  • If Fracture/Dislocation with Weak/No Pulse: Reduce and Reassess
    • Still None: Surgical Vascular Repair
    • Weak: CTA
• Irrigation & Debridement:
  • Timing Within 24 Hours or As Soon As Possible if Contaminated
  • Use NS at Low Pressure, 3 L Per Successive Gustilo Type (I: 3L, II: 6L, III: 9L)
• Antibiotics:
  • Gustilo Type I/II: First Generation Cephalosporin (Ancef)
  • Gustilo Type III: Add Gram Negative Coverage (Gentamicin)
  • Severe Contamination or Vascular Injury: Add Anaerobic Coverage (Penicillin)

Fracture Repair

• Early Operative Fixation Best
  • High ISS: Delay 2-4 Days
• Bony Stabilization Before Vascular Reconstruction
  • If Extremity is Grossly Ischemic or Actively Hemorrhaging – Control with a Temporary Shunt & Fasciotomy Prior to Bony Stabilization & Then Vascular Reconstruction
• Options:
  • Open Reduction and Internal Fixation (ORIF)
    • Types: IM Nail vs. Plating
    • Generally Preferred
    • Reduced Pulmonary Complications
  • External Fixation (Ex-Fix)
    • Indications: Extensive Soft Tissue Destruction, Contamination or Associated Vascular Injury

Throckmorton (John Thomas/JT) Sign

• Definition: When the Male Penis Points in the Direction of Unilateral Injury
• Classically Refers to Hip/Pelvic Fractures Seen on Plain Film XR
• Considered a Joke Term with No Real Diagnostic Utility