Management of Open Fractures in the Emergency Department

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Author: Bill Mulkerin, MD
Stanford/Kaiser Emergency Medicine Residency

Open fractures often result from high-energy impacts, such as motorcycle crashes, motor vehicle collisions, and pedestrians being struck by motor vehicles.[1,2] These injuries are usually associated with poly-trauma.[1] Up to 9% of open fractures result in compartment syndrome.[3] Open fractures are most commonly classified by the Gustilo classification:

• Type I – clean wound less than 1cm
• Type II – laceration more than 1cm long, without extensive soft tissue damage, flaps, or avulsions 
• Type IIIA – adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration or flaps, or high-energy trauma irrespective of the size of the wound 
• Type IIIB – extensive soft tissue injury with periosteum stripping and bony exposure. This is usually associated with massive contamination. 
• Type IIIC – Exposed fracture with arterial damage that requires repair[4,5]

OUCH! Forearm Fractures Board Review

Author: Meaghan Mercer, DO; AAEM/RSA President

Galeazzi Fractures: A typically isolated radial fracture with subluxation or dislocation of the ulnar head.

• Injury to a division of the median nerve known as the anterior interosseous nerve (AIN) can occur.

• AIN palsy can cause paralysis of the flexor pollicis longus and flexor digitorum profundus muscles.
      o Clinical manifestations: loss of the pinch mechanism between the thumb and index finger, ability to pronate forearm, and the ability to flex the thumb, index, and middle fingers.
• Requires open reduction and internal fixation (ORIF) in adults