OPEN FRACTURES

The associated soft tissue injuries add an element of urgency to the treatment of fractures. A fracture is classified as “open” if the fracture or fracture hematoma communicates with the air via a wound in the soft tissues. This can be caused from the bone protruding through the skin, “inside out,” or if there is a penetrating mechanism causing an injury from the “outside in.” Regardless, the implication is that environmental contamination can increase the incidence of infection and fracture healing complications. If there is a wound in the same limb segment as the fracture, it should be considered open until proven otherwise. A classification system for open fractures appears in Table 1. Infection rates are reported at 0%–2% for Type I, 2%–7% for Type II, and 10%–25% for Type III overall. Rates for type III are subclassified as follows: IIIA, 7%; IIIB, 10%–50%; and IIIC, 25%–50%.

Table 1 Classification of Open Fractures

Treatment of these fractures is therefore aimed at irrigation and debridement in the operating room within 8 hours. Preliminary or definitive stabilization of the fracture and appropriate antibiotic therapy should follow. It is apparent that short-course, high-dose antibiotic therapy is appropriate for open fractures and need not be continued over the course of the fracture healing process. Recommendations follow:

Trauma to the arm involving a severe crush component such as that from a conveyer belt or injuries with prolonged vascular compromised are at risk for development of compartment syndrome. Prophylactic fasciotomy may be necessary.

DISLOCATIONS

This is another situation that requires more urgent assessment, diagnosis, and treatment. By definition a dislocation is present when the joint is disrupted such that the articular surfaces are no longer in contact. The diagnosis of a joint dislocation is often made from the history and physical examination. The limb will usually be held in a fixed position characteristic of the dislocation direction. A posterior hip dislocation, for example, is seen with the limb in flexion, adduction, and internal rotation. Loss of the normal contour of the joint can be seen as evidenced by a “sulcus” sign in an anterior shoulder dislocation.

Radiographic evaluation is essential in the management of these injuries because associated fractures will otherwise go unrecognized and can have significant effects on the prognosis if not taken into account before reduction.

Neurovascular compromise is the reason for emergent reduction of the joint. Sciatic nerve injury has been reported to occur in 8%–19% of hip dislocations. Osteonecrosis is a known complication of hip dislocations as well, occurring in up to 17% of these injuries. This is due to the interruption of capsular blood supply from the increased tension caused by the dislocation. Other associated neurologic injuries can be seen in Table 2.

Table 2 Neurologic Injuries Associated with Upper Extremity Fractures

Dislocations and fractures with neurologic or vascular compromise should therefore be reduced as quickly as possible in order to reduce potential irreversible injury to the affected structures. Following reduction a repeat examination is warranted to see if there has been a change in the neurovascular status of the limb.

GUNSHOT WOUNDS

Special attention is deserved here due to the need to make an important distinction for the treatment of these injuries. It is important to determine if the wound was inflicted by a “low-” or “high-velocity” weapon. The exact distinction is somewhat cloudy, but according to the Wound Ballistics Manual of the Office of the Surgeon General, muzzle velocity greater than 2500 ft/sec constitutes “high velocity.” This is important because the kinetic energy of the bullet varies directly with the square of its velocity and only linearly with its mass.

Many low-velocity gunshot injuries can be treated to completion with closed methods, such as functional bracing or casting. If one chooses open management, it should be anticipated that the extent of the fracture is often more extensive than can be appreciated on plain radiographs. This should be taken into account in the preoperative planning.

There may also be associated neurologic deficits due to the “blast effect” of the initial injury that do not warrant immediate exploration, as many will often resolve. If persistent neurologic deficit occurs, an electromyograph (EMG) may be indicated at 3–6 weeks to assess the nerve for any evidence of fibrillation potential.

Gunshots to the forearm require special attention even if there is no associated fracture due to an increased risk for development of forearm compartment syndrome. During the past 4 years, we have treated five patients who developed forearm compartment syndrome from penetrating injuries. All were found to have arterial lacerations. Patients should be monitored for at least 8–12 hours for clinical evidence of increased pressure within the forearm, which include marked pain on passive digital extension, tense or swollen forearm, and reduced hand sensibility or paresthesias. Intracompartmental pressure measurements may be helpful but the diagnosis is made on clinical grounds.

Once the diagnosis is established, an emergent forearm fasciotomy is required to prevent Volkmann’s contracture.

IMAGING STUDIES

For fractures and dislocations, proper radiographic evaluation is essential before making any decisions regarding treatment of the injury. Ideally, two orthogonal views of the injured extremity should be obtained along with radiographs of the joints adjacent to the injured bone. Injuries to the shoulder girdle should have a minimum of three radiographic views in a standard trauma series, which includes anteroposterior (AP), scapular “Y,” and axillary views. Subtle injuries can be missed if adequate radiographs are not obtained. This is seen in Figure 1 of this missed posterior dislocation that was not properly diagnosed until a magnetic resonance image was obtained 6 months after the initial injury.

Figure 1 Anteroposterior radiograph on the left that depicts a missed posterior dislocation. There is overlap of the humerus and glenoid (single dashed arrow) and a large impaction fracture of the humeral head (white arrow). Magnetic resonance image on the right clearly shows the dislocation and associated humeral head impaction fracture.

INJURIES TO SHOULDER GIRDLE AND HUMERUS