What is your diagnosis?

Open fracture of the left distal radius and ulna 

What classification system is used to describe this type of injury?

The Gustilo Anderson classification system is used for open fractures. This classification system is used to guide the management of open fractures. Higher grade is associated with a higher risk of infection and related complications:

Grade 1 - Clean wound, <1 cm in length

Grade 2 - Wound 1-10 cm in length without extensive soft tissue damage

Grade 3 - Extensive soft tissue defect >10 cm in length (ie farm injuries, vascular emergencies, fractures open >8 hours) 

• Grade 3 open fractures can be further characterized (ie 3a, 3b, 3c) based on the degree of soft tissue and vascular injury present. The patient in this case presents with a Grade 1 Gustilo Anderson open fracture. 

What physical exam findings are expected?

Patients will have pain, swelling, and possibly ecchymosis at the wrist with an overlying skin defect or puncture wound. ROM may be significantly limited. Diminished radial pulse and/or sensory changes in the distal portion of the affected extremity may indicate signs of neurovascular compromise.  

What is the imaging modality of choice in the ED?

Plain film imaging with AP, lateral, and oblique views can be obtained to characterize the fracture. CT may be useful for surgical planning or post-reduction (obtain this based on conversations with Orthopedic surgery). CT angiogram of the affected extremity should be ordered if there is concern for an arterial injury. 

What is your management in the ED? Do I need to consult Orthopedic Surgery?

Open fractures are an orthopedic emergency due to increased risk of infection from bone exposure. After initial trauma survey and resuscitation (if needed), management in the ED will include the following:

• Irrigation - Perform thorough irrigation of the fracture site with multiple liters of sterile saline and dressing with sterile, saline-soaked gauze

• Pain control - Typically opioid

• Stabilization - Attempt at reduction if there is concern for vascular compromise. Stabilize fracture with a sugar-tong splint, brace, or traction and monitor distal pulses. 

• Antibiotics - Initiate as soon as possible; for Grade I & II fractures, cefazolin is appropriate. Traditionally, gentamicin is used for extended gram negative coverage for Grade III fractures and penicillin can be added for Clostridium coverage if there is concern for fecal wound contamination. However, newer data is trending toward the use of ceftriaxone and vancomycin for Grade III fractures. Antibiotic coverage should be broadened if there is concern for soil, freshwater or saltwater contamination

Contact orthopedic surgery as soon as possible. An orthopedic specialist should always be consulted in cases of open fracture. If your institution does not have on-call orthopedics, prioritize patient transfer to a facility with on-call orthopedics after the patient is stabilized. Patient should have a washout of the open fracture performed within 24 hours of the injury.