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Chapter 42. Orthopedic Surgery

Open fractures, defined as a break in the bone with violation of the skin and soft tissues requires the following management

A. Splinting

B. Bedside irrigation and splinting

C. Formal irrigation and debridement in the operating room with stabilization of fracture and antibiotics

D. VAC dressing

E. Plastic surgery consultation

The correct answer is C. An open fracture is defined as an osseous disruption with a break in the overlying skin and soft tissues resulting in communication between the fracture and the external environment. Open fractures can be classified using the Gustillo and Anderson classification: Grade 1, clean skin opening less than 1.0 cm, Grade 2, traumatic wound greater than 1.0 cm but less than 10 cm in size, and Grade 3, extensive soft tissue injury requiring flap and/or vascular repair. Antibiotic treatment, tetanus prophylaxis and urgert irrigation and debridement in the operation is necessary. Fractures should be stabilized with internal or external fixation and/or splinting to minimize additional soft tissue injury.

A 57-year-old woman is involved in a motor vehicle collision. She is transferred to the Emergency Department where radiographs confirm a closed pelvic fracture with symphyseal widening. She becomes acutely hypotensive in the resuscitation bay. The next important step in her treatment is

A. Immediate transfusion

B. Exploratory laparotomy

C. Move blood pressure cuff to the leg

D. Apply sheet or pelvic binder around the patient

E. Obtain more x-rays

The correct answer is D. Pelvic fractures are among the most serious orthopaedic injuries, resulting in life-threatening hemorrhage, neurologic and genitourinary injury. Hemodynamically unstable patients have a mortality of 40%-50%. Immediate care of the patient with a pelvic fracture must address the retroperitoneal hemorrhage, pelvic ring stability and injuries to the GU system. General resuscitation principles are applied and active bleeding from the pelvic can be controlled by wrapping a pelvic binder or sheet circumferentially around the pelvis to close down the pelvic volume.

A 23-year-old man presents to the Emergency Room with an acute injury to his left knee sustained playing football. He is unable to weight bear and on exam demonstrates anterior dislocation of the tibia. The next steps in management include

A. Emergent reduction, splinting, vascular studies, and neurologic exam

B. Knee immobilizer and outpatient follow-up

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