Lover’s Fracture

A 35-year-old construction worker was brought in by the ambulance to the Emergency Department. He was reported to have fallen from scaffolding at the height of approximately 4 meters and landed onto the concrete floor below feet first. He was found conscious by paramedics but in obvious pain, holding his right leg. Upon initial examination in the ED, the patient remains vitally stable but complains of severe, persistent pain in his right ankle and heel. After adequate analgesia, an X-ray of the right ankle and foot revealed signs of a calcaneal "Lover’s" fracture (Figure 1).

Figure 1
Figure 1: Image courtesy of Annelies van der Plas, and J.L. Bloem - http://www.startradiology.com/internships/general-surgery/ankle/x-ankle/

Calcaneal Fractures

Before we begin our discussion on calcaneal fractures, it is important to highlight the major anatomical structures visible on a standard X-ray of the ankle and foot.

Figure 2
calcaneus and foot anatomy

Figure 2 shows a lateral x-ray of the right ankle, demonstrating the calcaneus as the bone – commonly referred to as the heel – that makes up the majority of the hindfoot.

As would be expected, the size and position of the calcaneus predispose the bone to various forms of injury. A calcaneal fracture is most often sustained after a road traffic accident or a fall from significant height onto the feet as was the case with our patient. Due to the mechanism of injury, it is often colloquially dubbed as “Lover’s fracture” or the “Don Juan fracture”(1).

Epidemiology

Among fractures of the hindfoot, calcaneal fractures comprise 50-60% of all tarsal bone fractures (2). These fractures are usually intra-articular (3) and occur more commonly in young men aged between 20 and 40 years. Diseases which decrease bone density, such as osteoporosis, invariably increase the risk for development of the fracture when injury occurs.

Patient evaluation

Patients with calcaneal fractures will often present in severe pain, though they may not always be able to localize the exact source for their pain. Swelling at the ankle or heel along with bruising (ecchymosis) can also be expected. Due to the mechanism of fall, injury usually occurs bilaterally. Most patients are unable to bear any weight onto the affected limb.

The lower extremity or extremities in question should undergo a thorough neurovascular exam, as diminished pulses distal to the injury (dorsalis pedis) could indicate arterial compromise and mandate aggressive investigation with angiography or Doppler scanning. Though the gold standard for diagnosing calcaneal fractures remains a CT scan, a plain film X-ray is usually obtained first which should include an Antero-Posterior (AP), a lateral, and an oblique view.

Bohler’s Angle and Critical Angle of Gissane

Historically, physicians would measure Bohler’s angle and the critical angle of Gissane in cases where a calcaneal fracture was not clearly evident on a plain X-ray. Outlined in Figure 3, a calcaneal fracture would be suspected if Bohler’s angle was below 20 degrees or the critical angle of Gissane was noted to be more than 140 degrees. Bohler’s angle was found to be a lot more diagnostically reliable when compared to the critical angle of Gissane (4). However, both these methods of diagnosis are now considered obsolete and the same research that studied that utility of the angles found that Emergency Physicians were able to accurately identify calcaneal fractures approximately 98% of the time without the measurement of either angle.

Figure 3
853 - bohler angle - calcaneus
854 - Gissane angle- calcaneus

Figure 3- Bohler’s Angle and Critical angle of Gissane

Management

The goal of initial management in the Emergency Department is centered on adequate pain relief, immobilization and wound care (including antibiotics when there are signs of a contaminated wound). [See the link for open fractures and antibiotic choices.]

An important point to note is that the mechanism of injury in calcaneal fractures (namely fall from height) is a form of axial loading. The energy from landing on the ground will often be transmitted up through the body, usually to the spine causing compression fractures of the vertebrae. The patient, however, may not complain about pain in other areas due to the overwhelming and distracting pain in the calcaneus. Therefore, all calcaneal fractures should be managed with a high index of suspicion for associated injuries.

Other potential complications include compartment syndrome, wound infection, malunion and osteomyelitis. All patients diagnosed to have calcaneal fractures should be managed by a multidisciplinary team that includes an Orthopedic Surgeon to ensure definitive management and repair of the fracture.

Take Home Points

  • High energy impact with axial loading, usually from a road traffic accident or a fall from height should raise suspicion of a calcaneal fracture.

  • Perform a thorough evaluation of the site of injury and suspect associated injuries (check the spine and remember to check the other foot for concomitant injury).

  • Maintain adequate analgesia (these fractures hurt!) and involve the Orthopedic Surgeon as soon as the diagnosis is made.

References and Further Reading

  1. Lee P, Hunter TB, Taljanovic M. Musculoskeletal colloquialisms: how did we come up with these names? Radiographics. 2004;24 (4): 1009-27. doi:10.1148/rg.244045015
  2. Davis D, Newton EJ. Calcaneus Fractures. [Updated 2019 Mar 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan
  3. Jiménez-Almonte JH, King JD, Luo TD, Aneja A, Moghadamian E. Classifications in Brief: Sanders Classification of Intraarticular Fractures of the Calcaneus. Clin. Orthop. Relat. Res. 2019 Feb;477(2):467-471
  4. Jason R. K., Eric A. G., Gail H. B., Curt B. H. & Frank L. Boehler’s angle and the critical angle of gissane are of limited use in diagnosing calcaneus fractures in the ED. American Journal of Emergency Medicine. 24, 423–427 (2006)

Laceration Repair: A Rural Encounter

The word “emergency” carries some connotation with it. A lack of time to act, a situation that demands speed, a sense of acuity. Medicine on the other hand is related to healing, soothing and improving, a slow and gentle process. I sometimes wonder if the name of the specialty (Emergency Medicine) is an oxymoron.

Etymology aside, this specialty of medicine has meant at least two different things to me at two different settings. I have worked as an intern at Patan Hospital, a tertiary care center and as an in-charge of emergency services of Beltar Primary Healthcare Center (PHC), a government establishment in rural Nepal. I intend to describe my perspective and illustrate what different experiences of emergency medicine in different settings has to offer. I hope in doing so, I’ll be able to illustrate some of my workarounds that make the difference less overwhelming.

I have been posted at Beltar PHC, Nepal for the past 18 months. The center has been running primary emergency services. Initial stabilization and proper referral are two major ways Beltar PHC helps to save lives. The nearest city where cases are referred to are Dharan (50.5 km away) and Biratnagar (92 km away). Emergency personnel includes one doctor on call, one paramedic, two sisters for delivery and one office assistant. Laboratory and X-ray services are not available apart from office hours. Emergency investigations available include ECG, UPT and Obstetric USG. The government freely supplies medical equipment and a limited number of medicines.

Entrance to Emergency Services at Beltar PHC
Emergency Setup at Beltar Primary Healthcare Center

A 27-year-old male

A 27-year-old male with a cut injury on his right forearm was brought to the PHC. It was a quiet day at the Emergency Department (ED) and most of the cases were OPD cases that did not make it on time.

One-way ED helps people here, albeit not an ideal way, is to act as a rescue for patients who travel long distances to get to the OPD if they do not make it on time.

The patient had a clean wound, about 5 cm long with smooth edges. We washed the wound using tap water; a practice equally efficacious to using saline but way more affordable for a rural setup. To suture the wound, we made our equipment ready. A long suture thread was cut from a nylon thread roll sterilized in betadine, some gauze pieces prepared by our office assistant that had been autoclaved and stored in an old dressing drum were taken out.

Suture materials at Beltar PHC
Dressing Drums at Beltar PHC

The thread was inserted into a needle, probably too big (turns out what needle size to use and when was a dilemma of privilege). Sometimes, we use needles that come with 2 ml syringes instead; they are sharper for skin penetration than the big suture needles our government freely supplies. The wound was sutured and the patient discharged.

That night I reflected on how things would have been subtly but significantly different at Patan Hospital. A sterilized suture set, autoclaved, packed and ready to use along with a ready to use surgical suture would be available. The procedure would have taken place in a more private space and not where visitors had the opportunity to peak in through our foldable privacy screen. Maybe the patient would have had to wait longer to get attention but the difference would not have been much, considering the time it takes to prepare every instrument here.

Each minor aspect of this difference deserves to be heard, talked about and their solution sought for. I plan to write about each of these as a series of article that follows. Proper resource allocation is a time and economy intensive goal; nevertheless the ultimate one. Maybe small workarounds are what we need during the period of transition, especially for places like Beltar.

Laceration repair is a common procedure in every emergency department. Setting differs and with it the availability of resources. Nevertheless, the core principles that govern patient care and the science behind it remains the same. While we wait for more convenient and sophisticated solutions, which all patients deserve, here are some points to remember regarding laceration repair that can help provide an acceptable standard of care even in resource-limited settings.

  • While working in rural, one should be well aware of its limitations. Some lacerations that require surgical consultation and need to be referred include (1):
    • Deep wounds of the hand or foot
    • Full-thickness lacerations of the eyelid, lip, or ear
    • Lacerations involving nerves, arteries, bones, or joints
    • Penetrating wounds of unknown depth
    • Severe crush injuries
    • Severely contaminated wounds requiring drainage
  • Non-contaminated wounds can be successfully closed up to 18 hours post-injury while clean head wounds can be repaired up to 24 hours after injury (2).

  • Drinkable tap water can be used for wound irrigation instead of sterile saline. At least 50 to 100 ml of irrigation solution per 1 cm of wound length is needed at a pressure of 5 to 8 psi for optimal dilution of wound’s bacterial load. The wound can be put under running water or can be irrigated using a 19-gauge needle with a 35 ml syringe (3).

  • Local hair should be clipped, not shaved, to prevent wound contamination(4).

  • Strict sterile techniques are unnecessary to be followed during laceration repairs. The instruments touching wound (sutures, needles, etc.) should be sterile, but everything else only needs to be clean(1). Clean non-sterile examination gloves can be used instead of sterile gloves during wound repair(5).
  • Local anesthesia with lidocaine 1% or bupivacaine 0.25% is appropriate for small wounds while large wounds occurring on limbs may require a regional block (1). Epinephrine should not be used in anatomic areas with end arterioles, such as fingers, toes, nose, penis, and earlobes.
  • Maximum doses of local anesthetic are as follow (6):
    • Lidocaine (without epinephrine): 3 – 5 mg/kg
    • Lidocaine (with epinephrine): 7 mg/kg
    • Bupivacaine (without epinephrine): 1 – 2 mg/kg
    • Bupivacaine (with epinephrine): 3 mg/kg
  • The suture used for skin repair include non-absorbable sutures (nylon and polypropylene) while absorbable sutures (polyglactin, polyglycolic) is used to close deep lacerations. For skin closure, silk sutures are no longer used because of skin abscess formation, their poor tensile strength and high tissue reactivity. In general, a 3–0 or 4–0 suture is appropriate on the trunk, 4–0 or 5–0 on the extremities and scalp, and 5–0 or 6–0 on the face (6).
    • Sterilization of sutures can be done by complete immersion in povidone-iodine 10% solution for 10 minutes followed by rinsing in sterile saline/water. Sutures that can be sterilized or re-sterilized include monofilament sutures (Prolene or Nylon) and coated sutures (Vicryl, Ethibond) (7).

Timing of Suture Removal (6)

Wound Location Time of Removal (Days)
Face
3 - 5
Scalp
7 - 10
Arms
7 - 10
Trunk
10 - 14
Legs
10 - 14
Hands or Feet
10 - 14
Palms or Soles
14 - 21

Tetanus Prophylaxis (8)

Wound Previous Vaccine Tetanus Vaccine
Clean Wound
Previous vaccine ≥3 doses - The last dose within 10 years
No Need
Previous vaccine ≥3 doses - The last dose more than 10 years
Yes
Previous vaccine ≥3 doses - NOT RECEIVED
Yes
Contaminated Wound
Previous vaccine ≥3 doses - The last dose within 5 years
No
Previous vaccine ≥3 doses - The last dose more than 5 years
Yes
Previous vaccine ≥3 doses - NOT RECEIVED
Yes + TIG

Factors that may increase chances of wound infection (9)

  • wound contamination,
  • laceration > 5 cm,
  • laceration located on the lower extremities,
  • diabetes mellitus

Antibiotics

  • Prophylactic systemic antibiotics are not necessary for healthy patients with clean, non-infected, non-bite wounds(10). 
  • Prophylactic antibiotic use is recommended for (11): 
    • human bite wounds 
    • deep puncture wounds
    • wounds involving the palms and fingers
  • Topical antibiotic ointments decrease the infection rate in minor contaminated wounds. 

References and Further Reading

  1. Forsch RT. Essentials of Skin Laceration Repair. Am Fam Physician. 2008 Oct 15;78(8):945-95
  2. Berk WA, Osbourne DD, Taylor DD. Evaluation of the ‘golden period’ for wound repair: 204 cases from a third world emergency department. Ann Emerg Med. 1988;17(5):496–500.
  3. Wheeler CB, Rodeheaver GT, Thacker JG, Edgerton MT, Edilich RF. Side-effects of high pressure irrigation. Surg Gynecol Obstet. 1976;143(5):775–778./ Moscati RM, Reardon RF, Lerner EB, Mayrose J. Wound irrigation with tap water. Acad Emerg Med. 1998;5(11):1076–1080.
  4. Howell JM, Morgan JA. Scalp laceration repair without prior hair removal. Am J Emerg Med. 1988;6(1):7–10.
  5. Perelman VS, Francis GJ, Rutledge T, Foote J, Martino F, Dranitsaris G. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial. Ann Emerg Med. 2004;43(3):362–370.
  6. Forsch RT, Little SH, Williams C. Laceration Repair: A Practical Approach. Am Fam Physician. 2017 May 15;95(10):628-636.
  7. Cox I. Guidelines for Re-Sterilising Sutures. Community Eye Health. 2004;17(50): 30.
  8. Kretsinger K, Broder KR, Cortese MM, et al. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55(RR-17):1–37.
  9. Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: what are the risks for infection and has the ‘golden period’ of laceration care disappeared? Emerg Med J. 2014;31(2):96–100.
  10. Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies. Am J Emerg Med. 1995;13(4):396–400.
  11. Worster B, Zawora MQ, Hsieh C. Common Questions About Wound Care. Am Fam Physician. 2015 Jan 15;91(2):86-92.

A 57-year-old man fell from a height comes with neck pain

by Stacey Chamberlain

A 57-year-old man fell from a height of 12 feet while on a ladder. He did not pass out; he reports that he simply lost his footing. He fell onto a grassy area, hitting his head and complains of neck pain. He did not lose consciousness and denied headache, blurry vision, vomiting, weakness, numbness or tingling in any extremities. He denies other injuries. He was able to get up and ambulate after the fall and came in by private vehicle. He has not had previous spine surgery and does not have known vertebral disease. On exam, he is neurologically intact with a GCS of 15, does not appear intoxicated and has moderate midline cervical spine tenderness.

Should you get imaging to rule out a cervical spine fracture?

C-spine Imaging Rules

Canadian C-spine Rule

NEXUS Criteria for C-spine Imaging

  • Age ≥ 65
  • Extremity paresthesias
  • Dangerous mechanism (fall from ≥ 3ft / 5 stairs, axial load injury, high-speed MVC/rollover/ejection, bicycle collision, motorized recreational vehicle)
  • Focal neurologic deficit present
  • Midline spinal tenderness present
  • Altered level of consciousness present
  • Intoxication present
  • Distracting injury present

Both the Canadian C-spine Rule (CCR) and NEXUS Criteria are widely employed in clinical practice to reduce unnecessary cervical spine imaging in trauma patients with neck pain or obtunded trauma patients. The CCR uses mechanism and age criteria, whereas the NEXUS Criteria incorporates criteria including midline tenderness and additional factors that might limit a practitioner’s exam. The CCR can be difficult for some practitioners to remember all the criteria that qualify as a dangerous mechanism and is limited to ages > 16 and < 65. However, it can be used in intoxicated patients if the patients are alert and cooperative, allowing a full neurologic exam. The NEXUS Criteria are applicable over any age range (> 1 year old), but the sensitivity may be low in patients > 65 years of age. A single comparison study found the CCR to have better sensitivity (99.4% versus 90.7%); however, the study was performed by hospitals involved in the initial CCR validation study.

Case Discussion

By applying either criteria to this case, the patient would require C-spine imaging as by CCR, the patient would meet criteria for dangerous mechanism, and by NEXUS, the patient has midline tenderness to palpation.

A 36-year-old woman slipped on ice. CT or Not CT?

by Stacey Chamberlain

A 36-year-old woman slipped on ice and fell and hit her head. She reports loss of consciousness for a minute after the event, witnessed by a bystander. She denies headache. She denies weakness, numbness or tingling in her extremities and no changes in vision or speech. She has not vomited. She remembers the event except for the transient loss of consciousness. She doesn’t use any blood thinners. On physical exam, she has a GCS of 15, no palpable skull fracture and no signs of a basilar skull fracture.

Should you get a CT head for this patient to rule out a clinically significant brain injury?

Canadian CT Head Rule

High-Risk Criteria (rules out the need for neurosurgical intervention)

Medium Risk Criteria (rules out clinically important brain injury)

  • GCS < 15 at two hours post-injury
  • Suspected open or depressed skull fracture
  • Any sign of basilar skull fracture (hemotympanum, Raccoon eyes, Battle’s sign, CSF oto or rhinorrhea)
  • Retrograde amnesia to event  ≥ 30 minutes
  • Dangerous mechanism (pedestrian struck by motor vehicle, ejection from the motor vehicle, fall from > 3 feet or > 5 stairs)

The Canadian CT Head Rule (CCHR) only applies to patients with an initial GCS of 13-15, witnessed loss of consciousness (LOC), amnesia to the head injury event, or confusion. The study was only for patients > 16 years of age. Patients were excluded from the study if they had “minor head injuries” that didn’t even meet these criteria. Patients were also excluded if they had signs or symptoms of moderate or severe head injury including GCS < 13, post-traumatic seizure, focal neurologic deficits, or coagulopathy. Other studies have looked at different CDRs for traumatic brain injury including the New Orleans Criteria (NOC). However, CCHR has been found to have superior sensitivity and specificity.

Case Discussion

By applying this rule to the above case, the patient should be considered for imaging due to the mechanism. A fall from standing for an adult patient would constitute a fall from > 3 feet; therefore, although the patient would not likely be high risk and need neurosurgical intervention, the patient might have a positive finding on CT that in many practice settings would warrant an observation admission.

A 20-months-old head trauma: CT or Not CT?

by Stacey Chamberlain

A 20-month-old female was going up some wooden stairs, slipped, fell down four stairs, and hit the back of her head on the wooden landing at the bottom of the stairs. She did not lose consciousness and cried immediately. She was consolable after a couple of minutes and is acting normal per her parents. She has not vomited. On exam, she is well-appearing, alert, and has a normal neurologic exam. She is noted to have a left parietal hematoma measuring approximately 4×4 cm.

Should you get CT imaging of this child to rule out clinically significant head injury?

PECARN Pediatric Head Trauma Algorithm

Age < 2

Age ≥ 2

  • GCS < 15, palpable skull fracture, or signs of altered mental status
  • Occipital, parietal or temporal scalp hematoma; History of LOC≥5 sec; Not acting normally per parent or Severe Mechanism of Injury?
  • GCS < 15, palpable skull fracture, or signs of altered mental status
  • History of LOC or history of vomiting or Severe headache or Severe Mechanism of Injury?

The PECARN (Pediatric Emergency Care Applied Research Network) Pediatric Head Trauma Algorithm was developed as a CDR to minimize unnecessary radiation exposure to young children. The estimated risk of lethal malignancy from a single head CT in a 1-year-old is 1 in 1000-1500 and decreases to 1 in 5000 in a 10-year-old. Due to these risks, in addition to costs, length of stay and potential risks of procedural sedation, this CDR is widely employed given the frequency of pediatric head trauma ED visits. This CDR has the practitioner use a prediction tree to determine risk, but unlike some other risk stratification tools, the PECARN group does make recommendations based on what they consider acceptable levels of risk. In the less than 2-year-old group, the rule was found to be 100% sensitive with sensitivities ranging from 96.8%-100% sensitive in the greater than two-year-old group.

This algorithm does have some complexity and ambiguity. It requires the practitioner to know what were considered signs of altered mental status and what were considered severe mechanisms of injury. In addition, certain paths of the decision tree lead to intermediate risk zones. In these cases, the recommendation is “observation versus CT,” allowing for the ED physician to base his/her decision to image or not based on numerous contributory factors including physician experience, multiple versus isolated findings, and parental preference, among others.

Other pediatric head trauma CDRs rules have been derived and validated; however, in comparison trials, PECARN performed better than the other CDRs. Of note, in this study, physician practice (without the use of a specific CDR) performed as well as PECARN with only slightly lower specificity.

Case Discussion

For purposes of the case study, the patient falls into an intermediate risk zone of clinically important brain injury. However, a sub-analysis of patients less than two years old with isolated scalp hematomas suggests that patients were higher risk if they were < 3 months of age, had non-frontal scalp hematomas, large scalp hematomas (> 3cm), and severe mechanism of injury. Given the large hematoma in the case study patient and a severe mechanism of injury (a fall of > 3 feet in the under two age group), one might more strongly consider imaging due to these two additional higher risk factors.

Siedel Test

A 42 years old male, presents to the ED 1 hour after he was hammering a nail onto a wooden shelf, where the nail flew and strike his left open eye. In an attempt to help, his friend immediately removed the nail. After that, he has been having severe sharp pain and blurry vision in his left eye. On examination, the left eye had poor visual acuity, and he could only perceive light and movement. The pupil was fixed, dilated and non-reactive to light. Right eye examination was normal.

819.2 - eye penetran trauma 2 -siedel sign
819.1 - eye penetran trauma 1

How would you approach to this patient?

To learn more about it, read chapters below.

Read "Eye Trauma" Chapter

Read "Red Eye" Chapter

Quick Read

Globe rupture

It is an ophthalmologic emergency, consisting of a full-thickness injury in the cornea or sclera caused by penetrating or blunt trauma. Anterior rupture is usually observed, as this is the region where the sclera is the thinnest. Posterior rupture is rare and difficult to diagnose. It can be diagnosed through indirect findings such as contraction in the anterior chamber and decrease in intraocular pressure (IOP) in the affected eye. If there is a risk of globe rupture, a slit lamp test with 10% fluorescein must be conducted. Normal tissue is dark orange under a blue cobalt filter; a lighter color is observed in the damaged zone due to a lower dye concentration. Ultrasonography (USG) can be useful in making a diagnosis, especially with posterior ruptures. Computed tomography (CT) sensitivity ranges 56–75%. In cases of anterior globe injuries, USG use, and if there is a risk of a foreign metal body, magnetic resonance imaging, are contraindicated. Prompt ophthalmology consultation is required. While in the emergency department, tetanus prophylaxis, analgesics, bed rest, head elevation, and systemic antibiotic therapy are required. The most commonly preferred antibiotics are cefazolin and vancomycin. Age over 60 years; injury sustained by assault, on the street/highway, during a fall, or by gunshot; and posterior injuries are indications of a poor prognosis.

Siedel test

Seidel test is used to detect ocular leaks from the globe following injury. If there is penetration to the eye, aqueous leakage happens. However, the fluid is clear and hard to identify. Therefore, non-invasive test “Siedel” is used for better visualization of this leakage. Fluorescein 10% is applied to the injured eye, and the leakage becomes more prominent.

To learn more about it, read chapters below.

Read "Eye Trauma" Chapter

Read "Red Eye" Chapter

Open fracture! Antibiotic choice.

ERic Motorcycle accident

A 20-year-old male presents to your ED with a 5 cm wound after he fell off his motorbike. On physical exam, the wound overlays a fractured left tibia but does not show extensive soft tissue damage nor any signs of periosteal stripping or vascular injury. 

Which antibiotic should you give to this patient?

To learn more about it, read chapters below.

Read "Scores" Chapter
Read "Lower Extremity Injuries" Chapter

Quick Read

Gustilo-Anderson Classification

Gustilo-Anderson classification is used for fractures with open wounds and antibiotic coverage.

Gustilo-Anderson Classification

TypeDefinition
Type IOpen fracture, clean wound, wound <1cm in length
Type IIOpen fracture, wound >1cm in length without extensive soft tissue damage, flaps, avulsions
Type IIIOpen fracture with extensive soft tissue laceration, damage, or loss or an open segmental fracture. This type also includes open fractures caused by farm injuries, fractures requiring vascular repair, or fractures that have been open for 8 hours prior to treatment.
Type III AType III fracture with adequate periosteal coverage of the fractured bone despite extensive soft tissue laceration or damage
Type III BType III fracture with extensive soft tissue loss and periosteal stripping and bone damage. Usually associated with massive contamination. It will often need further soft tissue coverage procedure (i.e. free or rotational flap).
Type III CType III fracture associated with arterial injury requiring repair, irrespective of degree of soft tissue injury

According to the above classification, each class should receive the following antibiotics:

  • Type I: 1st generation cephalosporin
  • Type II: 1st generation Cephalosporin +/- Gentamycin
  • Type III: 1st generation Cephalosporin + Gentamycin +/- Penicillin

To learn more about it, read chapters below.

Read "Scores" Chapter
Read "Lower Extremity Injuries" Chapter

Eye Trauma chapter was added into the content list.

Depressed skull fracture

735.1i - head trauma - skull fracture
735.2 - head trauma - skull fracture 2

A 31-year-old male presented to the ER after falling from a 3-meter wall. He fell on his face and is complaining of face pain and body aches. He isn’t sure if he lost consciousness. GCS 15/15. Not much history was taken from the patient as he was in excruciating pain. Vitals HR: 105 bpm, RR: 19 bpm, BP: 106/59, Ox. Sat: 100%, Temp: 36.9.

This case is a kind of unusual. Having this amount of depression of the skull and showing almost no neurological abnormality is not happening very frequent.

We hope that you also recognized the air inside in the right image.

To learn more about how to read the CT scan, see the chapter below.

How to read head CT by Reza Akhavan

You may also see below infographic showing a mnemonic about reading head CT in the ED.

Seat Belt Sign

722.1 - seat belt sign 1

A 32 years old male was involved in an MVC where he was in the front seat as a passenger and had his seatbelt on. It was a direct front collision. The patient is stable. He is in moderate pain. Displacement of the lower part of the sternum as well as a retrosternal hematoma was noted after the ED care.

Trauma care is very important as globally recognized. It is also important to prevent injury. Seat belts are doing their part to prevent further injury. However, they may not be protective, or even cause injury if the other prevention measures were not applied such as speed limit.

This case shows dramatic skin lesions caused by the seatbelt. You can see various images of this in the clinical image archive (just click the image). What seatbelt sign says to us? INVESTIGATE FURTHER INNER INJURY… This patient has neck, chest, abdomen skin findings. Therefore, vascular injuries (aorta, vein), viscus injuries (perforation, bleeding), solid organ lacerations (spleen, liver, pancreas), contusions (cardiac) in the neck, chest, and abdomen should be investigated.

To learn more about trauma management read below chapter.

Multiple Trauma by Pia Jerot and Gregor Prosen by Dan O’Brien

A baby with burn!

711 - 2nd degree burn-2

11-month-old baby presented to the ED with a burn after accidental hot tea slippage over her.

Burn is a complicated injury for many reasons. It is severely painful, creates the risk of infection, potential volume loss may create further injuries in vital organs. Although these clinical problems are very important and should be managed appropriately, there is one thing we need to consider while we face with any child with a burn. This is child abuse or neglect. As a young physician, it is better to know and be familiar with this issue now because if you do not know it, you can not suspect it. We will have a post soon about the child abuse and neglect hints.

To learn about burn management, please read below chapter.

Burns by Rahul Goswami

How to stop bleeding!

712 - deep fore arm laceration

A 22-year-old male, aluminum factory worker, was brought by his friend to the ED after he accidentally fell on a sharp glass, 30 minutes ago. The patient presented with moderate bleeding from lacerations in his forearm. He was feeling dizzy and in severe pain.
Co-Morbid Conditions: None
Hand dominance: right-handed
Occupation: Aluminum factory worker
Denies smoking and use of the illicit drug
Last tetanus booster: unknown
Temperature oral: 36.7 C
Peripheral pulse rate: 91 bpm, regular
Respiratory rate: 17 bpm
Blood pressure: 164/75 mmHg
Oxygen saturation, on room air: 100%
GSC: 15/15

This is a deep laceration. Bleeding is one of the critical problems here. Because blood loss is a deadly situation, even with a simple laceration, we should concern about vascular injury. However, in the ED, our role is not the finding the actual problem in the early moments. Our role is to stop the bleeding immediately with some simple maneuvers or applications. Of course, this case should be evaluated for foreign body (direct visualization, x-ray, US may help), tendon and muscle injuries as well as nerve injuries. But, bleeding control is the first priority.

To learn about management, please read the chapter below.

Basics of Bleeding Control by Ana Spehonja and Gregor Prosen