Orthopedic Trauma and Fracture Care
Concepts
Fracture care is organized around the patient, the soft tissue and the bone. Start with ABCs and a documented neurovascular exam before and after reduction. Open fractures use Gustilo–Anderson: grade I is a clean wound under 1 cm; grade II is 1–10 cm without extensive soft-tissue damage; IIIA has adequate coverage despite high energy; IIIB needs a local or free flap; IIIC has an arterial injury requiring repair. Give tetanus prophylaxis and early IV antibiotics; timely debridement is the priority, not immediate definitive fixation.
Compartment syndrome is the classic trap. Pain out of proportion, pain on passive stretch, a tense compartment and paresthesias precede pulselessness, which is late and unreliable. Use delta pressure (diastolic minus compartment pressure) with a threshold under 30 mmHg in the right clinical context; do not wait for a pulse deficit before fasciotomy.
Understand damage-control orthopedics: temporary external fixation in the physiologically unstable polytrauma patient, then definitive care. Distinguish delayed union, nonunion (hypertrophic versus atrophic) and malunion, and know risk factors for each.
Rule of thumb: a low-energy gunshot wound without fracture or visceral injury does not need broad-spectrum antibiotics; a barnyard or soil-contaminated wound does, with gram-negative and anaerobic coverage.
Worked example: tibial shaft fracture six hours after a motorcycle crash, severe pain with passive toe extension, delta pressure 22 mmHg - proceed to fasciotomy, not observation or repeat imaging.