The Crushed Wrist in a Polytrauma Patient
A 34-year-old right-hand-dominant construction worker is brought in 4 hours after a 6-metre fall. He is intubated with a grade III splenic laceration being managed non-operatively, a stable pelvic ring injury, and an open right distal radius fracture (Gustilo-Anderson IIIA) with a 4 cm volar wound, gross contamination, and absent radial pulse. Capillary refill in the fingers is 3 seconds, the hand is dusky, and he is on norepinephrine at 0.15 mcg/kg/min to maintain MAP >65. He is coagulopathic (INR 1.9, platelets 78). Orthopedics is asked to decide on timing and method of fixation while the general surgeons plan repeat abdominal CT in 6 hours.
1. How do you sequence the management of the open distal radius fracture relative to his physiology? Justify your timing decision.
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The limb is threatened (absent radial pulse, dusky hand, prolonged caprefill) and the wound is open, so this is a time-critical limb salvage, not an elective fixation. Sequence:
- Immediate bedside actions: tetanus status, IV antibiotics (cefazolin + gentamicin for IIIA; add penicillin if soil/farm contamination), and urgent reduction with longitudinal traction to restore length and improve perfusion. Reassess pulse after reduction - many pulseless wrists reperfuse with reduction alone.
- Theatre within hours, not days. Open fracture with vascular compromise and gross contamination is an indication for urgent debridement and stabilization even in a polytrauma patient. Damage-control principles apply: do not attempt a 4-hour anatomic plate if the patient is coagulopathic and on pressors.
- Method: provisional spanning external fixation through the wound after debridement, with or without K-wire supplementation. This is fast, low-blood-loss, and offloads the soft tissues. Avoid a large volar plate in a contaminated wound with compromised soft-tissue envelope.
- Vascular assessment: if the pulse does not return after reduction and external fixation, obtain CT angiography or on-table Doppler/arteriography - radial artery injury or compartment syndrome must be excluded. Consider fasciotomy if compartment pressures are elevated.
- Coordinate with general surgery: do not delay limb-saving surgery for the repeat CT; the CT can be done post-operatively in ICU. Document the shared decision with the trauma team.
Definitive internal fixation is deferred 5–7 days once resuscitation is complete, coagulopathy corrected, and the wound is clean.
2. The wound is grossly contaminated and the patient is coagulopathic. What are your debridement and wound-management decisions at the first operation, and what would make you return to theatre?
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At the first operation:
- Radical debridement: excise all devitalized skin, fat, and muscle; remove free bone fragments without periosteal attachment. Copious low-pressure lavage (6–9 L normal saline). Do not close the wound primarily.
- Leave the wound open with a negative-pressure wound therapy (NPWT) dressing or antibiotic bead pouch over the fracture site. Plan a second-look at 48 hours (or sooner if clinical deterioration).
- Stabilize with external fixator as above; K-wires can be placed through the wound.
- Antibiotic duration: typically 24–48 hours after each debridement; extend if there is residual contamination or the wound cannot be closed.
Return to theatre urgently if: fever or rising inflammatory markers with wound deterioration, new necrosis on dressing change, persistent oozing, or signs of deep infection. In a coagulopathic patient, also watch for expanding hematoma under the NPWT dressing.
Key principle: in a IIIA open fracture, the decision between external fixation and internal fixation hinges on soft-tissue quality and contamination, not on the fracture pattern. A clean wound after debridement may allow delayed internal fixation at 5–7 days; a dirty wound mandates staged external fixation until cultures are negative.
3. Six weeks later he has a healed wound, a consolidated fracture, but a stiff wrist (flexion 10°, extension 15°) and a positive Tinel over the volar scar. How do you manage this, and what is the rationale?
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This is a post-traumatic stiff wrist with possible median nerve irritation - a different problem from the acute fracture.
- Assess the nerve first. Positive Tinel at the scar with any numbness, thenar weakness, or night pain suggests carpal tunnel syndrome from scar tethering or malunion. Obtain nerve conduction studies if symptoms are equivocal. If significant, carpal tunnel release is indicated - do not attribute all stiffness to the fracture.
- Stiff wrist rehabilitation: intensive hand therapy with static progressive or dynamic splinting, edema control, and a home program. Expect meaningful gains over 3–6 months. Warn the patient that full range is unlikely after a severe open injury.
- Malunion assessment: check volar tilt, radial inclination, and ulnar variance on radiographs. A symptomatic malunion with DRUJ incongruity or ulnar impaction may warrant corrective osteotomy, but only after soft-tissue optimization.
- Do not rush to arthrodesis or arthroplasty. In a young manual worker, preserve motion; a salvage procedure is a last resort.
Rationale: the exam tests whether you separate nerve pathology from mechanical stiffness and avoid operating on the wrong problem.