Open fracture management

[Creflo]

So had an open digital fracture, removed the comminuted fragments of the head of the proximal phalanx, then the postop x ray showed an apparent fragment, less than 1mm diameter, that remained in the toe. This wasn't visible using the mini c arm in the O.R. I know that this will probably be fine, but also know it is best to debride any bone fragments. Can anyone offer insight or article references on how this usually works out?

Another issue with fracture cases is the hematoma/red discoloration that is located along the tissue planes in the subcutaneous tissue and deeper. Does anyone have any pearls about removing the hematoma without taking the tissue that the hematoma is contained in? Thanks for any replies.

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[Creflo]

lesser toe

 

[sinustarsi]

In OR setting, you can use spinal needle to drain the hematoma.. You can squeeze the toe also. Toe fractures are also forgiving. You most likely missed the fragment by not taking oblique view.

I would also place pt for 24 hrs of IV abx depending on wound size after debriedmemt

 

[ldsrmdude]

In OR setting, you can use spinal needle to drain the hematoma.. You can squeeze the toe also. Toe fractures are also forgiving. You most likely missed the fragment by not taking oblique view.

I'm a bit confused about this. Are you talking about the hematoma under the nail or the hematoma along the tissue planes intra-operatively? I'm just not seeing how the spinal needle or squeezing the toe helps the hematoma in the subcutaneous tissues. Maybe you can clarify it a bit for me?

 

[dtrack22]

I'm a bit confused about this. Are you talking about the hematoma under the nail or the hematoma along the tissue planes intra-operatively? I'm just not seeing how the spinal needle or squeezing the toe helps the hematoma in the subcutaneous tissues. Maybe you can clarify it a bit for me?

Sounded to me like he was just talking about surrounding soft tissue that has turned red because the broken bone underneath has been bleeding. In which case, after irrigation, I would leave that. The hematoma (which would be tiny in a lesser digit phalanx fx) sounds like it was evacuated with the small fx fragments and that seems sufficient.

As a resident who is seeing consults in the ED I typically treat an open lesser toe in the ED. Remove fragments if needed (seems like more often than not I don't, though I can't remember the last isolated comminuted lesser toe fx I've seen), wash, and suture. ED gives PO abx and we f/u in clinic. IMO if you aren't pinning it or needing to repair tendon(s), you don't need to go to the OR with it. As an attending I imagine it could be different based on how your hospital handles call/consults (and what the ED is willing to tx on their own) and any billing discrepancies between doing something in the ED v OR.

 

[I post PRN]

Wash, debride, close in ED. 1 dose IV, PO Abx. It's a toe. Pow.

 

[air bud]

Trying to find the article, but there is a level 1 paper within the last 2 years saying the exact thing - type 1 gustillo fractures - wash in ED, 1 dose IV and then send home PO. In JBJS or JOT, will find soon

 

[heybrother]

Not exactly recent, but here's a couple more to go with whatever you find.

These 2 articles were used in a discussion piece of open fractures by JBJS - Current Concepts Review Trends in the Management of Open Fracture A Critical Analysis.

Orcutt S, Kilgus D, Zinger D: The treatment of low grade open fractures without operative debridement. J Orthop Trauma 3:170–171, 1989
Yang EC, Eisler J. Treatment of isolated type I open fractures: is emergent operative debridement necessary? Clin Orthop Relat Res. 2003;410:289-94.

 

[janV88]

Wash, debride, close in ED. 1 dose IV, PO Abx. It's a toe. Pow.

This.