Emergency Room NotesEmergency Room Notes

Stuff to keep in mindThe next time you see a lower

extremity injury

Puncture Wounds• Classify the injury (clean, contaminated, dirty, agricultural)

• Consider depth of penetration (epidermis, dermis, sub-Q, bone)

• Anything on the object will be in the skin (or bone)– Number one organism: Staph a.– Number two organism: Pseudomonas a.– Others: Salmonella, Strep and

Streptopeptococcus, Clostridium sp.

Puncture Wounds

• All wounds should be explored• All wounds should have antibiotics• Anything deeper than a superficial wound should

undergo I&D and be packed open• If you’re not sure about the depth, err to the extreme

and do an I&D• Look for tracts (sinus) and lavage• Use a solution similar to Nixon’s for the lavage:

Polysporin B, Bacitracin, Gentamicin (covers all organisms and foams well to help dig out dirt and debris

Consequence of Poor Puncture Wound Care

• Soft tissue scarring– Epidermoid inclusion cyst formation– Nerve entrapment with neuralgia/neuritis– Foreign body reaction– Calcinosis cutis reactions

• Osteomyelitis– Partial or complete amputation of digit or bone– Formation of Brodie’s abscess

– Possible seeding of other sites with infection of implant

Fracture ManagementStage it, treat it and refer it

Staging Fractures: digital

• Usually only needs a ‘buddy splint’• If grossly displaced, closed reduction with or without

anaesthesia

• If closed reduction fails, it has to go to the O.R.

Staging Fractures: midfoot

• ANY fracture must be treated with non- weight bearing and casting

• What is the quality of the fracture?– Position– Alignment– Rotation– Bayoneting – Angulation– Comminution

Staging Fractures: rearfoot and ankle• ‘Golden Period’

– 6-8 hours after the injury, any poor quality fracture should be splinted and taken to the O.R. at a later time

– Operating on grossly edematous tissue increases chances of dehiscence, infection and fracture blisters

– Closed reduction with anaesthesia and a Jones’ compression cast

• Consent• 6-lead EKG• Pulse Ox with nasal O2

• Portable X-ray• 2mg Versed with 4mg Morphine (X3 Q 15min)• Have Reversed and Narcan handy

• Any ankle trauma should have considerations for a high fibular fracture (Maisonneuve) and compartment syndrome check (palor, paralysis, pulselessness, paraesthesias)

Missed Ankle Fracture•Patient came to the Memorial E.R. with the complaint of a knee and ankle injury.

•Clear evidence of a high fibular fracture on the knee film was missed and went untreated.

Final Thoughts

• Over the last year, my office has inherited 15 cases of foot fractures sent out of the E.R. without crutches, cast or instructions to stay non-weight bearing to the area.

• Standard of care for a fracture is established by the community of physicians, but always includes casting and non-weight bearing

• Of these 15 cases, almost all have gone to the O.R. for open reduction with internal fixation, and didn’t need to initially. The others are on bone stimulators and may also go to the O.R.

• 5 of these people are now suing the initial treating doctors