TABLE 111.1 INDICATIONS FOR EMERGENT ORTHOPEDIC REFERRAL Injuries requiring emergent orthopedic referral Open fractures Concern for compartment syndrome Unacceptably displaced fractures that require reduction Significant growth plate or joint injuries Complete or displaced fractures of the long bones of the lower extremities Pelvic fractures (other than minor avulsions) Spinal fractures Dislocations of major joints other than the shoulder Injuries that can be managed initially by the emergency clinician with outpatient orthopedic follow-up Nondisplaced Salter–Harris type I fractures (exceptions are femur, proximal tibia) Clavicle fractures Nondisplaced upper extremity fractures Routine dislocations of the shoulder and minor joints (finger) with no fracture Nondisplaced fractures of the hand and foot Incomplete, nondisplaced fractures of the long bones of the lower extremities COMPLICATIONS OF FRACTURES: OPEN FRACTURES AND COMPARTMENT SYNDROME Goals of Treatment Rapid identification of a potential open fracture or compartment syndrome is important for urgent orthopedic consultation Open fractures have an increased risk of infection; therefore, early wound management, including tetanus prophylaxis as indicated and prophylactic antibiotics in the ED are vital Compartment syndrome, if not identified and treated, can progress to irreversible muscle and nerve damage Early consultation with orthopedics is necessary for fasciotomy CLINICAL PEARLS AND PITFALLS The laceration associated with an open fracture should not be closed in the ED, even if the fracture is nondisplaced Patients with an open fracture should receive antibiotics as soon as possible to minimize risk of infection Compartment syndrome associated with a fracture can occur in the forearm, hand, leg, or foot, with the leg being the most common location Fractures associated with compartment syndrome not need to be severe Pain out of proportion to the injury or increasing pain after analgesics, especially with passive extension, is one of the earliest signs of compartment syndrome Compartment syndrome may present shortly after the fracture is sustained, or may occur after reduction and casting Therefore, neurovascular status must always be checked in the injured extremity after casting Fasciotomy should be considered when clinical symptoms of compartment syndrome are present and/or when compartment pressures measured in the injured extremity are within 30 mm Hg of the patient’s diastolic blood pressure or the mean arterial pressure Current Evidence A fracture is considered to be “open” when the injury results in disruption of the skin and underlying soft tissues overlying the fracture, thus providing a communication between the fracture and the outside environment The organisms found to be contaminating an open fracture at the time of presentation not necessarily represent the microbes that will eventually cause infection; therefore, wound cultures are of minimal utility Most open fracture infections are caused by gram-negative rods and gram-positive staphylococci; however, clinicians should be mindful of a rising frequency of infections caused by methicillin-resistant Staphylococcus aureus (MRSA) While there is consensus supporting the timing of antibiotic administration to minimize risk of infection, there are variable recommendations on the optimal regimen Children with compartment syndrome may present with only one associated sign or symptom, with pain being the most common presentation In one study of compartment syndrome with tibial shaft fractures, adolescents (14 years and older) had an increased risk of compartment syndrome compared with younger children Clinical Considerations Clinical Recognition Open fractures typically occur due to a high-energy mechanism; therefore, a complete examination to identify other potentially life-threatening injuries is imperative A fractured extremity should be carefully examined for the presence of an open wound, potentially signifying an open fracture However, it is not always obvious if the injury is an open fracture or if it is a laceration that does not communicate with the fracture Operative exploration by the orthopedist may be necessary to determine this Compartment syndrome develops when there is an accumulation of intracompartmental pressure resulting in obstruction of venous outflow and then increased pressure in the nonelastic compartment If untreated, small arterioles and capillaries are eventually occluded, resulting in ischemia with irreversible muscle and neurovascular tissue damage Compartment syndrome must be suspected with any fracture or blunt tissue injury when there is pain out of proportion to the injury or if the pain is increasing, despite analgesic administration The patient may also complain of paresthesias and pain with passive extension On physical examination the patient may have pallor and pulselessness of the injured extremity, although these may be late findings Triage Considerations Children presenting with a concern for an open fracture or compartment syndrome should be evaluated immediately in the ED with urgent orthopedic consultation Clinical Assessment For open fractures, the wound should be carefully examined and considered in the context of the fracture location With compartment syndrome, the extremity may be pale and the muscular compartments may be swollen and feel hard and tense The pulses may be diminished or absent and the limb may have paralysis or muscle weakness Children may present with only a single sign or symptom of compartment syndrome Management Open wounds should be cleaned and a sterile dressing applied The fracture should be immobilized Prophylactic intravenous antibiotics should be administered, and tetanus prophylaxis should be given according to the standard guidelines Current antibiotic recommendations are for the administration of early, systemic, wide-spectrum antibiotic therapy directed at gram-positive and gram-negative organisms A commonly recommended regimen is for a firstgeneration cephalosporin (e.g., cefazolin) with the addition of an aminoglycoside (e.g., gentamicin) for larger open fractures (skin laceration >1 cm with significant soft tissue damage and gross contamination) As an alternative to aminoglycosides, a third-generation cephalosporin or other agent with activity against gram-negative bacteria may be selected For injuries at high risk for anaerobic infection (e.g., occurring on a farm), clinicians should add ampicillin or penicillin Urgent orthopedic consultation is necessary for surgical debridement, irrigation, and definitive care of the wound and fracture If there is suspicion for compartment syndrome, compartment pressures in the injured extremity should be obtained; however, this may be difficult in an awake young child, especially if less than years old Compartment pressures >30 mm Hg have been used to diagnose compartment syndrome Newer approaches suggest that compartment pressures should be interpreted in the context of systemic blood pressures Compartment pressures within 30 mm Hg of either the diastolic blood pressure or the mean arterial pressure are concerning for compartment syndrome Urgent orthopedic consultation is necessary if there is any concern for compartment syndrome, which may require treatment with fasciotomy Disposition All children with open fractures or with concern for/diagnosis of compartment syndrome should be admitted to the hospital for ongoing orthopedic care given the high risks for infection and neuromuscular injury MULTIPLE TRAUMA CLINICAL PEARLS AND PITFALLS