(1) What are your treatment options? Which one do you choose?

The open fracture should be taken to the OR and have an I&D.

Although it is not yet a standard protocol, in some cases with stable fracture and a clean 1-2 mm open wound, I have treated the patient with a single dose of IV antibiotics and a cast. That would not be appropriate for this case, due to the level of instability as well as the size of the wound.

Therefore, an I&D is a foregone conclusion. I might choose to do an internal fixation, despite the Grade I open status, in a simpler fracture and a stable patient. However, external fixation in this trauma patient would be a much shorter and simpler procedure. The definitive treatment should be deferred for a few days.

(2) The trauma surgeon obtains a CT of the pelvis, diagnoses an open book fracture, and plans to go to the OR to plate the symphysis pubis as soon as the head CT is completed and the head cleared. When do you want to go to the OR?

At the same time as the pelvic fixation, as the hand can be put on a hand table and both teams can work at the same time.

(3) Besides treating the open wound and the radius & the ulna, is there any additional procedure you would perform?

Given the high energy nature of his injury and the volar spike of bone, I would recommend a close documentation of the median nerve function and a median nerve release (this procedure is the same as a "carpal tunnel release" but should not be called that as it is for a different reason).

(4) What about this fracture configuration is going to be a challenge?

The discussion of the particular challenges of this fracture will be deferred to a later point in this presentation.

The post-reduction films are on the next page.

The case continues on the next page >>>