A 35-year-old motorcyclist was involved in an accident and had an open fracture of the right leg. He was given initial treatment including antibiotics, wound irrigation, and fracture stabilization with an external fixator. After 3 weeks of immobilization, he was discharged but later returned with a diagnosis of non-union fracture, which was treated with internal fixation and bone grafting.

2. Triage the patient

3. Red-severe,chest pain

4. Yellow-

5. Green moderate,MVA,urti,stable vital sign

6. Assess the ABC

7. Airway-check for any airway obstruction (assess by talking to the patient,airway intact)

8. Stabilize the neck

9. Remove any foreign body/vomitus by using finger or suction

10. If there is still no clear airway,orotracheal tube can be inserted.

11. Breathing –inspect chest movement,SPO2 monitoring,breath sound,chest compression-tenderness positive,unconscious-immobility of the rib

12. despite clear airway,the ventilation is inadequate.

13. check for atelactasis,pneumothorax or a flail segment.

14. Pneumothoraz managed by chest decompression

15. Closed sucking chest wound

16. Chest tube insertion

17. Flail chest-endotracheal intubation and positive pressure airway

18. Circulation-check the pulse and BP,signs of shock,CRT,extremities

19. External haemorrhage by compression

20. Send FBC,BUSE and cross matching

21. Deformity-bruises,bleeding,

22. Presence of fracture over the right leg-immoblize

23. Bleeding stop by direct pressure

24. Level of consciousness

25. Secondary survey-head to toes examination

27. Gustillo Anderson classification

28. Grade Criteria 1Open fracture with wound less than 1 cm,clean wound,minimal soft tissue injury,clean wound2Open fracture with clean wound size about 1-10 cm, moderate comminution soft tissue injury3Wound more than 10 cm,crush tissue injuryA-adequate soft tissue coveringB-inadequate soft tissue covering,need flapC-with vascular injury

29. What is your management for the open fracture?

30. Assess the ABC

31. Rule out any life threatening injury

32. Head,neck,chest and pelvic injury

33. Tetanus and antibiotic prophylaxis

34. Administer tetanus immune globulin and anti tetanus toxoid to prevent tetanus

35. (if patient had given toxoid in 3 or more doses within the last 10 years, then the globulin is not required)

36. For Grade 1 and 2, 1st (eg. Cefazolin) or 2nd ( eg. Cefuroxime) generation of cephalosporin is required.

37. For Grade 3, an aminoglycoside (eg, gentamicin or tobramycin) and metronidazole are added to complement treatment. These antibiotics will cover the gram negative bacteria and anaerobes.

38. If the injury is a “farmyard injury" or water-type injury, penicillin should also be added to provide prophylaxis against Clostridium perfringens. (4 to 5 million units for every 6 hours)

39. Wound irrigation

40. Wound irrigation:

41. to dilute the contaminants and therefore reduce the bacteria load

42. The wound is diluted with copious amount of normal saline (sterile)

43. Basic rule:

44. - Grade I : 3L

45. - Grade II : 6L

46. - Grade III : 9L

47. Wound debridement

48. Surgical debridement is the process where the devitalized or dead tissues are removed from a wound bed.

49. Devitalized tissues (esp. the dead muscle) produces denatured protein which is a good nutrition for the bacteria

50. 4 C’ for muscle debridement:

51. - colour: red vs pale

52. - consistency: firm + elastic vs fragile + easily torn

53. - contractility: contract vs not contract

54. - capacity to bleed: bleeding easily vs no bleeding

55. Fracture stabilization

56. By using external fixator

57. Reduced risk of infection,

58. Maximum to 6 weeks only

59. More than than high risk of infection,pin tract loosening

60. Other indication for external fixator

61. Open fracture

62. Infected fracture

63. Bone lengthening

64. Open book pelvic facture

65. Neurovascular injury

66. Complication of external fixator

67. Pin tract infection

68. Pin tract loosening

69. Joint stiffness

70. Neurovascular injury

72. Deep vein thrombosis

73. Pressure sore

74. How would you prevent the complications?

75. Deep vein thrombosisPressure soreStocking net compressionElevation of lower limb+/- subcutaneous heparinRipple bedFrequent changing position every two hours

76. If there is pressure sores, how you managed it?

77. Local

78. Regular wound dressing

79. Remove the necrotic tissue,the pus and the slough,clean it with the povidone,chlorohexidine or normal saline,depeneds on the condition of the wound

80. Closed it with gauze etc

81. Systemic

82. Check the albumin level,the electrolyte and the blood supply to the affecting area.

83. Correct the abnormality

84. Supplement-multivatamin

86. Non union fracture

88. Infection

89. Inadequate blood supply

90. Interposition of soft tissues between the fragment

91. Inadequate immobilization

92. Interconnected two bones

93. What is your management for non union fracture?

94. Internal fixator and bone graft