1. Emergency Room Notes
Stuff to keep in mind
The next time you see a lower
extremity injury

2. 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.

3. 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

4. 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

5. Fracture Management
Stage it, treat it and refer it

6. 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.

7. 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

8. 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)

9. 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.

10. 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