Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with an open fracture of the left distal radius following [mechanism of injury]. Patient reports severe pain, deformity, and functional impairment of the left wrist. Open wound noted at [location/aspect] with visible [bone/soft tissue involvement]. Neurovascular status distal to the injury is [intact/compromised].
Clinical Examination Findings
Left wrist examination reveals an open wound measuring [size] cm with [active/controlled] bleeding. Significant tenderness, crepitus, and gross deformity noted at the distal radius. Distal neurovascular exam: Radial pulse [present/absent], capillary refill [normal/delayed], sensation intact in median/ulnar/radial nerve distributions.
Treatment Protocol
Immediate management included irrigation and debridement of the open wound, administration of prophylactic antibiotics, and tetanus prophylaxis. The left wrist was immobilized in a [splint/external fixator]. Patient scheduled for urgent surgical intervention for open reduction and internal fixation (ORIF).