Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents following high-energy trauma to the right lower extremity. Examination reveals an open fracture of the right tibia with a wound measuring [X] cm. The wound exhibits adequate soft tissue coverage of the fracture site despite the extent of the injury, consistent with Gustilo-Anderson IIIA classification. Neurovascular status is intact distally.
Clinical Examination Findings
Right lower extremity: Open wound over the anterior tibia, [X] cm, with exposed bone visible. Significant surrounding soft tissue contusion and edema. Gustilo IIIA criteria met: adequate soft tissue coverage of the fracture site despite comminution. Distal pulses (DP/PT) are palpable and symmetric. Capillary refill < 2 seconds. Sensation intact to light touch in all dermatomes. No motor deficit noted in EHL/FHL.
Treatment Protocol
Immediate management: Irrigation and debridement (I&D) performed in the operating room. Fracture stabilized with [External Fixation/Intramedullary Nailing]. Prophylactic IV antibiotics (Cefazolin/Gentamicin) initiated. Tetanus prophylaxis updated. Wound dressed with sterile saline-soaked gauze. Limb elevated to reduce edema.