Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents following high-energy trauma to the left lower extremity. Physical examination reveals a visible bone fragment protruding through a [size] cm laceration on the [anterior/medial] aspect of the left tibia. Patient reports severe pain, inability to bear weight, and localized deformity. No neurovascular deficits noted distally.
Clinical Examination Findings
Left lower extremity examination: Obvious deformity of the tibial shaft with an open wound measuring [size] cm. Wound is [clean/contaminated] with [active/no] bleeding. Distal pulses (DP/PT) are [palpable/absent]. Capillary refill is <2 seconds. Sensation intact to light touch in all dermatomes. Motor function: [intact/impaired] in extensor hallucis longus and gastrocnemius.
Treatment Protocol
Immediate management: Irrigation and debridement of the open fracture, administration of intravenous antibiotics (Cefazolin/Gentamicin), and tetanus prophylaxis. Immobilization via [splint/external fixator]. Orthopedic surgery consultation for definitive fixation (IM nail vs. ORIF).