Rosen & Barkin's 5-Minute Emergency Medicine Consult (261 page)

• Tetanus prophylaxis: TDap 0.5 mL IM (TD only if >65 yr
  
• Wounds >12 hr old, especially of hands and lower extremities, crush wounds with devitalized tissue, contaminated wounds
  

• Cefazolin: 1 g IV/IM (peds: 20–40 mg/kg IV/IM single dose in ED)
  
• Cephalexin: 500 mg PO (peds: 25–50 mg/kg/d) QID for 7 days
  or
  
  • Amoxicillin/clavulanate: 875/125 mg PO (peds: 25 mg/kg/d) BID for 7 days
    
• Erythromycin: 333 mg PO TID (peds: 40 mg/kg/d q6h for 7 days)
  
• Contaminated wounds in patients with pre-existing valvular heart disease:
  
  • Cefazolin: 1 g IV/IM, then cephalexin 500 mg PO QID for 7 days
    
• Plantar through shoe at risk for Pseudomonas:
  
  • Ciprofloxacin 500 mg BID for 7–10 days or
    
  • Levofloxacin 500 mg QD for 7–10 days
    

If penicillin allergic:

• EES: 800 mg PO, then 400 mg PO q6h for 7 days
  or
  
• Clindamycin: 300 mg PO q6–8h for 7 days
  

FOLLOW-UP

• Emergent surgical consultation and admission are required for any penetrating wounds with potential for vascular compromise, associated compartment syndrome, and joint penetration.
  
• High-muzzle–velocity penetrating gunshot wounds
  
• Diabetic or immunocompromised patients with contaminated wounds
  

Penetrating extremity injuries not requiring surgical intervention may be discharged after appropriate wound care with instructions to elevate extremity, keep wound clean, and to return for recheck in 24–48 hr or for any signs of infection.

• Plantar puncture wounds: Close follow-up is necessary to assess for infection from unseen FB.
  
• Delayed primary closure is alternative for older or contaminated wounds.
  
• Wounds at high risk for infection should have close 1–2 day follow-up.
  

Return to the ED for increasing pain, numbness, tingling, redness, swelling drainage, fevers or other changes in clinical presentation.

• Presence of distal pulse does not exclude proximal vascular injury.
  
• High-pressure injuries of hand may have wounds that appear trivial on surface but track up tendon sheaths into more proximal aspects of hand.
  
• Plantar surface puncture wounds through shoes or socks have relatively high risk of retained foreign material – patients should be told of this possibility.
  
• Post-puncture wound infections failing to respond to antibiotics should be suspected of having retained FB.
  

• Bekler H, Gokce A, Beyzadeoglu T, et al. The surgical treatment and outcomes of high-pressure injection injuries of the hand.
  J Hand Surg Eur Vol
  . 2007;32(4):394–399.
  
• Belin R, Carrington S. Management of pedal puncture wounds.
  Clin Podiatr Med Surg.
  2012;29(3):451–458.
  
• Gonzalez RP, Scott W, Wright A, et al. Anatomic location of penetrating lower-extremity trauma predicts compartment syndrome development.
  Am J Surg.
  2009;197(3):371–375.
  
• Hogan CJ, Ruland RT. High-pressure injection injuries to the upper extremity: A review of the literature.
  J Orthop Trauma.
  2006;20(7):503–511.
  
• Manthey DE, Nicks BA. Penetrating trauma to the extremity.
  J Emerg Med
  . 2008;34(2):187–193.
  
• Newton EJ, Love J. Acute complications of extremity trauma.
  Emerg Med Clin North Am
  . 2007;25(3):751–761.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Bite, Animal
  
• Compartment Syndrome
  
• Ring/Constricting Band Removal
  

CODES

• 884.0 Multiple and unspecified open wound of upper limb, without mention of complication
  
• 894.0 Multiple and unspecified open wound of lower limb, without mention of complication
  
• 928.9 Crushing injury of unspecified site of lower limb
  

BASICS

• Typically blunt trauma from motor vehicle accidents, direct blows including assaults, or falls.
  
• Consider physical assault and domestic violence, especially in women and children.
  
• Open fractures common.
  
• Many facial fractures are complex and are not easily classified.
  

• Le Fort fractures involve the maxilla and are classified as:
  
  • Le Fort I: Transverse fracture of maxilla below nose but above teeth through lateral wall of maxillary sinus to lateral pterygoid plate.
    
  • Le Fort II: Pyramidal fracture from nasal and ethmoid bones through zygomaticomaxillary suture and maxilla, often involving maxillary sinuses and infraorbital rims.
    
  • Le Fort III: Craniofacial disjunction with elongated, flattened face owing to fractures through frontozygomatic suture, orbit, base of nose, and ethmoid bone.
    
  • Le Fort IV: Includes frontal bone in addition to Le Fort III.
    
  • A patient may have different level Le Fort fractures on each side of the face.
    
• Zygomatic arch fractures often occur in 2 or 3 places and can involve the orbit and maxilla (tripod fracture).
  
• Inner plate frontal sinus fractures are associated with CSF leaks and ocular injuries.
  
• Orbital fractures most commonly involve the orbital floor (blow-out fracture), and are commonly associated with ocular injuries but can involve the medial and lateral orbital walls.
  

• Falls most common cause.
  
• Zygoma most common bone fractured.
  
• Beware of associated cervical and intracranial injuries.
  

• Maxillofacial fractures rarely seen in children younger than 6 yr; suspect nonaccidental trauma.
  
• Falls and motor vehicle accidents account for most cases.
  
• Over 50% have severe associated injuries, high incidence of associated head injury.
  
• Fractures of the orbit are the most common facial fracture in children (excluding nose)
  

DIAGNOSIS

• Most post-traumatic deformities of the face represent underlying fractures.
  
• Pain, swelling, ecchymosis, and deformity.
  
• CSF rhinorrhea, facial hemorrhage, epistaxis, raccoon eyes.
  
• Facial anesthesia with nerve entrapment or injury.
  
• Associated injuries; tooth, mandible, eye, tear duct, skull, and neck.
  
• Bluish fluid-filled sac overlying nasal septum is a septal hematoma and is critical to detect.
  

• Mechanism of injury.
  
• Associated injuries.
  

• Immediately assess airway.
  
• Most important:
  
  • Palpate entire face for tenderness, step-offs, depressions, and crepitus.
    
  • Check for mandibular injuries or malocclusion.
    
  • Nasal speculum exam for septal hematoma or CSF leak.
    
  • Assess for areas of facial anesthesia.
    
  • Careful eye exam including funduscopic exam; obtain a visual acuity; assess for telecanthus (intercanthal width >30–35 mm), upward dysconjugate gaze (indicative of ocular muscle entrapment in an orbital floor blow-out fracture).
    
• Le Fort fractures are assessed by placing thumb and index finger of 1 hand on the bridge of the nose and pulling upper teeth with other hand:
  
  • Le Fort I: Movement of hard palate and maxillary dentition only (your hand on the nose will not feel movement).
    
  • Le Fort II: Movement of hard palate, maxillary dentition, and nose (your hand on the nose will feel movement).
    
  • Le Fort III: Movement of entire midface.
    

• Sedation may be needed to perform an adequate exam.
  

• After airway is secured, other injuries take precedence.
  
• Radiologic studies in all cases of suspected facial fractures.