This document describes the case of a 59-year-old Thai man who presented to the emergency department with an open fracture of the big toe on his left foot. He reported being injured when a water tank fell on his foot 4 hours prior. On examination, he had a 0.5 x 7 cm laceration wound exposing the bone of his big toe with limited range of motion due to pain. He was diagnosed with an open Gustilo type 2 fracture of the proximal and distal phalanx of the left big toe. His treatment included wound debridement, antibiotics, dressing, and tetanus booster.

1. Extern conference
Ext. Suthidar
Khemkhaeng

2. Patient profile
• ผู้ป่ วยชายไทยคู่ อายุ 59 ปี
• ภูมิลาเนาอาเภอพิมาย จังหวัด
นครราชสีมา
• ปฎิเสธโรคประจาตัว

3. Chief complaint
• เจ็บเท้าซ้าย 4 ชั่วโมงก่อนมา รพ.

4. Present illness
• 4 ชั่วโมงก่อนมา รพ. ผู้ป่ วยถูก
โอ่งแตกล้มทับเท้าซ้าย หลังจาก
นั้นมีแผลเปิ ดที่เท้าซ้าย เจ็บเท้า
ซ้าย เดินลงน้าหนักไม่ได้ ไม่มีเท้า
ชา จึงมา รพ.

5. Primary survey
A : Can talk , not tender along c
spine
B : Spontaneous breathing ,
normal breath sound
C : BP 118/91 mmHg, PR 70 bpm
D : E4V5M6 , pupil 3 mm RTLBE
E : Laceration wound at Lt. foot

6. Secondary survey
A : no drug – food allergy
M : no current medication
P : no underlying disease
L : last meal 6 hr PTA
E : โอ่งแตกล้มทับเท้าซ้าย

7. Physical examination
• GA : An elderly Thai man , good
conscious
• Vital signs : T 37.1 c , RR 16 /min ,
BP 117/91 mmHg , PR 69 /min
• HEENT : Not pale , no jaundice
• Chest : equal lung expansion ,CCT
negative, equal breath sound
• CVS : Normal S1 S2 no murmur
• Abdomen & pelvis : no wound, not

8. • Neurologic : E3V4M6 , pupil 3 mm
RTLBE motor power grade V all
• Extremities :
–Laceration wound 0.5 x 7 cm
exposed to bone with at Left big
toe. Limit ROM of due to pain .
–Capillary refill < 2 sec ,
–intact pinprick sensation
–Laceration wound at Left foot 1 x 4
cm , no active bleeding, not

12. Investigation
Film Left foot AP ,

13. Diagnosis
• Open fracture proximal and
distal phalanx Left big toe
gutsilo 2

14. Treatment
• Supportive treatment
–Pain control
–TT booster
–Dressing wound
–Cefazolin iv
• Specific treatment
–Excisional debridement with

16. Open fracture

17. Definition
• An open fracture is defined as
one in which the fracture
fragments communicate with
the environment through a
break in the skin

18. Classification
• Gustilo and Anderson
classification Based on
1. Size of wound
2. Amount of soft tissue injury
3. Presence/absence of NV
injury
4. Degree of contamination

19. Classification - I
–Clean wound <1 cm in
diameter
–Simple Fx pattern with
minimal comminution
–Minimal soft tissue
injury

20. Classification - II
• Laceration >1
cm diameter
• Moderate soft
tissue damage
(no flaps,
degloving, or
contusion)
• Fx pattern may
be more
complex
• Moderate

21. Classification - III
–An open segmental Fx or a single
Fx with extensive soft-tissue
injury. Also included are injuries
older than 8 hours
•>10cm long
•Highly contaminated
•Usually comminuted
–IIIA, IIIB, IIIC
•Depends on soft tissue injury

22. Classification - IIIA
• Severe soft tissue
injury
• Adequate soft-
tissue coverage of
the Fx is likely
(despite high-
energy trauma or
extensive
laceration or skin
flaps)

23. Classification - IIIB
• Inadequate
soft-tissue
coverage with
periosteal
stripping
• Soft-tissue
reconstructive
surgery is
necessary

24. Classification - IIIC
• Associated vascular injury that
requires repair
• Reconstructive surgery for skin
coverage

26. Management
1. Resuscitation
2. Wound management
3. Antibiotics
4. Anti-tetanus
5. Stabilize fractures
6. Early wound coverage
7. Early turn to normal function

27. Wound management
• Debridement and irrigation thorough
debridement is critical to prevention of
deep infection
• Saline shown to be most effective
irrigating agent

28. Antibiotics
• Gustilo Type I and II :
–1st generation cephalosporin
–clindamycin or vancomycin can
also be used if allergies exist
• Gustilo Type III
–1st generation cephalosporin and
aminoglycoside
–Farm injuries or possible bowel

29. Complications
1.Wound infection
2.Osteomyelitis
3.Non-union
4.Tetanus infection
5.Neurovascular injury
6.Compartment syndrome