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Urgent open reduction internal fixation and fibular osteoseptocutaneous flap
1%
31/2902
Irrigation and debridement and external fixation
82%
2393/2902
Irrigation and debridement, repair of the radial nerve and retrograde intramedullary nail
6%
165/2902
CT scan, urgent open reduction internal fixation and IV antibiotics for 6 weeks
39/2902
Closed reduction, CT scan, immobilization in a coaptation splint
9%
250/2902
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This patient has sustained a shotgun blast to the midshaft humerus. The next best step would be irrigation and debridement, and external fixation of the fracture. Shotgun injuries are typically treated as open fractures, whereas low-energy gunshot wounds are treated as closed fractures. The initial operative treatment of shotgun wounds should include irrigation and debridement and stabilization with external fixation. The goal of treatment is to stabilize the severe soft-tissue injury and bone loss, as well as to aggressively debride devitalized tissue and gross contamination. Dougherty et al. reviewed gunshot fractures to the humerus. They report that peripheral nerve injuries are relatively common with these injuries, with a more common incidence in distal injuries than proximal. Joshi et al. looked at low velocity gunshot fractures to the humerus. They found that these injuries can be safely treated as closed fractures with local wound care, fracture brace and oral antibiotics. The time to union was similar in the non-operative and open treatment group. Berick et al. examined the indications for nerve exploration with humerus gunshot fractures. They recommend continued observation of isolated nerve palsies associated with gunshot fractures of the humerus. However, consider early nerve exploration of palsies when associated with a concomitant vascular injury. Figure A shows a high velocity shotgun fracture to the left humerus with retained buck fragments. Illustration A shows a similar injury stabilized with external fixation. Incorrect Answers: Answer 1: Due to the severity of soft tissue injury, external fixation should be considered for initial stabilization. Vascularized fibular grafts has been expanded to an osteoseptocutaneous flap by including a cutaneous flap on the lateral aspect of the lower leg. These are not typically used in the acute setting. Answer 3: Retrograde intramedullary nail would not be the ideal implant for this injury, acutely. Answer 4 and 5: There is no indication for a CT scan or prolonged antibiotics. The fracture and soft-tissue injury should be initially stabilized with external fixation. Coaptation splinting will interfere with soft tissue care.
3.0
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