What is the initial assessment and management of a patient with musculoskeletal trauma, including ABCs, analgesia, tetanus prophylaxis, immobilization, imaging, antibiotic coverage for open fractures, and definitive orthopedic care?

Initial Assessment and Management of Musculoskeletal Trauma

Immediate Life-Threatening Hemorrhage Control

Apply a tourniquet immediately for life-threatening bleeding from open extremity injuries that cannot be controlled with direct pressure. 1

• Minimize time between injury and definitive treatment, as delays directly increase mortality. 1
• For extremity wounds with active hemorrhage, apply direct manual compression with a pressure dressing first; escalate to tourniquet only if bleeding remains uncontrolled. 2
• Document tourniquet application time and reassess circulation distal to the injury. 1

Primary Survey (ABCs)

Proceed with standard trauma primary survey: airway with cervical spine protection, breathing assessment, and circulatory status evaluation. 3

• Maintain normoventilation unless signs of imminent cerebral herniation are present. 1
• Assess hemodynamic stability using patient physiology, anatomical injury pattern, mechanism of injury, and response to initial resuscitation. 1
• Use serum lactate or base deficit (not isolated hematocrit) to estimate and monitor the extent of bleeding and shock. 1

Immediate Analgesia

Administer intravenous morphine titration as the first-line analgesic for acute trauma pain, using a protocolized approach. 1

• For elderly patients specifically, initiate intravenous acetaminophen 1g every 6 hours as first-line in a multimodal approach. 1
• Consider femoral nerve block or fascia iliaca block for lower extremity fractures, which can be administered by trained emergency department staff. 1
• Avoid NSAIDs in patients with renal dysfunction (GFR <60 mL/min/1.73m²), which affects approximately 40% of hip fracture patients. 1
• For elderly patients with severe pain, add NSAIDs cautiously after assessing renal function and bleeding risk. 1

Tetanus Prophylaxis

Administer tetanus prophylaxis based on wound type and immunization history according to the following algorithm: 4, 5

• Clean, minor wounds: Give tetanus toxoid (Td) only if >10 years since last dose; no tetanus immune globulin (TIG) needed. 5
• All other wounds (contaminated, puncture, traumatic): Give Td if >5 years since last dose PLUS TIG 250 units IM if <3 doses or unknown immunization history. 4, 5
• Administer TIG and Td in different extremities using separate syringes. 4
• For children <7 years, calculate TIG dose at 4.0 units/kg, though administering the full 250-unit vial is advisable regardless of size. 4

Antibiotic Prophylaxis for Open Fractures

Administer systemic antibiotics within the first hour of presentation for all open fractures and continue for maximum 48-72 hours unless proven infection develops. 6, 1

Antibiotic Selection Algorithm:

• All open fractures (Gustilo-Anderson Type I-III): Cefazolin 2g IV, or clindamycin 900mg IV if beta-lactam allergy. 6, 2, 7
• Type II and all Type III open fractures: Add gram-negative coverage with piperacillin-tazobactam 3.375g IV (preferred over aminoglycosides). 6, 2
• Grossly contaminated wounds or farm injuries: Consider adding penicillin for clostridial coverage. 8
• Continue antibiotics for 48-72 hours maximum; prolonged prophylaxis beyond 72 hours provides no additional benefit and increases resistance. 6, 9

Wound Management and Immobilization

Photograph the wound, then cover with sterile saline-moistened dressing and immobilize the extremity before any manipulation. 2, 9

• Remove gross contamination with gentle irrigation using normal saline only—avoid antiseptics, soap, or additives as they provide no benefit and may cause tissue harm. 2
• Realign grossly displaced fractures to restore length and reduce soft tissue tension, then re-cover and splint. 9
• Apply splints to immobilize joints above and below the fracture site to prevent further neurovascular injury. 2, 3

Imaging

Obtain plain radiographs (AP and lateral views) of the injured extremity including joints above and below the fracture. 9

• For hemodynamically stable patients with torso trauma, proceed to CT imaging to detect free fluid and assess for additional injuries. 1
• Obtain CT angiography if vascular injury is suspected based on absent pulses, expanding hematoma, or penetrating injury near major vessels. 9
• For hemodynamically unstable patients, use bedside ultrasound (FAST) to detect free fluid before proceeding to intervention. 1

Surgical Timing Decision Algorithm

The decision for immediate versus delayed surgery depends on hemodynamic stability and fracture location:

Hemodynamically Stable Patients:

• Proceed to definitive surgical management within 24 hours for débridement, irrigation, fracture stabilization, and wound coverage. 6, 2
• Early surgery (within 24 hours) provides the most effective analgesia and reduces infection risk. 1, 6
• Achieve wound coverage within 7 days from injury to reduce infection risk and improve outcomes. 6

Hemodynamically Unstable Patients or Hemorrhagic Shock:

• Apply damage control strategy with temporary external fixation for initial stabilization. 6, 2
• Delay definitive internal fixation until hemodynamic stability is achieved and resuscitation is complete. 6
• External fixation is particularly important for grossly contaminated fractures requiring serial débridements. 6

Thromboprophylaxis

Initiate low molecular weight heparin (LMWH) or unfractionated heparin within 36 hours of injury once hemorrhage is controlled, adjusted for renal function and bleeding risk. 1, 2

• For elderly patients, dose LMWH according to weight and creatinine clearance. 1
• Mechanical prophylaxis (sequential compression devices) should begin immediately if pharmacologic prophylaxis is contraindicated. 1

Critical Pitfalls to Avoid

• Never delay antibiotic administration beyond 1 hour—infection rates increase significantly with each hour of delay. 6, 8
• Never use wound additives (antiseptics, hydrogen peroxide, soap) during irrigation—saline alone is superior and additives cause tissue damage. 2
• Never dismiss escalating pain as "normal"—it may indicate evolving compartment syndrome requiring immediate fasciotomy. 6
• Never delay surgical débridement beyond 24 hours when feasible—this increases infection and complication rates. 6, 9
• Never rely solely on single hematocrit measurements to assess bleeding—use serial lactate or base deficit instead. 1

Definitive Orthopedic Care Coordination

Activate the trauma team and orthopedic surgery immediately upon identifying significant musculoskeletal trauma. 1

• Implement an institutional evidence-based treatment algorithm with checklists to guide clinical management and ensure protocol adherence. 1
• For open fractures, coordinate operating room availability for débridement within 24 hours. 6
• Arrange plastic surgery consultation early if soft tissue defects will require flap coverage. 6
• For elderly patients, involve orthogeriatric or geriatric medicine teams early to optimize medical comorbidities and plan rehabilitation. 1