The management of long bone open extremity fractures has included initial wound cultures, antibiotics, operative debridement, and fracture repair, if indicated. The value of initial wound cultures is unclear. We examined whether primary wound cultures predict which wounds will become infected, and whether bacterial growth on primary wound cultures correlates with bacteria cultured from infected wounds. This prospective study involved patients presenting to a regional trauma center. Before any interventions were performed, initial aerobic and anaerobic cultures of the wounds of 117 consecutive open extremity fractures grades I-III were obtained. The results of these cultures were correlated with the development of a wound infection, and if an infection occurred, the organism grown from the infected wound was compared with any organism grown from the primary wound cultures. Of the initial cultures, 76% (89/117) did not demonstrate any growth, while the other 24% (28/117) only grew skin flora. There were only 7 (6%) wound infections, and 71% (5/7) initially did not grow any organisms. Of the isolates that grew from the initial cultures, none were the organisms that eventually led to wound infections. The use of primary wound cultures in open extremity injuries has no value in the management of patients suffering long bone open extremity fractures.

Soft tissue defects of the foot and ankle region are difficult to treat, given the lack of local flaps. Some methods available are unreliable, multistaged, have significant donor-site morbidity, or are technically complex, requiring significant training and postoperative equipment or monitoring not available at all institutions. We report the largest experience using the extensor digitorum brevis muscle flap for foot and ankle reconstruction. The charts of 20 patients were retrospectively reviewed. Eighty-five percent of the wounds were successfully treated with this flap, with minimal donor-site morbidity. The extensor digitorum brevis muscle flap has minimal morbidity, is easy to elevate, does not require microsurgical skills, and can be performed at most institutions. The extensor digitorum brevis muscle flap is a practical option for wounds located at the foot and ankle region and should be considered in patients potentially requiring a free flap.

Victims of train-related injuries were predominantly young and male. Many patients required an amputation. Multistaged and complex reconstructive procedures may not be realistic in a group of patients in whom follow-up is poor.

Necrotizing fasciitis is a disfiguring condition that can be fatal if not diagnosed in a timely fashion. Diagnosis and treatment require a high index of suspicion, immediate operative intervention, broad-spectrum antibiotics, and appropriate supportive care.

Traumatic atlanto-occipital dislocation is usually instantaneously fatal when it occurs. Survival is possible with minimal remaining neurologic deficits if diagnosed quickly and treated appropriately. The authors present three reports of patients who survived the incident, and they review the anatomy of the atlanto-occipital joint, clinical presentation, diagnosis, and treatment of this traumatic injury.