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Introduction
  • Open fracture definition
    • a fracture with direct communication to the external environment
Basic Principles of Open Fracture Management in the Emergency Room
  • Fracture management begins after initial trauma survey and resuscitation is complete
  • Antibiotics
    • initiate early IV antibiotics and update tetanus prophylaxis as indicated 
  • Control bleeding
    • direct pressure will control active bleeding
    • do not blindly clamp or place tourniquets on damaged extremities
  • Assessment
    • soft-tissue damage
    • neurovascular exam
  • Dressing
    • remove gross debris from wound 
    • place sterile saline-soaked dressing on the wound
  • Stabilize
    • splint fracture for temporary stabilization
      • decreases pain, further injury from bone ends, and disruption of clots
Basic Principles of Open Fracture Management in the Operating Room
  • Aggressive debridement and irrigation 
    • thorough debridement is critical to prevention of deep infection
    • low and high pressure lavage are equally effective in reducing bacterial counts 
    • saline shown to be most effective irrigating agent
      • on average, 3L of saline are used for each successive Gustilo type
        • Type I: 3L
        • Type II: 6L
        • Type III: 9L
    • bony fragments without soft tissue attachment can be removed
  • Fracture stabilization
    • can be with internal or external fixation, as indicated
  • Staged debridement and irrigation
    • perform every 24 to 48 hours as needed
  • Early soft tissue coverage or wound closure is ideal 
    • timing of flap coverage for open tibial fractures remains controversial
    • increased risk of infection beyond 7 days 
  • Can place antibiotic bead-pouch in open dirty wounds
    • beads made by mixing methylmethacrylate with heat-stable antibiotic powder 
Antibiotic Treatment
  • 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 contamination
    • add penicillin for anaerobic coverage (clostridium)  
  • Duration
    • initiate as soon as possible
      • studies show increased infection rate when antibiotics are delayed for more than 3 hours from time of injury
    • continue for 24 hours after initial injury if wound is able to be closed primarily
    • continue until 24 hours after final closure if wound is not closed during initial surgical debridement
Bone Gap Reconstruction
  • Reconstruction options
    • Masquelet technique 
    • distraction osteogenesis
    • vascularized bone flap
Tetanus Prophylaxis
  • Initiate in emergency room or trauma bay
  • Two forms of prophylaxis 
    • toxoid dose 0.5 mL, regardless of age
    • immune globulin dosing
      • <5-years-old receives 75U
      • 5-10-years-old receives 125U
      • >10-years-old receives 250U
    • toxoid and immunoglobulin should be given intramuscularly with two different syringes in two different locations
  • Guidelines for tetanus prophylaxis depend on 3 factors 
    • complete or incomplete vaccination history (3 doses)
    • date of most recent vaccination
    • severity of wound
 

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