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Average 4.3 of 71 Ratings
A 43-year-old male sustains the injury shown in Figure A. He has an overlying 3 centimeter wound with exposed bone. Which of the following antibiotics is indicated for initial prophylaxis?
Select Answer to see Preferred Response
The scenario described above is of a type II open fracture, and current initial recommendations for these injuries include tetanus prophylaxis/update and a first generation cephalosporin (if no allergies).
Hauser et al review the literature on antibiotics and open fractures. They note that use of first-generation cephalosporins, along with appropriate fracture care, minimize risk of infection. They also state that current treatment is often rooted in old (>30 years) low-level data.
Saveli et al report that although methicillin-resistant Staphylococcus aureus (MRSA) is increasingly common, no evidence exists to recommend for use of MRSA prophylaxis. They recommend selecting antibiotics against MRSA for these open fractures only if significant prevalence of MRSA carriers is seen or other risk factors are present.
Zalavras et al review open fracture treatment protocols and state that although controversy exists regarding optimal treatment of open fractures, immediate intravenous antibiotic administration should be done in order to minimize infection. They also report that the goals of treatment of these injuries are the prevention of infection, union of the fracture, and restoration of function.
Figure A shows an short oblique tibial shaft fracture with evidence of subcutaneous air.
Answer 1: Fluoroquinolones can be used in these injuries as second-line agents if allergies are present.
Answer 2: Vancomycin is not currently recommended as a first-line agent for prophylaxis.
Answer 3: Penicillin can be added in contaminated type III injuries.
Answer 4: Gentamycin can be added in type III injuries.
Hauser CJ, Adams CA Jr, Eachempati SR.
Surg Infect (Larchmt). 2006 Aug;7(4):379-405. PMID: 16978082 (Link to Abstract)
Saveli CC, Belknap RW, Morgan SJ, Price CS.
Orthopedics. 2011 Aug;34(8):611-6; quiz 617. PMID: 21800816 (Link to Abstract)
Saveli, ORTHO 2011
Zalavras CG, Patzakis MJ.
J Am Acad Orthop Surg. 2003 May-Jun;11(3):212-9. PMID: 12828451 (Link to Abstract)
Zalavras, JAAOS 2003
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Average 3.0 of 13 Ratings
A 25-year-old male involved in a motorcyle accident sustains the injury seen in Figures A and B. After initial adequate debridement of nonviable tissue, which of the following irrigation methods and devices should be used?
Antibiotic solution applied by low pressure gravity flow device
Antibiotic solution applied by high pressure pulsatile flow device
Saline solution applied by low pressure gravity flow device
Saline solution applied by high pressure pulsatile flow device
Antibiotic solution applied by high pressure pulsatile flow device followed by low pressure gravity flow device
Initial wound treatment is critical in the treatment of open fractures and contaminated wounds. Figures A and B reveal a Type IIIB open tibia fracture with obvious gross contamination and devitalized tissue. Systemic antibiotics and tetanus prophylaxis should be administered immediately upon arrival, and the lower extremity should be splinted while the remaining trauma workup takes place. Once cleared, this injury should be adequately debrided of all devitalized tissue and subsequently irrigated with a saline solution to reduce the bacterial count. Some evidence suggests that high-pressure pulsatile lavage damages bone structure and disrupts soft tissue.
In an animal model, Hassinger et al showed that high-pressure pulsatile lavage caused deeper penetration of bacteria and results in greater bacterial retention in soft tissue when compared with low-pressure lavage.
Owens et al, in a sheep model of contaminated soft tissue, compared low and high pressure lavage with normal saline solution, bacitracin solution, castile soap, and benzalkonium chloride. At 48 hours the group treated by low pressure lavage and saline showed the lowest rebound in bacterial counts.
Hassinger SM, Harding G, Wongworawat MD
Clin. Orthop. Relat. Res.. 2005 Oct;439:27-31. PMID: 16205133 (Link to Abstract)
Hassinger, CORR 2005
Owens BD, White DW, Wenke JC
J Bone Joint Surg Am. 2009 Jan;91(1):92-8. PMID: 19122083 (Link to Abstract)
Owens, JBJS 2009
Average 3.0 of 43 Ratings
A 27-year-old man sustains a Gustilo and Anderson type II open tibia fracture during a motorcycle accident. He had his full 3 doses of tetanus vaccination as an infant. He also had a tetanus booster vaccination 18 months ago when he began a new job. In addition to intravenous antibiotics, what tetanus prophylaxis should be administered?
No prophylaxis required
Tetanus immune globulin
Tetanus vaccine and tetanus immune globulin
Tetanus vaccine and tetanus immune globulin with a booster vaccine required 6 months from now
Any time an open wound is encountered, the tetanus prophylaxis protocol should be initiated in the emergency room. The correct treatment depends upon the severity of the wound and the patient's tetanus vaccine status. Treatment may entail no further action, vaccination, or vaccination and administration of the tetanus immune globulin. The tetanus vaccine, booster, and immune globulin are used to enhance the immune response to clostridium tetani, a gram positive bacillus found in soil. In this case, the patient's tetanus had been updated within the past 5 years so he does not need an update of the vaccination or immune globulin. Illustration A is a concise table that can be used as an algorithm to provide appropriate tetanus prophylaxis.
Average 3.0 of 34 Ratings
HPI - Injury occurred two day ago - crush injury to the big toe.
What is your treatment plan for this patient?
HPI - Proximal tibia metaphyseal-diaphyseal junction open fx due to farm accident
What is the Gustillo classification of this injury?
HPI - 35 year-old-male referred from outside hospital following road traffic accident. Large open wound of the plantar foot that was primarily closed. Failed trial of closed reduction at outside institution
What is the best management of this injury?
HPI - Blast injury to both legs of 3 month duration treated initially with
Ex-fix, transfered to our hospital one week after her injury in which there was an ongoing infection.
radical attack on infection established, weeks after the infection subsided plastic was consulted for soft tissue coverage
What is the best choice of fixation to use right now?
HPI - fall in the bathroom injury to the right elbow.sustained open fracture proximal ulna
How will you initially treat this injury?
HPI - RTA. Patient was a pedestrian, when she was hit by a car. Her main injury was an open injury to her left tibia. ATLS protocols were followed.
What are the options for treating this fracture definitively?
HPI - A 60 year old man with open tibial fx treated with Ex fix 9 months ago.Ex fix was removed after 9 mo.(The patient not reffered to clinic for follow up ). What is the next step in your opinion?ORIF with BG,Illizarov with BG ,..............?
Esr =14 CRP=neg
what is the next step?