Updated: 8/4/2019

Open Fractures Management

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Evidence
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Cases
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Introduction
  • Overview
    • open fractures are a fracture with direct communication to the external environment
      • treatment requires immediate IV antibiotics and urgent irrigation and debridement
  • Epidemiology
    • incidence
      • 30.7 per 100,000 persons per year
    • demographics
      • average age is 45 years old
    • location
      • tibia and phalanx are most common
  • Pathophysiology
    • mechanism of injury
      • high-energy trauma
  • Associated conditions
    • often associated with additional injuries (30%)
    • compartment syndrome
      • the presence of an open wound does not preclude the occurrence of compartment syndrome in the injured limb
  • Prognosis
    • in the absence of life-threatening injuries, there is no clinical advantage to performing surgery within 6 hours of injury versus 6-24 hours
    • contamination with dirt and debris and devitalization of the soft tissues increase the risk of infection and other complications
Classification
  • Gustilo classification
  • Tscherne classification
Presentation
  • History
    • obtain information regarding mechanism, location, and timing of injury
  • Physical exam
    • assess soft-tissue damage
      • the size and nature of the external wound may not reflect the damage to the deeper structures
    • perform neurovascular exam
      • if concern for vascular insult, ankle brachial index (ABI) should be obtained
        • normal ratio is > 0.9
        • vascular surgery consult and angiogram is warranted if ABI < 0.9
    • consider saline load test or CT scan if concern for traumatic arthrotomy
      • some studies show CT scan more effective than saline load test
Imaging
  • Radiographs
    • indications
      • obtain radiographs including joint above and below fracture
Treatment
  • Nonoperative
    • emergent IV antibiotics, tetanus prophylaxis, and extremity stabilization and dressing
      • indications
        • initial treatment for all open fractures
          • a soft tissue wound in proximity to a fracture should be treated as an open fracture until proven otherwise
        • antibiotic type indicated by injury pattern and location (see technique below)
  • Operative
    • urgent I&D, temporary fracture stabilization, and soft tissue coverage
      • indications
        • consider I&D as soon as possible, may be beneficial within 6 hours in terms of decreasing infection risk
        • ideal time of soft tissue coverage controversial, but most centers perform within 5 days
    • definitive reconstruction and fracture fixation
      • indications
        • once soft tissue coverage is obtained and an adequate sterility is achieved
Technique
  • Antibiotics
    • timing
      • 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 for 24 hours after final closure if wound is not closed during initial surgical debridement (72 hours for type III wounds)
    • types
      • Gustilo type I and II
        • 1st generation cephalosporin 
        • clindamycin or vancomycin can also be used if allergies exist
      • Gustilo type III
        • 1st generation cephalosporin + aminoglycoside
      • farm injuries, heavy contamination, or possible bowel contamination
        • add high dose penicillin for anaerobic coverage (clostridium)  
      • special considerations
        • fresh water wounds
          • fluoroquinolones or 3rd or 4th generation cephalosporin
        • saltwater wounds
          • doxycycline + ceftazidime or a fluoroquinolone 
  • Tetanus prophylaxis
    • timing
      • initiate in emergency room or trauma bay
    • two forms of prophylaxis 
      • toxoid
        • 0.5 mL, regardless of age
      • immunoglobulin 
        • < 5 years old receive 75 U
        • 5-10 years old receive 125 U
        • >10 years old receive 250 U
      • 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
  • Extremity Stabilization & Dressing
    • stabilization
      • splint, brace, or traction for temporary stabilization
      • decreases pain, minimizes soft tissue trauma, and prevents disruption of clots
    •  dressing
      • remove gross debris from wound, do not remove any bone fragments
      • place sterile saline-soaked dressing on wound
      • little evidence to support aggressive irrigation or irrigation with antiseptic solution in the ED, as this can push debris further into wound
  • Urgent Irrigation & Debridement   
    • timing
      • data is conflicting but most centers performed irrigation within 6 hours
      • staged debridement and irrigation
        • perform every 24 to 48 hours as needed
    • technique
      • incision
        • expose fracture by recreating mechanism of injury, extend wound proximally and distally in line with extremity
      • irrigation
        • low-pressure bulb irrigation vs. high-pressure pulse lavage 
          • studies have shown that low pressure bulb irrigation is less expensive than high pressure pulse lavage and has no difference in infection rates
        • saline vs. saline with castile soap vs. antibiotic solution 
          • studies have shown that saline with castile soap had decreased primary wound healing problems when compared to antibiotic solutions
        • on average, 3L of saline are used for each successive Gustilo type
          • Type I: 3L
          • Type II: 6L
          • Type III: 9L
      • debridement
        • thorough debridement is critical to prevention of deep infection
        • bony fragments without soft tissue attachments should be removed
      • antibiotic beads
        • indications
          • can place antibiotic bead-pouch in open dirty wounds
          • beads made by mixing methylmethacrylate with heat-stable antibiotic powder 
  • Soft Tissue Coverage
    • timing
      • early soft tissue coverage or wound closure is ideal  
        • timing of flap coverage for open tibial fractures remains controversial, < 5 days is desired
        • increased risk of infection beyond 7 days
    • technique
      • can proceed with bone grafting after wound is clean and closed
      • negative-pressure wound therapy may be utilized during debridement until definitive coverage can be achieved (increased risk of infection if open >7 days)
  • Reconstruction for Bone Loss
    • technique
      • Masquelet technique 
      • distraction osteogenesis
      • vascularized bone flap/transfer
Complications
  • Infection
  • Neurovascular injury
  • Compartment syndrome
    • can still occur in the setting of open fractures
 

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Questions (18)
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(OBQ12.220) 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? Review Topic

QID: 4580
FIGURES:
1

Ciprofloxacin

1%

(67/5300)

2

Vancomycin

1%

(73/5300)

3

Penicillin

2%

(107/5300)

4

Gentamycin

3%

(142/5300)

5

Cefazolin

92%

(4875/5300)

ML 1

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PREFERRED RESPONSE 5
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(OBQ10.50) 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? Review Topic

QID: 3138
FIGURES:
1

Antibiotic solution applied by low pressure gravity flow device

5%

(149/2821)

2

Antibiotic solution applied by high pressure pulsatile flow device

2%

(60/2821)

3

Saline solution applied by low pressure gravity flow device

85%

(2406/2821)

4

Saline solution applied by high pressure pulsatile flow device

5%

(151/2821)

5

Antibiotic solution applied by high pressure pulsatile flow device followed by low pressure gravity flow device

2%

(44/2821)

ML 2

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PREFERRED RESPONSE 3
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(OBQ06.135) 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? Review Topic

QID: 321
1

No prophylaxis required

82%

(533/647)

2

Tetanus vaccine

5%

(35/647)

3

Tetanus immune globulin

9%

(58/647)

4

Tetanus vaccine and tetanus immune globulin

2%

(14/647)

5

Tetanus vaccine and tetanus immune globulin with a booster vaccine required 6 months from now

0%

(3/647)

ML 2

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PREFERRED RESPONSE 1
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