Updated: 11/6/2021

Open Fractures Management

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  • Summary
    • Open fractures are fractures with direct communication to the external environment.
    • Diagnosis is made clinically by assessing the size and nature of the external wound as well as obtaining radiographs of the bone at the location of the soft tissue injury. 
    • Treatment depends on location of fracture but generally requires immediate IV antibiotics and urgent irrigation and debridement followed by surgical fixation as needed.
  • Epidemiology
    • Incidence
      • common
        • 30.7 per 100,000 persons per year
    • Demographics
      • average age is 45 years old
    • Anatomic location
      • tibia and finger phalanx are most common
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • high-energy trauma
        • "inside-out" open fractures
    • 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
  • Classification
    • Gustilo classification
    • Tscherne classification
  • Presentation
    • History
      • obtain information regarding mechanism, location, and timing of injury
    • Physical exam
      • inspection
        • assess soft-tissue damage
          • the size and nature of the external wound may not reflect the damage to the deeper structures
      • neurovascular
        • 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
      • provocative tests
        • consider saline load test or CT scan if concern for traumatic arthrotomy
          • some studies now show CT scan more sensitive than saline load test for the knee
  • Imaging
    • Radiographs
      • indications
        • obtain radiographs including joint above and below fracture
    • CT
      • indications
        • peri-articular injuries
        • evaluation for traumatic arthrotomy of the knee
  • Treatment
    • Nonoperative
      • urgent 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
            • mutlidisciplinary training of open fracture management has been associated with decreased timing to antibiotic administration
          • antibiotic type indicated by injury pattern and location
    • Operative
      • I&D, temporary fracture stabilization, local antibiotic administration and soft tissue coverage
        • indications
          • consider I&D as soon as possible
          • ideal time of soft tissue coverage controversial, but most centers perform within 5-7 days
        • outcomes
          • infection rates of open fracture depend on zone of injury, periosteal stripping and delay in treatment
          • incidence of fracture-related infection range from <1% in type I open fractures to 30% in type III fractures
      • definitive reconstruction and fracture fixation
        • indications
          • once soft tissue coverage is obtained and an adequate sterility is achieved
        • outcomes
          • definitive treatment with internal fixation leads to significantly decreased time to union, improved functional outcomes, and decreased time in the hospital compared to those definitively fixed with external fixation
  • Technique
    • Urgent IV antibiotics, tetanus prophylaxis, extremity stabilization and dressings
      • 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 (48 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
            • some institutions use vancomycin + cefepime
          • 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
    • I&D, temporary fracture stabilization, local antibiotic administration and soft tissue coverage
      • Irrigation and debridement
        • timing
          • recent meta-analysis (GOLIATH study) have recommended debridement within 24 hours to minimize risk of infection for type III fractures
            • within 12 hours for type IIIB open tibia fractures
          • staged debridement and irrigation
            • perform every 24 to 48 hours as needed
        • technique
          • incision
            • extend wound proximally and distally in line with extremity to adequate expose open fracture
          • 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 or union 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 (i.e 9L for type III)
          • debridement
            • thorough debridement of devitalized tissue is critical to prevent deep infection
            • bony fragments without soft tissue attachments should be removed
      • temporary fracture stabilization
        • technique
          • performed at the time of initial debridement
          • external fixation is temporary initial treatment of choice for majority of high energy open fractures of the lower extremity
      • local antibiotic administration
        • indications
          • significantly contaminated wounds with large soft tissue defects
          • large bony defects
        • technique
          • beads made by mixing methylmethacrylate with heat-stable antibiotic powder
          • vancomycin and tobramycin most commonly used
      • soft tissue coverage
        • timing
          • early soft tissue coverage or wound closure is ideal
            • timing of flap coverage for open tibial fractures remains controversial, < 7 days is desired
            • increased risk of infection beyond 7 days
              •  odds of infection increase by 16% for each day beyond day 7 
              • early studies demonstrated increased infection with delay beyond 72 hours, however recent studies do not support this finding (LEAP study)
            • studies have not shown any statistical difference between rate of infection when ORIF is performed before fasciotomy closure, at fasciotomy closure, or after fasciotomy closure
        • 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)
    • Definitive reconstruction and fracture fixation
      • no critical bone defect
        • open reduction and internal fixation or intramedullary treatment depending on fracture location and morphology
      • critical bone defect
        • technique
          • Masquelet technique ("induced-membrane" technique)
            • 2 stage technique
              • 1st stage: I&D, cement spacer and temporizing fixation
              • 2nd stage: placement of bone graft into "induced membrane" and definitive fixation
                • Studies show optimal time frame for bone grafting to be 4-6 weeks after placement of cement spacer
          • distraction osteogenesis
          • vascularized bone flap/transfer
  • Complications
    • Surgical site infection
      • incidence
        • fracture-related infection ranges from <1% in type I open fractures to 30% in type III fractures
    • Osteomyelitis
      • incidence
        • ranges between 1.8% to 27% depending on the bone involved and fracture characteristics.
        • the tibia is the most common site of post-surgical osteomyelitis following surgical treatment of open fractures
        • risk factors include:
          • blast mechanism of injury
          • acute surgical amputation
          • delay in defintive soft tissue coverage greater than 7 days
          • more severe Gustillo-Anderson classification.
    • Neurovascular injury
    • Compartment syndrome
  • Prognosis
    • To minimize risk of infection, debridement recommended to be performed within 24 hours for all type III fractures and within 12 hours for type IIIB open tibia fractures
    • Contamination with dirt and debris and devitalization of the soft tissues increase the risk of infection and other complications
    • Infection rates higher in open injuries due to blunt trauma compared to penetrating trauma

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Flashcards (43)
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Questions (27)

(OBQ20.128) A 37-year-old male presented to the Emergency Department after his autonomous vehicle failed to recognize a deer in the road resulting in a high-speed motor vehicle collision. He was found to have an isolated, open tibial shaft fracture as depicted in Figure A. Antibiotics were promptly given upon arrival and he was taken immediately to the operating room for a thorough debridement with internal stabilization. It is determined that the patient will require a soft tissue flap. When compared to definitive flap coverage <7 days after injury, undergoing definitive flap coverage >7 days after injury is associated with which of the following?

QID: 215539
FIGURES:

Increased amputation rates

68%

(897/1310)

Increased deep vein thrombosis (DVT) rates

4%

(54/1310)

Decreased osteomyelitis rates

9%

(118/1310)

Decreased pneumonia rates

0%

(5/1310)

Equivalent complication rates

17%

(227/1310)

L 3 E

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(SBQ18TR.46) Figure 1 is the clinical photograph of a 41-year-old male who presented to the ED at 11 PM, 3 hours following a rural zip lining accident. The patient was transferred by personal car from the scene. Within 30 minutes of his arrival to the hospital the patient was given IV antibiotics and the leg was splinted. The following morning the patient was taken to the OR for irrigation, debridement and reamed intramedullary nailing of this injury. A negative pressure dressing was initially utilized over the open wound and definitive closure was performed on hospital day 3. In this scenario, which of the following is independently linked to this patient's increased risk of infection?

QID: 211606
FIGURES:

Reamed nailing

2%

(25/1097)

Timing of definitive soft tissue closure

11%

(117/1097)

Personal transport from scene

7%

(77/1097)

Timing of antibiotics

73%

(798/1097)

Delayed surgical treatment

6%

(63/1097)

L 3 E

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(SBQ18TR.3) A 32-year-old male sustained a right grade IIIB open tibial shaft fracture 10 months ago when he fell down a ledge while hiking. Due to the location of the injury, it took EMS 15 hours to transport the patient to the ED, where IV antibiotics were promptly started. Subsequently, the patient underwent external fixation with serial debridements followed by definitive flap coverage and unreamed intramedullary nailing six days after the injury. The patient continues to have pain in the leg with weight-bearing but denies any fevers or chills. His surgical wounds appear well-healed with a small sinus tract over the open fracture site. Figures A and B are the current radiographs. Recent labs reveal an ESR, CRP and 25-hydroxyvitamin D2 of 32 mm/hr (reference 0-20 mm/hr), 15 mg/dL (reference 0-3 mg/dL), and 50 ng/mL (reference 20-100 ng/mL). What factor is most likely associated with this patient's current condition?

QID: 211133
FIGURES:

Delay in definitive wound coverage

5%

(100/1902)

Definitive treatment with an unreamed intramedullary nail

4%

(73/1902)

Prolonged time to antibiotic administration

87%

(1664/1902)

Hypovitaminosis D

1%

(16/1902)

Low-pressure irrigation during debridements

1%

(11/1902)

L 1 A

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(SBQ12FA.68) A 25-year-old male presents to the emergency department after a lawnmower accident with traumatic loss of his great toe. On examination, his wound is grossly contaminated with soil. In addition to a cephalosporin and an aminoglycoside, penicillin is given. Which of the following is true with regards to the organism that penicillin is targeting in this injury?

QID: 3875

It is an Aerobic, Gram-positive rod

19%

(735/3895)

It is an Anaerobic, Gram-positive coccus

22%

(861/3895)

It is an Anaerobic, Gram-negative rod

19%

(735/3895)

It is Catalase positive

5%

(176/3895)

It may cause botulism

35%

(1366/3895)

L 5 C

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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?

QID: 4580
FIGURES:

Ciprofloxacin

1%

(73/6093)

Vancomycin

1%

(88/6093)

Penicillin

2%

(127/6093)

Gentamycin

3%

(162/6093)

Cefazolin

92%

(5596/6093)

L 1 C

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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?

QID: 3138
FIGURES:

Antibiotic solution applied by low pressure gravity flow device

5%

(176/3560)

Antibiotic solution applied by high pressure pulsatile flow device

2%

(79/3560)

Saline solution applied by low pressure gravity flow device

86%

(3049/3560)

Saline solution applied by high pressure pulsatile flow device

5%

(185/3560)

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

1%

(53/3560)

L 2 B

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(SBQ09TR.68.1) Which of the following statements is true regarding the outcomes when using a high-pressure pulse lavage irrigation system versus simple low-pressure bulb irrigation for the treatment of the open fracture shown in Figure A?

QID: 212601
FIGURES:

It is more cost effective when including the cost of reoperation

2%

(37/1706)

There is an increased rate of associated nerve injury

3%

(46/1706)

There is an increased rate of primary wound healing problems

13%

(221/1706)

There is increased rate of infection

25%

(418/1706)

There is no difference in union rates

57%

(977/1706)

L 4 B

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(SBQ07PE.3) A 8-year-old girl sustained a Gustilo-Anderson grade III open tibia fracture 1 week ago and underwent two debridements with definitive fracture fixation. She now has a soft-tissue defect that measures 7 cm × 7 cm on the distal third leg that is a 3 centimeters proximal to the ankle. There is exposed bone on the medial aspect of her leg. A Negative pressure wound therapy (NPWT) device was applied to her leg. All of the following are benefits of the NPWT EXCEPT:

QID: 1488

Decrease likelihood of complex secondary soft tissue reconstruction

7%

(153/2101)

Permits outpatient management of complex wound

2%

(46/2101)

Reduce edema to wound

1%

(24/2101)

Stimulation of granulation tissue

1%

(25/2101)

Decreases wound angiogenesis

87%

(1832/2101)

L 1 D

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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 a full course of tetanus vaccination as an infant and child. He also had a tetanus booster vaccination 12 months ago when he began a new job. In addition to intravenous antibiotics, what tetanus prophylaxis should be administered?

QID: 321

No prophylaxis required

80%

(898/1119)

Tetanus vaccine

6%

(65/1119)

Tetanus immune globulin

9%

(106/1119)

Tetanus vaccine and tetanus immune globulin

3%

(33/1119)

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

1%

(6/1119)

L 2 D

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