Updated: 6/8/2021

Open Fractures Management

0%
Topic
Review Topic
0
0
N/A
N/A
Questions
23
0
0
0%
0%
Evidence
54
0
0
100%
0%
Videos / Pods
3
100%
0%
Cases
8
Topic
Images
https://upload.orthobullets.com/topic/1004/images/clinical picture of type iiia open tibia.jpg
https://upload.orthobullets.com/topic/1004/images/screen_shot_2018-06-24_at_9.52.21_pm.jpg
https://upload.orthobullets.com/topic/1004/images/screen_shot_2018-06-24_at_9.51.35_pm.jpg
  • 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, may be beneficial within 6 hours in terms of decreasing infection risk
          • ideal time of soft tissue coverage controversial, but most centers perform within 5-7 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 grade I open fractures to 30% in grade 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
              • 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 grade I open fractures to 30% in grade III fractures
    • Osteomyelitis
      • incidence
        • ranges between 1.8% to 27% depending on the bone involved and grade/fracture type.
        • 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
          • higher grade 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

Please rate this review topic.

You have never rated this topic.

Thank you. You can rate this topic again in 12 months.

Questions (23)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(OBQ14.128) A 24-year-old male presents following a motorcycle crash with an isolated injury to his right lower extremity. He has a 3x2cm wound over the fracture site, and he immediately receives Gram positive and Gram negative coverage along with a tetanus booster. The patient is splinted, optimized, and brought to the operating room where the wound is debrided and classified as a Type IIIB fracture. Deemed stable, the plastic surgery team arrives and acutely performs a free flap for coverage, following definitive fixation with an intramedullary nail. All of the following are factors that have been shown to increase infection risk EXCEPT:

QID: 5538
FIGURES:
1

Time to antibiotic administration

3%

(114/3511)

2

Thoroughness of debridement

5%

(160/3511)

3

Time to initial debridement

13%

(467/3511)

4

Ability to close/cover an open wound

9%

(314/3511)

5

Time to definitive fixation

69%

(2422/3511)

L 3 A

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(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
1

It is an Aerobic, Gram-positive rod

19%

(652/3376)

2

It is an Anaerobic, Gram-positive coccus

22%

(736/3376)

3

It is an Anaerobic, Gram-negative rod

19%

(644/3376)

4

It is Catalase positive

4%

(149/3376)

5

It may cause botulism

35%

(1175/3376)

L 5 C

Select Answer to see Preferred Response

(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:
1

Ciprofloxacin

1%

(70/5812)

2

Vancomycin

1%

(82/5812)

3

Penicillin

2%

(121/5812)

4

Gentamycin

3%

(154/5812)

5

Cefazolin

92%

(5339/5812)

L 1 C

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(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:
1

Antibiotic solution applied by low pressure gravity flow device

5%

(166/3204)

2

Antibiotic solution applied by high pressure pulsatile flow device

2%

(71/3204)

3

Saline solution applied by low pressure gravity flow device

85%

(2735/3204)

4

Saline solution applied by high pressure pulsatile flow device

5%

(167/3204)

5

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

2%

(49/3204)

L 2 B

Select Answer to see Preferred Response

(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:
1

It is more cost effective when including the cost of reoperation

2%

(29/1503)

2

There is an increased rate of associated nerve injury

3%

(42/1503)

3

There is an increased rate of primary wound healing problems

14%

(205/1503)

4

There is increased rate of infection

25%

(379/1503)

5

There is no difference in union rates

56%

(841/1503)

L 4 B

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(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
1

Decrease likelihood of complex secondary soft tissue reconstruction

7%

(119/1646)

2

Permits outpatient management of complex wound

2%

(32/1646)

3

Reduce edema to wound

1%

(20/1646)

4

Stimulation of granulation tissue

1%

(20/1646)

5

Decreases wound angiogenesis

87%

(1438/1646)

L 1 D

Select Answer to see Preferred Response

(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
1

No prophylaxis required

81%

(642/789)

2

Tetanus vaccine

5%

(43/789)

3

Tetanus immune globulin

9%

(74/789)

4

Tetanus vaccine and tetanus immune globulin

2%

(16/789)

5

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

1%

(6/789)

L 2 D

Select Answer to see Preferred Response

Evidence (54)
VIDEOS & PODCASTS (4)
CASES (8)
EXPERT COMMENTS (71)
Private Note