Updated: 5/3/2020

Open Fractures Management

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Introduction
  • Overview
    • open fractures are fractures 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
      • "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
  • 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
    • 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
        • 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
          • 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, < 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)  
  • 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
  • Neurovascular injury
  • Compartment syndrome
 

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Questions (18)
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(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: Review Topic | Tested Concept

QID: 5538
FIGURES:
1

Time to antibiotic administration

3%

(109/3304)

2

Thoroughness of debridement

5%

(150/3304)

3

Time to initial debridement

13%

(440/3304)

4

Ability to close/cover an open wound

9%

(303/3304)

5

Time to definitive fixation

69%

(2269/3304)

L 3 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? Review Topic | Tested Concept

QID: 3875
1

It is an Aerobic, Gram-positive rod

20%

(568/2895)

2

It is an Anaerobic, Gram-positive coccus

22%

(640/2895)

3

It is an Anaerobic, Gram-negative rod

19%

(564/2895)

4

It is Catalase positive

4%

(127/2895)

5

It may cause botulism

34%

(975/2895)

L 5 B

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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 | Tested Concept

QID: 4580
FIGURES:
1

Ciprofloxacin

1%

(69/5568)

2

Vancomycin

1%

(78/5568)

3

Penicillin

2%

(117/5568)

4

Gentamycin

3%

(149/5568)

5

Cefazolin

92%

(5117/5568)

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? Review Topic | Tested Concept

QID: 3138
FIGURES:
1

Antibiotic solution applied by low pressure gravity flow device

5%

(159/3010)

2

Antibiotic solution applied by high pressure pulsatile flow device

2%

(68/3010)

3

Saline solution applied by low pressure gravity flow device

85%

(2563/3010)

4

Saline solution applied by high pressure pulsatile flow device

5%

(157/3010)

5

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

2%

(48/3010)

L 2 B

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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? Review Topic | Tested Concept

QID: 321
1

No prophylaxis required

82%

(562/689)

2

Tetanus vaccine

6%

(38/689)

3

Tetanus immune globulin

9%

(64/689)

4

Tetanus vaccine and tetanus immune globulin

2%

(14/689)

5

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

0%

(3/689)

L 2 D

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