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Introduction
  • Open fracture definition
    • a fracture with direct communication to the external environment
    • historically described as a "compound" fracture
    • a soft tissue wound in proximity to a fracture should be treated as an open fracture until proven otherwise
  • Often associated with additional injuries
  • Orthopaedic urgency
    • in the absence of life-threatening injuries, there is no clinical advantage to performing surgery within 6 hours of injury versus 6-24 hours
Classification
Antibiotic Management
  • 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 
  • Duration
    • 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)
Tetatnus
  • Initiate in emergency room or trauma bay
  • Two forms of prophylaxis 
    • toxoid dose 0.5 mL, regardless of age
    • immune globulin dosing
      • <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
Emergency Room Management
  • Fracture management begins after initial trauma survey and resuscitation is complete: airway, breathing, circulation, disability, and exposure (ABCDE)
  • Antibiotics
    • initiate early IV antibiotics and update tetanus prophylaxis as indicated 
    • low-energy gunshot wounds should be treated with a single dose of a 1st generation cephalosporin in the ED
  • Control bleeding
    • direct pressure will control active bleeding
    • do not blindly clamp or place tourniquets on damaged extremities
  • Assessment
    • soft-tissue damage
    • 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 if concern for traumatic arthrotomy
  • 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
  • Stabilize
    • splint, brace, or traction for temporary stabilization 
      • decreases pain, minimizes soft tissue trauma, and prevents disruption of clots
Operating Room Management
  • Aggressive debridement and irrigation 
    • thorough debridement is critical to prevention of deep infection; remove foreign bodies
    • expose fracture by recreating mechanism of injury, extend wound proximally and distally in line with extremity
    • low pressure irrigation is preferred over high pressure pulse lavage 
    • saline shown to be most effective irrigating agent
      • on average, 3L of saline are used for each successive Gustilo type
        • Type I: 3L
        • Type II: 6L
        • Type III: 9L
    • bony fragments without soft tissue attachments should be removed
  • Fracture stabilization
    • internal fixation, external fixation, or intramedullary nail as indicated
      • avoid placement of pins in proximity to planned definitive incisions
  • Staged debridement and irrigation
    • perform every 24 to 48 hours as needed
  • 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 
    • 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
  • Can place antibiotic bead-pouch in open dirty wounds
    • beads made by mixing methylmethacrylate with heat-stable antibiotic powder 
  • Reconstruction options for bone loss
    • 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 (19)
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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%

(62/4876)

2

Vancomycin

1%

(63/4876)

3

Penicillin

2%

(102/4876)

4

Gentamycin

3%

(134/4876)

5

Cefazolin

92%

(4487/4876)

Select Answer to see Preferred Response

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%

(133/2590)

2

Antibiotic solution applied by high pressure pulsatile flow device

2%

(58/2590)

3

Saline solution applied by low pressure gravity flow device

86%

(2216/2590)

4

Saline solution applied by high pressure pulsatile flow device

5%

(133/2590)

5

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

2%

(40/2590)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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

83%

(451/544)

2

Tetanus vaccine

6%

(31/544)

3

Tetanus immune globulin

8%

(45/544)

4

Tetanus vaccine and tetanus immune globulin

2%

(10/544)

5

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

1%

(3/544)

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PREFERRED RESPONSE 1
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