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Open Fractures
Objectives
 Introduction
 Classification
 ED Management
 Antibiotic Management
 Tetanus
 Operating Room Management
 Complications
Introduction
 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
 Orthopedic 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
 Gustilo Classification:
 5 types according to size, involvement of soft tissue and blood vessels,
contamination and pattern of trauma
 Tscherne Classification:
 For closed and open fractures
Closed: 0,1,2,3
Open: I, II, III, IV
ED Management
 Fracture management begins after initial trauma survey and resuscitation
is complete (ABCDE)
ED Management
 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
 do not blindly clamp or place tourniquets on damaged extremities
ED Management
 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
ED Management
 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
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:
 freshwater wounds: Fluoroquinolones or 3rd or 4th generation Cephalosporin
 saltwater wounds: Doxycycline + Ceftazidime or a fluoroquinolone
Antibiotic Management
 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)
Tetanus “Clostridium tetani”
 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
Tetanus “Clostridium tetani”
 Guidelines for tetanus prophylaxis depend on 3 factors:
 complete or incomplete vaccination history (3 doses)
 date of most recent vaccination (10 years for clean wound, 5 years for other
wounds)
 severity of wound
Tetanus “Clostridium tetani”
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 (I: 3L,
II: 6L, III: 9L)
 bony fragments without soft tissue attachments should be removed
Operating Room Management
 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
Operating Room Management
 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
 negative-pressure wound therapy may be utilized during debridement until
definitive coverage can be achieved
 can proceed with bone grafting after wound is clean and closed
Operating Room Management
 Can place antibiotic bead-pouch in open dirty wounds:
 beads made by mixing methyl-methacrylate 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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Open fractures

  • 2. Objectives  Introduction  Classification  ED Management  Antibiotic Management  Tetanus  Operating Room Management  Complications
  • 3. Introduction  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  Orthopedic 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
  • 4.
  • 5. Classification  Gustilo Classification:  5 types according to size, involvement of soft tissue and blood vessels, contamination and pattern of trauma  Tscherne Classification:  For closed and open fractures Closed: 0,1,2,3 Open: I, II, III, IV
  • 6.
  • 7. ED Management  Fracture management begins after initial trauma survey and resuscitation is complete (ABCDE)
  • 8. ED Management  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  do not blindly clamp or place tourniquets on damaged extremities
  • 9. ED Management  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
  • 10. ED Management  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
  • 11. 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:  freshwater wounds: Fluoroquinolones or 3rd or 4th generation Cephalosporin  saltwater wounds: Doxycycline + Ceftazidime or a fluoroquinolone
  • 12. Antibiotic Management  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)
  • 13. Tetanus “Clostridium tetani”  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
  • 14. Tetanus “Clostridium tetani”  Guidelines for tetanus prophylaxis depend on 3 factors:  complete or incomplete vaccination history (3 doses)  date of most recent vaccination (10 years for clean wound, 5 years for other wounds)  severity of wound
  • 16. 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 (I: 3L, II: 6L, III: 9L)  bony fragments without soft tissue attachments should be removed
  • 17. Operating Room Management  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
  • 18. Operating Room Management  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  negative-pressure wound therapy may be utilized during debridement until definitive coverage can be achieved  can proceed with bone grafting after wound is clean and closed
  • 19. Operating Room Management  Can place antibiotic bead-pouch in open dirty wounds:  beads made by mixing methyl-methacrylate with heat-stable antibiotic powder  Reconstruction options for bone loss:  Masquelet technique  distraction osteogenesis  vascularized bone flap/transfer
  • 20. Complications  Infection  Neurovascular injury  Compartment syndrome  can still occur in the setting of open fractures