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OPEN FRACTURE EPIDEMIOLOGY, CLASSIFICATION, TREATMENT
- 2. 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
- 3. 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
- 5. SHORTER VERSION Type I wound ≤1 cm, minimal contamination or muscle damage Type II wound 1-10 cm, moderate soft tissue injury Type IIIA wound usually >10 cm, high energy, extensive soft-tissue damage, contaminated adequate tissue for flap coverage farm injuries are automatically at least Gustillo IIIA Type IIIB extensive periosteal stripping, wound requires soft tissue coverage (rotational or free flap) Type IIIC vascular injury requiring vascular repair, regardless of degree of soft tissue injury Most accurate way to grade open fratures is by intra-operative examination
- 8. 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
- 9. IMAGING RADIOGRAPHS INDICATIONS OBTAIN RADIOGRAPHS INCLUDING JOINT ABOVE AND BELOW FRACTURE CT INDICATIONS PERI-ARTICULAR INJURIES EVALUATION FOR TRAUMATIC ARTHROTOMY OF THE KNEE
- 10. 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
- 11. 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
- 12. 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
- 13. 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)
- 14. 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
- 15. 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)
- 16. 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
- 17. 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
- 18. 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
- 19. 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
- 20. 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)
- 21. 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
- 22. 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
- 23. 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
- 24. THE END