Management of Open Fractures

1. Management of Open Fractures Christine Kennedy Pediatric Emergency Fellow October 22, 2009

2. Objectives • Review the different types of open fractures • Discuss the current treatment of open fractures • Review the literature supporting non-operative management of Type 1 open fractures

3. Introductory Case • 8 yr boy with a midshaft radius & ulna # • Obvious deformity on clinical exam • Small scab on volar surface of forearm • not actively bleeding • Xray….

6. Case • Question was…Does this need to go to the OR? • Ortho consulted…advised to attempt a closed reduction and give a dose of Ancef • If successful, mark wound area on cast, send home on Keflex and F/U in ortho clinic • During the reduction…wound started to ooze on my foot…

7. Post-reduction X-Rays

8. Case-Follow up at day 39

9. Open Fracture ClassificationGustilo and Anderson • Type I • Clean wound <1 cm in length • # is simple, transverse or oblique with little comminution • Type II • Laceration >1cm without extensive soft tissue damage, flaps or avulsions • Type III • Extensive soft tissue damage, crushing or a traumatic amputation • Subtypes 3A, 3B, 3C

10. Open Fracture Classification • Type 3 subtypes • 3A: Adequate soft tissue coverage • 3B: Inadequate soft tissue coverage • 3C: Arterial injury requiring repair 3B

11. Open Fracture Classification

12. Open Fracture Classification Type I Type I Type IIIc Type IIIb

13. Open Fracture ClassificationGustilo and Anderson • Type I Infection rate 0-2% • Clean wound <1 cm in length • # is simple, transverse or oblique with little comminution • Type II Infection rate 2-7% • Laceration >1cm without extensive soft tissue damage, flaps or avulsions • Type III Infection rate 10-25% • Extensive soft tissue damage, crushing or a traumatic amputation Gustilo et al. Current Concepts Review The Management of Open Fractures. Journal of Bone and Joint Surgery. 1990;72:299-304.

14. Open Fracture vs Abrasion

15. Open Fracture vs Abrasion Open fracture • disruption of the dermis with communication into the subcutaneous tissue contiguous with the bone

16. Open Fracture vs Abrasion Abrasion • Soft tissue injury into the dermis (not through the dermis) • usually due to friction or shearing • An abrasion on its own over a fracture does not communicate with the fracture because the sc tissue is intact • The pattern of bleeding from an abrasion is pinpoint dermal bleeding • If you squeeze an abrasion, you may get bleeding but the pattern is different than a laceration that extends into the deeper tissue

17. How do the Orthopedic Surgeons decide? • Probing the wound is not recommended • Pull on the skin adjacent to the wound to see if you can SEE any subcutaneous fat as evidence that the dermis is broken • Contact the on call surgeon to discuss

18. How Common are Open Fractures? • For forearm fractures (most common fracture pattern in children) • 0.5%-4.5% are open Luhmann et al. Complications and Outcome of Open Pediatric Forearm Fractures. J Pediatr Orthop 2004;24:1-6.

19. Management of Open Fractures • Traditionally • Considered a “true surgical emergency” • Required operative debridement and fracture stabilization • “Golden Period” was 6-12 hours from time of patient arrival

20. Management of Open Fractures • Now…. • Type II & III • Require surgical debridement • Wounds with high energy injuries result in devitalized tissue, local edema & ischemia • This alters the ability of local host defenses to resist infection

21. Management of Open Fractures • Type 1 • Operative vs non-operative, why the controversy?

22. Type 1 Open Fractures • Maintain a relatively intact soft tissue envelope therefore the vascular supply to the zone of injury is preserved • This decreases the risk factors for development of infection • Devitalized tissue • Ischemia • Edema

23. Type 1 Open Fractures • Allows adequate penetrance of the host defense mechanisms and IV antibiotics to protect further against possible infection

24. Type 1 Open Fractures • Routine operative debridement might cause increased soft tissue trauma, periosteal stripping and osseous devascularization

25. Type 1 Open Fractures • Children have better healing potential than adults • Differences in the malleability & strength of the bone • Better vascular supply to the extremities • Thicker periosteum

26. In the old orthopedic literature… • Cases of gas gangrene in children with open fractures managed non-operatively • Before the routine use of antibiotics

27. Infection Rate with Operative Management • Literature’s infection rate for type 1 open fractures treated operatively is an average of 1.9%*

28. Infection Rate with Operative Management

29. Infection Rate with Operative Management

30. Organisms Cultured from Open Fractures • The majority of bacteria cultured are normal skin flora • Staphylococcus epidermidis • Proprionibacterium acnes • Corynebacterium species

31. Organisms Cultured from Open Fractures • Farm related injuries increase the risk of • Clostridium perfringens • Exposure to fresh water increases the risk of • Pseudomonas aeruginosa • Aeromonas hydrophilia

32. Organisms Cultured from Open Fractures • The frequent growth of S. aureus & P. aeruginosa from patients who have an infection contrasts with the infrequent growth of these organisms on initial wound culture • Suggests that these infections are acquired in the hospital

33. Importance of Antibiotics • Prospective, double blind, randomized study • Infection rate was • 13.9% in placebo group • 9.7% in group treated with Penicillin & Streptomycin • 2.3% in group treated with a 1st generation cephalosporin Patzakis et al. The Role of Antibiotics in the Management of Open Fractures. The Journal of Bone and Joint Surgery 1974;56:532-541.

34. Importance of Antibiotics • Meta-analysis demonstrated a significant reduction in wound infections in patients who received antibiotics for all types of open fractures • 13.4% of patients who were not treated with antibiotics developed an infection • 5.5% of treated patients developed an infection • NNT 13 [8-25]

35. Which Antibiotic? • Most common pathogens causing infections after open fractures • Staphylococcus aureus • Facultative gram-negative bacilli • In type I open fractures • 1st generation cephalosporin sufficient • In type II & III • Combinations therapy with a cephalosporin and an aminoglycoside OR 3rd generation cephalosporin

36. Timing of Antibiotics is Important • One study with over 1000 open fractures found that starting antibiotics within 3 hours of injury lowered the infection rate* • Infection rate 4.7% if antibiotics w/in 3 hours • Infection rate 7.4% if antibiotics started >3h after injury • Of note, surgical debridement was performed for all open fractures in this study

37. Guidelines for Antibiotic Length? • No standardized protocol for length of Abx following open fractures • One report published which demonstrated no difference b/w 1 & 5 days of IV Abx • In the adult literature, anywhere from 1-3 days of antibiotics is the recommendation

38. Non Operative Management of Type 1 Open Fractures • What does the literature say these days?

39. Reviews the results of non operative management of type I open fractures in children • Retrospective chart review (1998-2003) • 40 patients followed until healed • clinically & radiographically • 1 deep infection occurred • overall infection rate 2.5%

40. 0% infection rate in the 32 upper extremity type I open fractures • 0% infection rate in the 23 patients under 12 years

41. Details of Study #1 • 40 patients diagnosed with type 1 open fracture • 33 boys, 7 girls • Age 10 years [range 4-15y] • Fracture distribution • 8 tibia • 18 diaphyseal radius & ulna • 14 distal radius & ulna • Mechanism • Most low-moderate energy • Falls from bikes, skateboards, rollarblades, scooters • 7 kids hit by motor vehicle

42. Details of Study #1 Treatment: Initiated in the ED • Initiation of IV antibiotics • Cleansing and/or irrigation of the open wound with Betadine & saline • Protecting the wound with Xeroform & sterile gauze • Tetanus prophylaxis if needed • Closed reduction & immobilization

43. Details of Study #1 • Patients were admitted to hospital for 48-72 hours for observation, continued IV antibiotics and wound management • Patients were discharged w/o abx • but 4/40 were sent home on 1 week of Keflex, at the treating surgeon’s discretion

44. Details of Study #1 • Patients were followed until fracture union • Clinically: no longer tender at fracture site • Radiologically: bridged by sufficient callus

45. Details of Study #1 • Definitions • Deep infection: proceeded to debridement • Increasing pain, drainage from the wound and radiologic changes within the bone • Superficial infections • Inflammation of the skin/subcutaneous tissue w/o radiologic evidence of osteomyelitis

46. Results of Study #1 • Average hospital stay: 2.5 days (1-5) • No documented fevers • No patients developed malunion/nonunion • No patients developed osteomyelitis • No wound complications during admission • No superficial infections • 1 deep infection of the tibia (at 3 months)

47. Results of Study #1

48. Results of Study #1

49. Results of Study #1

50. Results of Study #1