Open Fractures

1. Open Fractures Phillip Pullen, DO Orthopaedic Surgery Resident

2. Definition • Break in the skin and soft tissue leads directly to the fracture • Force causing the injury is dissipated by the soft tissue and osseous structures • Vacuum is created by the soft tissue shock wave which can pull material into the wound

3. Initial Assessment • ABC’s • Identify injuries to the extremities • Assess neurovascular status • Note skin and soft tissue damage • Identify bony injury

4. Radiographic Evaluation • AP and lateral of affected bone • Joint above and below the injury • Any other area that is painful • Angiography if there is a vascular injury

5. Classification • Mechanism of injury • Degree of soft tissue damage • Configuration of the fracture • Level of contamination

6. Gustilo and Anderson Classification • Grade I: -clean skin opening of <1cm -usually from inside to outside -minimal muscle contusion -simple transverse or short oblique fractures

7. Gustilo Classification • Grade II: -laceration >1cm long -extensive soft tissue damage, flap or avulsion -minimal to moderate crushing component -simple transverse or short oblique fractures with minimal/mod comminution -moderate contamination

8. Gustilo Classification • Grade III: -extensive soft tissue damage -high energy injury with severe crushing component IIIA: -adequate bone coverage -minimal periosteal stripping IIIB: -periosteal stripping and bone exposure IIIC: -vascular injury requiring repair

9. Management ER • Saline soaked gauze on the wound with a sterile wrap • DO NOT irrigate or debride - this may further contaminate the wound • DO NOT remove bone or close the wound • DO NOT culture the wound • X-rays • Splint anatomically

10. Definitive Treatment • Patient to the OR as soon as possible • Debridement less than eight hours after injury has a lower incidence of infection • Thorough debridement is crucial -Extend wound proximally and distally -Begin with the skin -Expose the fracture surfaces -Discard osseous fragments devoid of soft tissue

11. Treatment -Perform pulsatile irrigation with or without antibiotic solution (bacitracin-polymyxin solution) -Intraoperative cultures…controversial -Do not close the traumatic wound -Close the surgically extended portion only -Cover the wound with a saline soaked dressing

12. Treatment Cont’d -Repeat debridements every 24 to 48 hours until there is no evidence of necrotic tissue or bone • Fracture stabilization -Fractures with extensive soft tissue injury should be stabilized with internal or external fixation -Stabilization provides protection from additional soft tissue injury and access for wound management

13. Antibiotic Therapy • Type I: a single dose of 2.0 grams of a cephalosporin (1st or 2nd generation) then 1 gm q 6-8 hours for 48-72 hours • Type II or Type III: combined therapy to cover G+ and G- organisms. Cephalosporin as above plus an aminoglycoside with therapy lasting for 3 days. • Pencillin is added if the patient sustained a farm injury (10,000,000 units)

14. Incidence of Infection • Type I fractures - rates from 0-2% • Type II fractures – rates from 2-7% • Type III fractures – rates from 10-25% • Type III A - 7% • Type III B - 10-50% • Type III C - 25-50% with a 50% or greater amputation rate