Transcript Open Fracture Management

Open Fracture Management
Paul Fawson
1st Year Resident
Goals
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Treat all frx as an emergency
Thorough exam of life threatening injuries
Begin abx
Debride type II-III frx
Stabilize the frx
Leave wound open for 5-7 days
Early autogenous cancellous bone grafting
Rehab the jacked-up extremity
Classification
• Type I- < 1 cm. Moderately clean puncture, little
soft tissue damage, no crushing injury, little
comminution. Simple, transverse, or oblique frx
• Type II- > 1 cm, no extensive soft tissue damage,
slight/moderate crushing injury, moderate
comminution and contamination.
• Type III- Extensive soft tissue damage,
comminution, and contamination.
– IIIA- Adequate soft tissue coverage
– IIIB- Loss of soft tissue
– IIIC- Arterial injury that needs repaired
H&P
• Preliminary Exam performed in the ER
• History and Physical
• Location?
– Farm? Water contact to wound?
Sterile Dressing
• Cover the Wound with Sterile dressing to
prevent further contamination
Antibiotic Therapy
• Immediate, appropriate and effective
antibiotic therapy.
• > 70% of open frx are contaminated at time of
injury.
• Gram – and aerobic gram + are most common
– S. aureus, S. epidermitis, P. Aeruginosa,
streptococcus, Enterobacteriaceae, B. fragilis
Antibiotic Therapy
• Type I- Start 2.0 g of Cephalosporin
(Cephazolin) upon admission
– Then 1.0 g q 6-8 hours for 48-72 hours
• Type II-III- Ceph + aminoglycoside
• Add 10 million units of penicillin if frx
occurred on a farm.
• 3-7 days only
• 3-7 days again with delayed procedures.
Debridement
• Debridement of wound with copious intermittent
lavage.
– 5,000-10,000 mL of NS or DW
– 2,000 mL bacitracin-polymyxin solution??
• Small puncture wounds and lacerations should be
extended for adequate exposure.
• Discard any small or large fragments or fragments
of devitalized, unattached cortical bone.
• Don’t put back bone found from the scene into
the pt.
Soft Tissue Reconstruction
• Early is recommended if a clean, stable wound
has been achieved.
• This is the key to reduce infection in type III
• Keep wound moist until complete coverage in
5-7 days.
Stabilization of Fracture
• Osseous stability reduces the risk of infection
and protects the integrity of the remaining
soft tissue
• External
– Ease of application with minimal operative trauma
– Maintenance of access to the wound
– Good option for type III
Stabilization of Fracture
• Intramedullary nailing with reaming
– Not recommended with open tibial frx. A large
study showed 6% infx rate with IM nail compared
to 0-1% infx rate in open frx management
• Plate and screws
– Indicated for displaced intra-articular and
metaphyseal frx of LE.
Splints and casts
• Plaster cast can be used for a stable, isolated
type I frx until wound is healed. After this,
immobilized in a cast
• Avoid circular cast in acute stage.
Coverage and Closure of Wound
• Goal is safe, early closure of wound in 7-10
days.
• Type I-IIIA, delayed primary closure in 5-7 days
• IIIB-IIIC, multiple debridements required
• Clinical decision to determine is infection is
still present.
Compartment Syndrome
• 3-9% of open tibial frx found to have
compartment syndrome
• Recommends decompressive fasciotomies to
all 4 leg compartments.
Bone grafts
• Blood flow is imperative
• Autogenous cancellous bone grafting is
indicated with loss of bone or marked
comminution after wound has healed (2-3
weeks)
• Type III- delay grafts to 6 weeks after wound
heals.
Amputation
• 2 absolute indications for primary amputation
– A type IIIC with disruption of post tib nerve and…
– IIIC with loss of soft tissue, massive
contamination, severe comminution, or massive
loss of bone.
• Or type IIIC remained untreated for > 8 hours.
• Delayed amputation is more $$$ and tends to
be a more proximal amputation vs primary
amputation.
References
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