Open Fractures. Acute Management
Open fractures are common conditions for orthopaedic surgeons. I wrote this few paragraphs to explain my approach in the ED for quick reference.
Think of the patient as a hole. Apply ATLS principles:
Look for lessions that may kill the patient
Open fractures are usually messy, eye catching and a source of distraction from other life threatening injuries.
History and Physical exploration before treating the wound: (allergies, Neurovascular status of the limb…)
The Objectives in treating open fractures are:
Stabilization of the broken bone segment
Definitively or temporarily
To prevent further bleeding, pain, inflamation, compartment pressure
Prevent further damage
Prevent INFECTION
Is the most important complication related to this injuries, It is very common and related directly with the Gustillo and Anderson Classification Grade. LINK GOLIATH
Treated two ways
IV antibiotics
Debridment
Compartment Syndrome
Mustn’t be ruled out because the wound is open.
Open fracture doesn't rule out Compartment syndrome.
Always suspect of CS with: increased circumference of the limb, pain with passive stretch and opioid consumption.
Diagnose associated injuries
Of the same limb
Neurovascular
The Principles are:
Antibiotic as soon as possible
Throughout debridment
Stable construct of the bone segment
Emergency Department - First Steps
As soon possible (first thing) - IV Antibiotic
Usually a cefalosporine (depending on local resistances and Infectious disseasse protocols). For 24-72h max
Cefazoline 2g every 8hours
Ceftriaxone 2g
It is recommended to add Aminoglucosids (gentamicin) 240mg once (if type III) (Counter Evidence) (NO gentamicin paper)
Gentamicin covers G- and it is prefered to be given in 1 dose as multiple dosis may affect renal filtration.
Other Ab to consider
Vancomicin
Clindamicin
Penicilin
Clean the wound using copious irrigation LINK FLOW
Sterile saline solution non pressurized
Some authors give the following rule of thumb
3Litters for GI
6L for GII
9L for GIII
Take Fotos of the Open Fracrure
Legal, educational and documentation purposes
And follow guidelines of your institution or Country
(No identification marks, informed consent, written or oral, Data protection…)
Cover the Wound
Temporary Staples
Clean Gauze
Plaster Back slab
Consider Tetanus Booster
Finish with Xray, writing ED notes, talking to patient and family, Informed consent related to surgery, blood test, Anestesiology consult…
Anticipate needing to call the Plastic surgeon or vascular surgeon if difficulty with clossing the wound or vascular lession is suspected
Planning for Nailling or External fixator needs to be decided and checked for the apropiate implants
OR - Final Steps
As soon as possible schedule surgery for debridment and bone stabilization.
Timming. It is said that 3-6h is ideal but there are published good results even with 12-24h of delay if AB is correctly applied and debridment is done well (TIDE)
Debridement will determine the Tscherne and Gustilo definitive classification.
Debridment needs to be complete and exhaustive. Remove soft tissue with signs of non viability, muscle non contractile, white, Small bone fragments whith no periosteal or soft tissue attachments.
Gustillo classification is not only related to wound length (1, 1-10cm, >10cm). But also the grade of contamination, soft tissue injury, bone injury, severity of the accident, conminution, vascular injury, possibility of clossure…
Consider "Fix and Flap"
Tibia nail + Flap for coverage
Nail Grade IIIb Tibial fractures if colaboration with orthoplastic surgeon is available
Consider patient status so Early appropiate care is donde
Nail vs External fixator
Nail may be reammed (SPRINT trial)
VAC or negative pressure therapy can be used if no other coverage option is available as a temporary fix until definitive surgery
Once Finalized there needs to be more test taken, new xrays, blood test, CT Scan… so definitive managment and appropiate treatment can be schedulled.
Stay alert at any changes in pain and don’t forget that Compartment syndrome strikes in a few minutes/hours and needs to be treated quickly with open fasciotomies.
Take away Points
IV Antbiotic as soon as possible (golden hour rule)
Most important modificable factor for preventing infection
Second factor is time to get to a trauma centre
Gustillo classification can be done pre-surgery but needs to be moddified post-debridment
Really good throughout debridement, eliminating dead bone and soft tissue is more important than being quicker to the ER
Nail if stable patient (other injuries, Lactic acid <2…. ) Early appropiate care
Ext. Fixator if not (damage control)
Bibliography
Curso COT Tema 13 - Fracturas: Tratamiento
Elniel AR, Giannoudis PV. Open fractures of the lower extremity: Current management and clinical outcomes. EFORT Open Rev. 2018 May 21;3(5):316-325. doi: 10.1302/2058-5241.3.170072. PMID: 29951271; PMCID: PMC5994617.
ICL 67
Orthobullets
https://www.orthobullets.com/trauma/1002/tscherne-classification
https://www.orthobullets.com/trauma/1004/open-fractures-management
FLOW Investigators; Bhandari M, Jeray KJ, Petrisor BA, Devereaux PJ, Heels-Ansdell D, Schemitsch EH, Anglen J, Della Rocca GJ, Jones C, Kreder H, Liew S, McKay P, Papp S, Sancheti P, Sprague S, Stone TB, Sun X, Tanner SL, Tornetta P 3rd, Tufescu T, Walter S, Guyatt GH. A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds. N Engl J Med. 2015 Dec 31;373(27):2629-41. doi: 10.1056/NEJMoa1508502. Epub 2015 Oct 8. PMID: 26448371.
Foote CJ, Tornetta P 3rd, Reito A, Al-Hourani K, Schenker M, Bosse M, Coles CP, Bozzo A, Furey A, Leighton R; GOLIATH Investigators. A Reevaluation of the Risk of Infection Based on Time to Debridement in Open Fractures: Results of the GOLIATH Meta-Analysis of Observational Studies and Limited Trial Data. J Bone Joint Surg Am. 2021 Feb 3;103(3):265-273. doi: 10.2106/JBJS.20.01103. Erratum in: J Bone Joint Surg Am. 2021 Mar 17;103(6):e25. PMID: 33298796.
Hand TL, Hand EO, Welborn A, Zelle BA. Gram-Negative Antibiotic Coverage in Gustilo-Anderson Type-III Open Fractures. J Bone Joint Surg Am. 2020 Aug 19;102(16):1468-1474. doi: 10.2106/JBJS.19.01358. PMID: 32310842.
Depcinski SC, Nguyen KH, Ender PT. Cefazolin and an aminoglycoside compared with cefazolin alone for the antimicrobial prophylaxis of type III open orthopedic fractures. Int J Crit Illn Inj Sci. 2019 Jul-Sep;9(3):127-131. doi: 10.4103/IJCIIS.IJCIIS_7_19. Epub 2019 Sep 30. PMID: 31620351; PMCID: PMC6792399.
Li J, Wang Q, Lu Y, Feng Q, He X, Li Md Z, Zhang K. Relationship Between Time to Surgical Debridement and the Incidence of Infection in Patients with Open Tibial Fractures. Orthop Surg. 2020 Apr;12(2):524-532. doi: 10.1111/os.12653. Epub 2020 Mar 22. PMID: 32202051; PMCID: PMC7189037.
Mener A, Staley CA, Lunati MP, Pflederer J, Reisman WM, Schenker ML. Is Operative Debridement Greater Than 24 Hours Post-admission Associated With Increased Likelihood of Post-operative Infection? J Surg Res. 2020 Mar;247:461-468. doi: 10.1016/j.jss.2019.09.059. Epub 2019 Oct 24. PMID: 31668434.
Rupp M, Popp D, Alt V. Prevention of infection in open fractures: Where are the pendulums now? Injury. 2020 May;51 Suppl 2:S57-S63. doi: 10.1016/j.injury.2019.10.074. Epub 2019 Oct 25. PMID: 31679836.
Hendrickson SA, Wall RA, Manley O, Gibson W, Toher D, Wallis K, Ward J, Wallace DL, Lamyman M, Giblin AV, Wright TC, Khan U. Time to Initial Debridement and wound Excision (TIDE) in severe open tibial fractures and related clinical outcome: A multi-centre study. Injury. 2018 Oct;49(10):1922-1926. doi: 10.1016/j.injury.2018.07.023. Epub 2018 Jul 27. PMID: 30082111.
Schenker ML, Yannascoli S, Baldwin KD, Ahn J, Mehta S. Does timing to operative debridement affect infectious complications in open long-bone fractures? A systematic review. J Bone Joint Surg Am. 2012 Jun 20;94(12):1057-64. doi: 10.2106/JBJS.K.00582. PMID: 22572980.
