Open Fractures Management

Topic updated on 05/04/16 8:12pm
  • Open fracture definition
    • a fracture with direct communication to the external environment
Basic Principles of Open Fracture Management in the Emergency Room
  • Fracture management begins after initial trauma survey and resuscitation is complete
  • Antibiotics
    • initiate early IV antibiotics and update tetanus prophylaxis as indicated 
  • Control bleeding
    • direct pressure will control active bleeding
    • do not blindly clamp or place tourniquets on damaged extremities
  • Assessment
    • soft-tissue damage
    • neurovascular exam
  • Dressing
    • remove gross debris from wound 
    • place sterile saline-soaked dressing on the wound
  • Stabilize
    • splint fracture for temporary stabilization
      • decreases pain, further injury from bone ends, and disruption of clots
Basic Principles of Open Fracture Management in the Operating Room
  • Aggressive debridement and irrigation 
    • thorough debridement is critical to prevention of deep infection
    • low and high pressure lavage are equally effective in reducing bacterial counts 
    • saline shown to be most effective irrigating agent
      • on average, 3L of saline are used for each successive Gustilo type
        • Type I: 3L
        • Type II: 6L
        • Type III: 9L
    • bony fragments without soft tissue attachment can be removed
  • Fracture stabilization
    • can be with internal or external fixation, as indicated
  • Staged debridement and irrigation
    • perform every 24 to 48 hours as needed
  • Early soft tissue coverage or wound closure is ideal 
    • timing of flap coverage for open tibial fractures remains controversial
    • increased risk of infection beyond 7 days 
  • Can place antibiotic bead-pouch in open dirty wounds
    • beads made by mixing methylmethacrylate with heat-stable antibiotic powder 
Antibiotic Treatment
  • Gustilo Type I and II
    • 1st generation cephalosporin 
    • clindamycin or vancomycin can also be used if allergies exist
  • Gustilo Type III
    • 1st generation cephalosporin and aminoglycoside
  • Farm injuries or possible bowel contamination
    • add penicillin for anaerobic coverage (clostridium)
  • Duration
    • 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 until 24 hours after final closure if wound is not closed during initial surgical debridement
Bone Gap Reconstruction
  • Reconstruction options
    • Masquelet technique 
    • distraction osteogenesis
    • vascularized bone flap
Tetanus Prophylaxis
  • Initiate in emergency room or trauma bay
  • Two forms of prophylaxis 
    • toxoid dose 0.5 mL, regardless of age
    • immune globulin dosing
      • <5-years-old receives 75U
      • 5-10-years-old receives 125U
      • >10-years-old receives 250U
    • 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)
    • date of most recent vaccination
    • severity of wound


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Qbank (6 Questions)

(OBQ12.220) A 43-year-old male sustains the injury shown in Figure A. He has an overlying 3 centimeter wound with exposed bone. Which of the following antibiotics is indicated for initial prophylaxis? Topic Review Topic
FIGURES: A          

1. Ciprofloxacin
2. Vancomycin
3. Penicillin
4. Gentamycin
5. Cefazolin

(OBQ10.50) A 25-year-old male involved in a motorcyle accident sustains the injury seen in Figures A and B. After initial adequate debridement of nonviable tissue, which of the following irrigation methods and devices should be used? Topic Review Topic
FIGURES: A   B        

1. Antibiotic solution applied by low pressure gravity flow device
2. Antibiotic solution applied by high pressure pulsatile flow device
3. Saline solution applied by low pressure gravity flow device
4. Saline solution applied by high pressure pulsatile flow device
5. Antibiotic solution applied by high pressure pulsatile flow device followed by low pressure gravity flow device

(OBQ06.135) A 27-year-old man sustains a Gustilo and Anderson type II open tibia fracture during a motorcycle accident. He had his full 3 doses of tetanus vaccination as an infant. He also had a tetanus booster vaccination 18 months ago when he began a new job. In addition to intravenous antibiotics, what tetanus prophylaxis should be administered? Topic Review Topic

1. No prophylaxis required
2. Tetanus vaccine
3. Tetanus immune globulin
4. Tetanus vaccine and tetanus immune globulin
5. Tetanus vaccine and tetanus immune globulin with a booster vaccine required 6 months from now

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