Open Fractures - Wheeless' Textbook of Orthopaedics

- See: open tibia fractures, open fractures of femur

- Discussion:
- treat all open fractures as an emergency;
- perform thorough initial eval to dx other life-threatening injuries: (see trauma management);
- open joint injuries
- gun shot wounds:

- Sequential Management:

- antibiotics:
- therapeutic doses of ancef and tobramycin for 48 hrs are appropriate;
- w/ contamination consider anaerobic antibiotics (penicillins, clindamycin, flaggyl);
- tetanus prophylaxis if appropriate;
- references:
- Once daily high-dose gentamicin to prevent infection in open fractures of the tibial shaft: a preliminary investigation.
                  - Once daily, high dose versus divided, low dose gentamicin for open fractures.
                  - Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, cipro, to combination antibiotic therapy in open fracture wounds.
- Ciprofloxacin Inhibition of Experimental Fracture-Healing.
- Clostridial myonecrosis.
  - The use of antibiotics in open fractures.
   - Duration of preventive antibiotic administration for open extremity frx;

- debridement and irrigation:
         - bacterial cultures:
- initial bacterial cultures are probably not helpful;
- references:
- Efficacy of primary wound cultures in long bone open extremity fractures: are they of any value?
- Epidemiology of bacterial infection during management of open leg fractures.
- Efficacy of cultures in the management of open fractures.
                      - The significance of perioperative cultures in open pediatric lower-extremity fractures.
         - debridement of open tibial fractures:
- skin preparation:
- topical antimicrobials:
- pressure irrigation;
- immediately debride the wound using copious irrigation (9 lit) and, for type-II and type-III fractures, repeat the debridement in 24 to 72 hours;
- note that wounds contaminated by dirt (vs grease, asphault ect) need aggressive repeated debridement inorder to avoid
infection and subsequent osteomyeltis);
- references:
- Comparison of isotonic saline, distilled water and boiled water in irrigation of open fractures.
- The use of bacitracin irrigation to prevent infection in postoperative skeletal wounds. An experimental study.
- Efficacy of cultures in the management of open fractures.
- The Effect of Surgical Delay on Acute Infection Following 554 Open Fractures in Children.
- Comparison of Soap and Antibiotic Solutions for Irrigation of Lower-Limb Open Fracture Wounds.
- Outcomes in open tibia fractures: relationship between delay in treatment and infection.
- A review of open tibia fractures in children.
- The use of detergent irrigation for musculoskeletal wounds.
- Treatment of isolated type I open fractures: is emergent operative debridement necessary?
                 - The effect of the timing of antibiotics and surgical treatment on infection rates in open long-bone frx: A 9-yr prospective study from a district general hospital.

- fracture stabilization:
         - synthes product menu
         - open tibia fractures
         - open fractures of femur
         - references:
- The role of early internal fixation in the management of open fractures. Chapman COOR: 138: 120-131, 1979;
- Immediate internal fixation of open fractures of the diaphysis of the forearm.
- The influence of skeletal implants on incidence of infection. Experiments in a canine model.
- Nonoperative management of pediatric type I open fractures.

- timing of wound closure:
- wound closure of open tibial fractures
- soft tissue coverage:
- general wound management:
- contaminated wound care:
- drains and closure of wounds
- wound dressings and wound vac:
- in most cases, a delayed primary closure is performed for open wounds, but surgical incisions made during the case can be closed primarily;
- issues involve complete removal of foreign debris as well as need to reassess devitalized muscle;
- antibiotic bead pouch or wound vac are useful methods of covering the wound;
- second look debridement can be performed at 48 hours w/ wound closure;

- bone grafting:
- management of tibial defects and bone grafting for open tibia fracture
- it is controversial as to whether bone grafting should be performed in open fractures;
- in the study by Chapman et al (JBJS 1997) 31% of open fractures were treated w/ bone graft substitutes and 28% of open fractures were
treated w/ autogenous bone grafts;
- in this same study, infection at the fracture site occured in 5% of patients in which bone graft substitutes were used versus 13% of fractures in
which autogenous grafts were used;

- references:

Local antibiotic therapy for severe open fractures. A review of 1085 consecutive cases.

Review: Treatment of Compound Fractures.

The early management of open joint injuries. A prospective study of one hundred and forty patients.

The use of quantitative bacterial counts in open fractures.

Year Book: Risk of Infection After Open Fracture of the Arm or Leg.

Prevention of Infection in the Treatment of 1,025 open fractures of long bones. Gustilo RB, Anderson JT. JBJS 58-A: p 453-458, 1976. .

The early management of open joint injuries. A prospective study of one hundred and forty patients.

Lead arthropathy: arthritis caused by retained intra-articular bullets.

Duration of preventive antibiotic administration for open extremity frx;