Open Fracture Management

Paul Fawson 1st Year Resident

Goals

1) Treat all frx as an emergency2) Thorough exam of life threatening injuries3) Begin abx4) Debride type II-III frx5) Stabilize the frx6) Leave wound open for 5-7 days7) Early autogenous cancellous bone grafting8) 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• I . BEHRENS, FRED, and SEARLS, KATE: External Fixation of the Tibia. Basic Concepts and Prospective Evaluation. J. Bone and Joint Surg. , 68-• B(2): 246-254, 1986.• 2. BLICK, S. S. ; BRUMBACK, R. J. ; POKA, ATTILA; BURGESS, A. R. ; and EBRAHEIM, N. A.: Compartment Syndrome in Open Tibial Fractures. J.• Bone and Joint Surg. , 68-A: 1348-1353, Dec. 1986.• 3. BONDURANT, F. J. ; COTLER, H. B. ; BUCKLE, R. : MILLER-CROTCHETT, P. ; and BROWNER, B. D. : The Medical and Economic Impact of Severely• Injured Lower Extremities. J. Trauma, 28: 1270-1273, 1988.• 4. BONE, L. B. ; JOHNSON, K. D.; WEIGELT, JOHN; and SCHEINBERG, R. : Early versus Delayed Stabilization of Femoral Fractures. A Prospective• Randomized Study. J. Bone and Joint Surg. , 71-A: 336-340, March 1989.• 5. BUNKIS, JURIS; WALTON, R. L. ; and MATHES, S. J. : The Rectus Abdominis Free Flap for Lower Extremity Reconstruction. Ann. Plast. Surg.,• 11: 373-380, 1983.• 6. CAUDLE, R. J. , and STERN, P. J. : Severe Open Fractures of the Tibia. J. Bone and Joint Surg. , 69-A: 801-807, July 1987.• 7. CHAPMAN, M. W. : The Role of Intramedullary Fixation in Open Fractures. Clin. Orthop. , 212: 26-33, 1986.• 8. CHAPMAN, M. W. , and MAHONEY, MICHAEL: The Role of Early Internal Fixation in the Management of Open Fractures. Clin. Orthop. , 138:• 120-131, 1979.• 9. CHAPMAN, M. W. ; GORDON, J. E. ; and ZISsIM0S, A. : Compression-Plate Fixation of Acute Fractures of the Diaphyses of the Radius and Ulna.• J. Bone and Joint Surg. , 71-A: 159-169, Feb. 1989.• 10. CIERNY, GEORGE, III: BYRD, H. S. ; and JONES, R. E. : Primary versuDeslayed Soft Tissue Coverage for Severe Open Tibial Fractures. A• Comparison of Results. Clin. Orthop. , 178: 54-63, 1983.• 1 1 . DELLINGER, E. P. ; MILLER, S. D. ; WERTZ, M. J. ; GRYPMA, MARTIN; DROPPERT, BETH; and ANDERSON, P. A. : Risk of Infection after Open• Fracture of the Arm or Leg. Arch. Surg. , 123: 1320-1327, 1988.• 12. DELLINGER, E. P. ; CAPLAN, E. S. ; WEAVER, L. D.; WERTZ, M. J. ; DROPPERT, B. M.; HOYT, NANCY; BRUMBACK, ROBERT; BURGESS, A.; POKA,• ATTILA; BENIRSCHKE, S. K.; LENNARD, E. S.; and LoU, M. A. , SR.: Duration of Preventive Antibiotic Administration for Open Extremity• Fractures. Arch. Surg. , 123: 333-339, 1988.• 13. GUSTILO, R. B. , and ANDERSON, J. T. : Prevention of Infection in the Treatment of One Thousand and Twenty-five Open Fractures of Long Bones.• Retrospective and Prospective Analyses. J. Bone and Joint Surg. , 58-A: 453-458, June 1976.• 14. GUST1LO, R. B.; GRUNINGER, R. P.; and DAVIS, TRACY: Classification of Type III (Severe) Open Fractures Relative to Treatment and Results.• Orthopedics, 10: 1781-1788, 1987.• 15. GUSTILO, R. B.; MENDOZA, R. M.; and WILLIAMS, D. N.: Problems in the Management ofType III (Severe) Open Fractures. A New Classification• of Type III Open Fractures. J. Trauma, 24: 742-746, 1984.• 16. KARLSTROM, GORAN, and OLERUD, SVEN: Percutaneous Pin Fixation of Open Tibial Fractures. Double-Frame Anchorage Using the Vidal-Adrey• Method. J. Bone and Joint Surg. , 57-A: 915-924, Oct. 1975.• 17. KLEMM, K. W. , and BORNER, M.: Interlocking Nailing of Complex Fractures of the Femur and Tibia. Clin. Orthop., 212: 89-100, 1986.• 18. LANGE, R. H. ; BACH, A. W.; HANSEN, S. T. , JR.; and JOHANSEN, K. H.: Open Tibial Fractures with Associated Vascular Injuries. Prognosis for• Limb Salvage. J. Trauma, 25: 203-208, 1985.• 19. LAWRENCE, R. M.; HOEPRICH, P. D. ; HUSTON, A. C.; BENSON, D. R.; and RIGGINS, R. S.: Quantitative Microbiology of Traumatic Orthopedic• Wounds. J. Clin. Microbiol. , 8: 673-675, 1978.

References• 20. LHOWE, D. W. , and HANSEN, S. T.: Immediate Nailing of Open Fractures of the Femoral Shaft. J. Bone and Joint Surg. , 70-A: 812-820, July• 1988.• 21. MCCRAW, J. B. , and ARNOLD, P. G.: McCraw and Arnold’s Atlas of Muscle and Musculocutaneous Flaps. Norfolk, Virginia, Hampton Press,• 1986.• 22. MCCRAW, J. B.; FISHMAN, J. H. ; and SHARZER, L. A.: The Versatile Gastrocnemius Myocutaneous Flap. Plast. and Reconstr. Surg. , 62: 15-23,• 1978.• 23. MCGRAW, J. M. , and LIM, E. V. A. : Treatment of Open Tibial-Shaft Fractures. External Fixation and Secondary Intramedullary Nailing. J. Bone• and Joint Surg. , 70-A: 900-91 1 , July 1988.• 24. MATHES, S. J. ; MCCRAW, J. B. ; and VASCONEZ, L. 0. : Muscle Transposition Flaps for Coverage of Lower Extremity Defects. Surg. Clin. North• America, 54: 1337-1354, 1974.• 25. MAY, J. W. ; GALLICO, G. G. , III; JUPITER, J. ; and SAVAGE, R. C. : Free Latissimus Dorsi Muscle Flap with Skin Graft for Treatment of Traumatic• 304 R. B. GUSTILO, R. L. MERKOW, AND DAVID TEMPLEMAN Chronic Bony Wounds. Plast. and Reconstr. Surg. , 73: 641-649, 1984.• 26. MOED, B. R. ; KELLAM, J. F.; FOSTER, R. J.; TILE, MARVIN; and HANSEN, S. T.: Immediate Internal Fixation of Open Fractures of the Diaphysis• of the Forearm. J. Bone and Joint Surg. , 68-A: 1008-1017, Sept. 1986.• 27. NEALE, H. W. ; STERN, P. J.; KREILEIN, J. G.; GREGORY, R. 0.; and WEBSTER, K. L.: Complications of Muscle-Flap Transposition for Traumatic• Defects of the Leg. Plast. and Reconstr. Surg., 72: 512-515, 1983.• 28. OLERUD, SVEN, and KARLSTROM, GORAN: The Spectrum of Intramedullary Nailing of the Tibia. Clin. Orthop., 212: 101-112, 1986.• 29. PATZAKIS, M. J. ; HARVEY, J. P. , JR. ; and IVLER, DANIEL: The Role of Antibiotics in the Management of Open Fractures. J. Bone and Joint Surg.,• 56-A: 532-541, April 1974.• 30. PATZAKIS, M. J. ; WILKINS, J. ; and MOORE, T. M. : Considerations in Reducing the Infection Rate in Open Tibial Fractures. Clin. Orthop. , 178:• 36-41, 1983.• 31 . PONTEN, BENGT: The Fasciocutaneous Flap: Its Use in Soft Tissue Defects of the Lower Leg. British J. Plast. Surg., 34: 215-220, 1981.• 32. RITTMANN, W. W. ; SCHIBLI, M. ; MATTER, P. ; and ALLGOWER, M. : Open Fractures. Long-Term Results in 200 Consecutive Cases. Clin. Orthop.,• 138: 132-140, 1979.• 33. ROMMENS, P. , and SCHMIT-NEUERBURG, K. P. : Ten Years of Experience with the Operative Management of Tibial Shaft Fractures. J. Trauma,• 27: 917-927, 1987.• 34. ROSENSTE1N, B. D. ; WILSON, F. C. ; and FUNDERBURK, C. H. : The Use of Bacitracin Irrigation to Prevent Infection in Postoperative Skeletal• Wounds. J. Bone and Joint Surg. , 71-A: 427-430, March 1989.• 35. ROTH, A. I.; FRY, D. E.; and POLK, H. C. , JR.: Infectious Morbidity in Extremity Fractures. J. Trauma, 26: 757-761 , 1986.• 36. TAKAMI, HIR0SHI; TAKAHASHI, SADAO; and AND0, MASASHI: Microvascular Free Musculocutaneous Flaps for the Treatment of Avulsion Injuries• of the Lower Leg. J. Trauma, 23: 473-477, 1983.• 37. TEMPLEMAN, D. C. ; SWEENY, CHRISTOPHER T. ; CHAPMAN, M. W. ; GUSTILO, R. B.; KYLE, R. F. ; BRAY, R. J. T. ; and GORDON, J. E. : Critical• Analysis of the Management of Open Femur Fractures at Two Regional Trauma Centers. Read at the Annual Meeting of The American Academy• of Orthopaedic Surgeons, Las Vegas, Nevada, Feb. 13, 1989.• 38. TOLHURST, D. E. : Surgical Indications for Fasciocutaneous Flaps. Ann. Plast. Surg. , 13: 495-503, 1984.• 39. VELAZCO, A. ; WHITES1DES, T. E. , JR. ; and FLEMING, L. L. : Open Fractures of the Tibia Treated with the Lottes Nail. J. Bone and Joint Surg.,• 65-A: 879-885, Sept. 1983.

References

• 40. WEILAND, A. J. ; MooRE, J. R. ; and HOTCHKISS, R. N. : Soft Tissue Procedures for Reconstruction of Tibial Shaft Fractures. Clin. Orthop. , 178: 42-53, 1983.

• 41. WISS, D. A.: Flexible Medullary Nailing of Acute Tibial Shaft Fractures. Clin. Orthop., 212: 122-132, 1986.

• 42. WORLOCK, PETER; SLACK, RICHARD; HARVEY, LEN; and MAWHINNEY, ROD: The Prevention of Infection in Open Fractures. J. Bone and Joint Surg. , 70-A: 1341-1347, Oct. 1988.

• 43. WRIGHT, J. K. , and WATKINS, R. P.: Use of the Soleus Muscle Flap to Cover Part of the Distal Tibia. Plast. and Reconstr. Surg. , 12: 957-958,1981.