Open fracture: Difference between revisions
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==Background== | ==Background== | ||
*Fractures that have communication with the outside environment are considered open | *Fractures that have communication with the outside environment are considered "open". | ||
*The fractured portion does not have to be overtly exposed | **The fractured portion does not have to be overtly exposed. | ||
*True orthopedic emergency | **Infection can lead to serious complications including nonunion and osteomyelitis. | ||
*True orthopedic emergency due to increased risk of infection from exposure of bone. | |||
**Early initial antimicrobial prophylaxis has been shown to reduce the risk of infection (ARR 6.5%, NNT = 16).<ref>The NNT. Accessed 4/23/2022. https://www.thennt.com/nnt/antibiotics-for-open-fractures/</ref> | |||
**Antibiotic prophylaxis for >24 hours duration has not been demonstrated to improve outcomes, including for type III open fractures.<ref>Dunkel N, Pittet D, Tovmirzaeva L, et al: Short duration of antibiotic prophylaxis in open fractures does not enhance risk of subsequent infection. Bone Joint J 2013;95-B:831-837.</ref> | |||
==Clinical Features== | ==Clinical Features== | ||
[[File:OpenFracture.JPG|thumb|Open fracture of finger wound]] | |||
[[File:Gustilo type 2 fracture.png|thumb|Gustilo Type 2 open fracture.]] | |||
[[File:PMC4292122 IJPS-47-412-g004.png|thumb|Open fracture grade IIIb, with lateral condyle tibia fracture site exposed.]] | |||
[[File:PMC3162697 JETS-4-325-g003.png|thumb|Type IIIb open fracture of mid leg.]] | |||
*Fracture with overlying wound suspected of reaching bone (i.e. "communicating"), regardless of how narrow wound may be | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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==Evaluation== | ==Evaluation== | ||
*ATLS | *[[ATLS]] | ||
*X-ray | *X-ray | ||
**Shows fracture type | |||
**Free air on x-ray may suggest open fracture in more equivocal cases (not sensitive) | |||
*Trauma labs | *Trauma labs | ||
===Grade I=== | ====Additional Considerations==== | ||
*Additional sites of injury found in 40-80% of cases | |||
*Nerve, vascular, muscular, and/or ligamentous injury | |||
===Gustilo-Anderson grading scale=== | |||
''As the grade increases, so does the risk of infection'' | |||
====Grade I==== | |||
*Wound <1cm | *Wound <1cm | ||
*Little soft tissue injury or crush injury | *Little soft tissue injury or crush injury | ||
*Moderately clean puncture site | *Moderately clean puncture site | ||
*Infection risk 0-12% | *Infection risk 0-12% | ||
===Grade II=== | |||
====Grade II==== | |||
*Laceration >1cm | *Laceration >1cm | ||
*No extensive soft tissue damage, but slight or moderate crush injury | *No extensive soft tissue damage, but slight or moderate crush injury | ||
*Moderate contamination | *Moderate contamination | ||
*Infection risk 2-12% | *Infection risk 2-12% | ||
===Grade III=== | |||
====Grade III==== | |||
*Extensive damage to soft tissue, including neurovascular structures and muscle | *Extensive damage to soft tissue, including neurovascular structures and muscle | ||
*High degree of contamination | *High degree of contamination | ||
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**III B: Loss of soft tissue and evidence of bone stripping (Infection risk 10-50%) | **III B: Loss of soft tissue and evidence of bone stripping (Infection risk 10-50%) | ||
**III C: Any fracture with an associated arterial injury that requires surgical repair (Infection risk 25-50%) | **III C: Any fracture with an associated arterial injury that requires surgical repair (Infection risk 25-50%) | ||
==Management== | ==Management== | ||
===Pain control=== | ===Pain control=== | ||
*[[Fentanyl]] | *Typically opioid pain control | ||
**[[Fentanyl]] (preferred initially for trauma patients with concern for possible [[hemorrhagic shock]]) or [[morphine]] (for longer-acting control) | |||
{{Antibiotics Open Fracture}} | {{Antibiotics Open Fracture}} | ||
===Wound Managment=== | |||
*Surgical debridement and washout | ===Wound Managment <ref>Ketonis C, Dwyer J, Ilyas AM. Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review. Hand (N Y). 2017;12(2):119-126.</ref>=== | ||
**Irrigation may be started in the ED for grossly contaminated wounds | *Surgical debridement and washout within 24 hours. | ||
**Thorough ED irrigation and debridement appears safe for hand (metacarpal, phalanx) fractures without excessive contamination | |||
*Irrigation may be started in the ED for grossly contaminated wounds | |||
**Place a sterile dressing over wound to decrease continued contamination | |||
*[[Tetanus prophylaxis]] | *[[Tetanus prophylaxis]] | ||
==Disposition== | ==Disposition== | ||
Admission to ortho or trauma surgery | *Admission to ortho or trauma surgery | ||
*Discharge may be considered for select fractures (e.g. metacarpal, phalanx without excessive contamination), typically after bedside washout by consulting service (e.g. orthopedics) | |||
==See Also== | ==See Also== | ||
Latest revision as of 09:32, 14 May 2022
Background
- Fractures that have communication with the outside environment are considered "open".
- The fractured portion does not have to be overtly exposed.
- Infection can lead to serious complications including nonunion and osteomyelitis.
- True orthopedic emergency due to increased risk of infection from exposure of bone.
Clinical Features
- Fracture with overlying wound suspected of reaching bone (i.e. "communicating"), regardless of how narrow wound may be
Differential Diagnosis
Extremity trauma
- Compartment syndrome
- Contusion
- Crush syndrome
- Degloving injury
- Fracture
- Laceration
- Myositis ossificans
- Open joint injury
- Peripheral nerve injury
- Rhabdomyolysis
- Tendon injury
- Vascular injury
Evaluation
- ATLS
- X-ray
- Shows fracture type
- Free air on x-ray may suggest open fracture in more equivocal cases (not sensitive)
- Trauma labs
Additional Considerations
- Additional sites of injury found in 40-80% of cases
- Nerve, vascular, muscular, and/or ligamentous injury
Gustilo-Anderson grading scale
As the grade increases, so does the risk of infection
Grade I
- Wound <1cm
- Little soft tissue injury or crush injury
- Moderately clean puncture site
- Infection risk 0-12%
Grade II
- Laceration >1cm
- No extensive soft tissue damage, but slight or moderate crush injury
- Moderate contamination
- Infection risk 2-12%
Grade III
- Extensive damage to soft tissue, including neurovascular structures and muscle
- High degree of contamination
- Infection risk 5-50%
- Further subcategorized:
- III A: Fracture covered by soft tissue (Infection risk 5-10%)
- III B: Loss of soft tissue and evidence of bone stripping (Infection risk 10-50%)
- III C: Any fracture with an associated arterial injury that requires surgical repair (Infection risk 25-50%)
Management
Pain control
- Typically opioid pain control
- Fentanyl (preferred initially for trauma patients with concern for possible hemorrhagic shock) or morphine (for longer-acting control)
Prophylactic Antibiotics for Open fractures
Initiate as soon as possible; increased infection rate when delayed[3]
Grade I & II Fractures Options
- Cefazolin (Ancef) 2 g IV (immediately and q8 hours x 3 total doses)[4]
- Cephalosporin allergy: clindamycin 900 mg IV (immediately and q8 hours x 3 total doses)[4]
Grade III Fracture Options
- Ceftriaxone 2 g IV (immediately x 1 total dose) PLUS vancomycin 1 g IV (immediately and q12 hours x 2 total doses)[4]
- Cephalosporin allergy: aztreonam 2 g IV (immediately and q8 hours x 3) PLUS vancomycin 1 g IV (immediately and q12 hours x 2 total doses)[4]
Special Considerations
- Concern for clostridium (soil contamination, farm injuries, possible bowel contamination): additionally add penicillin[5][4]
- Fresh water wounds: fluoroquinolones OR 3rd/4th generation cephalosporin
- Saltwater wounds (vibrio): doxycycline + ceftazidime OR fluoroquinolone
Wound Managment [6]
- Surgical debridement and washout within 24 hours.
- Thorough ED irrigation and debridement appears safe for hand (metacarpal, phalanx) fractures without excessive contamination
- Irrigation may be started in the ED for grossly contaminated wounds
- Place a sterile dressing over wound to decrease continued contamination
- Tetanus prophylaxis
Disposition
- Admission to ortho or trauma surgery
- Discharge may be considered for select fractures (e.g. metacarpal, phalanx without excessive contamination), typically after bedside washout by consulting service (e.g. orthopedics)
See Also
External Links
References
- ↑ The NNT. Accessed 4/23/2022. https://www.thennt.com/nnt/antibiotics-for-open-fractures/
- ↑ Dunkel N, Pittet D, Tovmirzaeva L, et al: Short duration of antibiotic prophylaxis in open fractures does not enhance risk of subsequent infection. Bone Joint J 2013;95-B:831-837.
- ↑ Gosselin RA, et al. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004; (1):CD003764.
- ↑ 4.0 4.1 4.2 4.3 4.4 Garner MR, et al. Antibiotic Prophylaxis in Open Fractures: Evidence, Evolving Issues, and Recommendations. Journal of the American Academy of Orthopaedic Surgeons. April 15, 2020. 28(8):309-315
- ↑ HoffWS, Bonadies JA, Cachecho R, Dorlac WC: East practice management guidelines work group: Update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma 2011;70:751-754.
- ↑ Ketonis C, Dwyer J, Ilyas AM. Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review. Hand (N Y). 2017;12(2):119-126.