Open fracture: Difference between revisions
| (4 intermediate revisions by 2 users not shown) | |||
| Line 16: | Line 16: | ||
*Trauma labs | *Trauma labs | ||
===Grade I=== | ===Gustilo-Anderson grading scale=== | ||
''As the grade increase, 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 | ||
| Line 35: | Line 40: | ||
**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%) | ||
===Additional Considerations=== | ====Additional Considerations==== | ||
*Fracture with non-communicating overlying wound | *Fracture with non-communicating overlying wound | ||
*Additional sites of injury found in 40-80% of cases | *Additional sites of injury found in 40-80% of cases | ||
| Line 46: | Line 51: | ||
===[[Antibiotics (Main)|Prophylactic Antibiotics]]=== | ===[[Antibiotics (Main)|Prophylactic Antibiotics]]=== | ||
{{Antibiotics Open Fracture}} | {{Antibiotics Open Fracture}} | ||
===Wound Managment=== | ===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>=== | ||
*Surgical debridement and washout | *Surgical debridement and washout within 24 hours. | ||
**Irrigation may be started in the ED for grossly contaminated wounds | **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]] | ||
Revision as of 00:34, 6 November 2019
Background
- Fractures that have communication with the outside environment are considered open
- The fractured portion does not have to be overtly exposed
- True orthopedic emergency
Clinical Features
- Suspect open fracture with overlying wound regardless of how small
- Free air on x-ray may suggest open fracture in more equivocal cases
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
- Trauma labs
Gustilo-Anderson grading scale
As the grade increase, 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%)
Additional Considerations
- Fracture with non-communicating overlying wound
- Additional sites of injury found in 40-80% of cases
- Nerve, vascular, muscular, and/or ligamentous injury
Management
Pain control
Prophylactic Antibiotics
Prophylactic Antibiotics for Open fractures
Initiate as soon as possible; increased infection rate when delayed[1]
Grade I & II Fractures Options
- Cefazolin (Ancef) 2 g IV (immediately and q8 hours x 3 total doses)[2]
- Cephalosporin allergy: clindamycin 900 mg IV (immediately and q8 hours x 3 total doses)[2]
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)[2]
- 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)[2]
Special Considerations
- Concern for clostridium (soil contamination, farm injuries, possible bowel contamination): additionally add penicillin[3][2]
- Fresh water wounds: fluoroquinolones OR 3rd/4th generation cephalosporin
- Saltwater wounds (vibrio): doxycycline + ceftazidime OR fluoroquinolone
Wound Managment [4]
- 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
See Also
External Links
References
- ↑ Gosselin RA, et al. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004; (1):CD003764.
- ↑ 2.0 2.1 2.2 2.3 2.4 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.