Overview
Open fractures are common and have a high potential for morbidity and mortality. They are commonly associated with infection, osteomyelitis, compartment syndrome, and amputation. The tibia is the most commonly involved bone.
- 4 essentials of managing open fractures
- Antibiotic and Tetanus prophylaxis
- Wound and fracture debridement
- Stabilization of the fracture (reduction and fixation)
- Early definitive wound cover
Classification of Open Fractures
The Gustilo-Anderson classification is commonly used to classify open fractures. It is useful because it accounts for the risk factors for infection which are related to the injury itself (size of the wound, degree of soft tissue injury, soft tissue coverage, and degree of contamination). A limitation of the Gustilo-Anderson classification system is that it does not differentiate the degree of vascular damage.
Gustilo-Anderson Classification of Open Fractures
| Grade | Infection risk | Energy of trauma | Wound size | Soft tissue injury | Contamination | Fracture pattern | Soft tissue coverage | Vascular injury |
|---|---|---|---|---|---|---|---|---|
| I | 0 – 2 % | Low | < 1cm | Low | No | Simple. No comminution. | Yes | No |
| II | 2 – 7 % | Moderate | 1 – 10 cm | Moderate | Low | Simple. Some comminution. | Yes | No |
| IIIA | 10 – 25 % | High | > 10 cm | Extensive | Severe | Severe Comminution. | Yes | No |
| IIIB | 10 – 50 % | High | > 10 cm | Extensive | Variable | Severe Comminution. | No, requires reconstruction | No |
| IIIC | 25 – 50 %. 50 % amputation rate | High | > 10 cm | Extensive | Variable | Severe Comminution. | Variable | Yes |
A Type IIIC fracture is associated with vascular (arterial) injury irrespective of the degree of soft-tissue injury (even though it is typically a high-energy injury with contamination and significant soft tissue injury). A traumatic amputation can be classified as a Grade IIID. A type IIIB fracture has extensive soft-tissue loss + periosteal stripping + bone damage requiring flaps for soft-tissue coverage.
Antibiotic and Tetanus prophylaxis
Open fractures have a high risk of infection from staphylococcus and streptococcus. Gram negative species can also infect Type III fractures. Antibiotic treatment should be initiates as soon as possible (within 3 hours of injury). Washout should be performed within 6 hours and antibiotics should be continued no more than 24 hours after the wound is closed (OR 72 hours for type III fractures if the wound is not closed).
- When should antibiotics be given for open fractures?
- As soon as possible (within 3 hours of injury)
- Gustilo I: Continued prophylaxis after surgery (wound closure) for 24 hours
- Gustilo II/III: continued prophylaxis between procedures and after final surgery (if the wound is not closed) for 72 hours
- What to give patient with unknown history of tetanus vaccination?
- Tetanus Toxoid + Human Tetanus Immune Globulin
- What to give patient with last history of vaccination ≥ 5 years ago?
- Tetanus Toxoid
- When can gentamicin be given for open fractures?
- For type III fractures (gram negative coverage)
- At debridement; added onto co-amoxiclav
- When can gentamicin + vancomycin (or teicoplanin) be given for open fractures?
- At delayed closure for Gustilo type II, III
Antibiotics used for open fractures
| Antibiotics | Coverage | Open Fractrure |
|---|---|---|
| First-generation cephalosporin (Cefazolin) | Gram positive | All open fracture |
| Clindamycin | Gram positive if anaphylactic allergy to cephalosporin | All open fractures |
| Aminoglycoside (Gentamicin) | Gram negative | Added for Gustilo III |
| Piperacillin/Tazobactam | Broad spectrum gram-positive and gram-negative coverage | Farmyard, soil, or standing water regardless of injury |
Tetanus prone wounds
| Wound characteristic | Tetanus prone |
|---|---|
| Time since injury < 6 hours | No |
| Time since injury > 6 hours | Yes |
| Depth < 1cm | No |
| Depth > 1cm | Yes |
| Crush, burn, gunshot, frostbite, penetrating injury through clothing | Yes |
| Presence of necrotic or devitalized tissue | Yes |
| Foreign material (dirt or grass) present | Yes |
Determining appropriate tetanus treatment
| Year since immunization | Wound characteristic | Tetanus treatment |
|---|---|---|
| < 5 years | Clean or tetanus prone | None |
| 5-10 years | Clean | None |
| Tetanus prone | Tetanus toxoid 0.5 mL IM (booster) | |
| > 10 years | Clean or tetanus prone | Tetanus toxoid 0.5 mL IM (booster |
| Never immunized | Clean | Full tetanus immunization regimen: Tetanus toxoid 0.5 mL IM 0 day, 4 weeks, and 6-12 months |
| Tetanus prone | Full tetanus immunization regimen: Tetanus toxoid 0.5 mL IM 0 day, 4 weeks, and 6-12 months. Also give human tetanus immunoglobulin 250 IU, deep IM but not in the same area as the toxoid injection |
Wound and Fracture Debridement
- Principles to follow during wound debridement
- Wound excision: excise wound margins only enough to leave healthy skin edges
- Wound extension: for thorough cleaning, extend the wound at fasciotomy incisions (longitudinally) to avoid damaging important perforator vessels
- Delivery of the fracture: extract the bone from within the wound (in the manner in which it was forced at the moment of injury) to examine the fracture surfaces
- Removal of devitalized tissue: remove dead muscle, dead fracture ends or other soft tissue. Viable tissue should bleed. Viable muscle should bleed and contract.
- Wound cleansing: irrigate with up to 3L for type I, 6L for type II, and 9L for Type III wounds. Adding antibiotics or antiseptics to the solution has no added benefit
- Nerves and tendons: best to leave them alone. Repair only when the wound is absolutely clean, no dissection is required, and experts are available
Stabilization of the Fracture
- When is external fixation used as a temporary measure for open fractures
- For delayed closure: It is much safer to use a temporizing external fixator, then replace it with an internal fixator in 7 days than by using an internal fixator at the time of surgery
- What conditions must be met for the external fixator to be exchanged for internal fixation at definitive wound cover
- Delay to wound cover is less than 7 days
- Wound contamination is not visible
- Internal fixation can control the fracture just as well as the external fixator
Definitive Wound Cover
- Which Gustilo grades can be closed primarily at the time of debridement
- Gustilo I
- Gustilo II (may also require delayed closure)
- Which Gustilo grades undergo delyed closure
- Gustilo IIIA (closure after ‘second look’ procedure preferred by most surgeons)
- Gustilo IIIB/C
