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Management of Open Fractures

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Title: Management of Open Fractures


1
Management of Open Fractures
  • Christine Kennedy
  • Pediatric Emergency Fellow
  • October 22, 2009

2
Objectives
  1. Review the different types of open fractures
  2. Discuss the current treatment of open fractures
  3. Review the literature supporting non-operative
    management of Type 1 open fractures

3
Introductory Case
  • 8 yr boy with a midshaft radius ulna
  • Obvious deformity on clinical exam
  • Small scab on volar surface of forearm
  • not actively bleeding
  • Xray.

4
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5
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6
Case
  • Question wasDoes this need to go to the OR?
  • Ortho consultedadvised to attempt a closed
    reduction and give a dose of Ancef
  • If successful, mark wound area on cast, send home
    on Keflex and F/U in ortho clinic
  • During the reductionwound started to ooze on my
    foot

7
Post-reduction X-Rays
8
Case-Follow up at day 39
9
Open Fracture ClassificationGustilo and Anderson
  • Type I
  • Clean wound lt1 cm in length
  • is simple, transverse or oblique with little
    comminution
  • Type II
  • Laceration gt1cm without extensive soft tissue
    damage, flaps or avulsions
  • Type III
  • Extensive soft tissue damage, crushing or a
    traumatic amputation
  • Subtypes 3A, 3B, 3C

10
Open Fracture Classification
  • Type 3 subtypes
  • 3A Adequate soft tissue coverage
  • 3B Inadequate soft tissue coverage
  • 3C Arterial injury requiring repair

3B
11
Open Fracture Classification
12
Open Fracture Classification
Type I
Type I
Type IIIc
Type IIIb
13
Open Fracture ClassificationGustilo and Anderson
  • Type I Infection rate 0-2
  • Clean wound lt1 cm in length
  • is simple, transverse or oblique with little
    comminution
  • Type II Infection rate 2-7
  • Laceration gt1cm without extensive soft tissue
    damage, flaps or avulsions
  • Type III Infection rate 10-25
  • Extensive soft tissue damage, crushing or a
    traumatic amputation

Gustilo et al. Current Concepts Review The
Management of Open Fractures. Journal of Bone
and Joint Surgery. 199072299-304.
14
Open Fracture vs Abrasion
15
Open Fracture vs Abrasion
  • Open fracture
  • disruption of the dermis with communication into
    the subcutaneous tissue contiguous with the bone

16
Open Fracture vs Abrasion
  • Abrasion
  • Soft tissue injury into the dermis (not through
    the dermis)
  • usually due to friction or shearing
  • An abrasion on its own over a fracture does not
    communicate with the fracture because the sc
    tissue is intact
  • The pattern of bleeding from an abrasion is
    pinpoint dermal bleeding
  • If you squeeze an abrasion, you may get bleeding
    but the pattern is different than a laceration
    that extends into the deeper tissue

17
How do the Orthopedic Surgeons decide?
  • Probing the wound is not recommended
  • Pull on the skin adjacent to the wound to see if
    you can SEE any subcutaneous fat as evidence that
    the dermis is broken
  • Contact the on call surgeon to discuss

18
How Common are Open Fractures?
  • For forearm fractures (most common fracture
    pattern in children)
  • 0.5-4.5 are open

Luhmann et al. Complications and Outcome of Open
Pediatric Forearm Fractures. J Pediatr Orthop
2004241-6.
19
Management of Open Fractures
  • Traditionally
  • Considered a true surgical emergency
  • Required operative debridement and fracture
    stabilization
  • Golden Period was 6-12 hours from time of
    patient arrival

20
Management of Open Fractures
  • Now.
  • Type II III
  • Require surgical debridement
  • Wounds with high energy injuries result in
    devitalized tissue, local edema ischemia
  • This alters the ability of local host defenses to
    resist infection

21
Management of Open Fractures
  • Type 1
  • Operative vs non-operative, why the controversy?

22
Type 1 Open Fractures
  • Maintain a relatively intact soft tissue envelope
    therefore the vascular supply to the zone of
    injury is preserved
  • This decreases the risk factors for development
    of infection
  • Devitalized tissue
  • Ischemia
  • Edema

23
Type 1 Open Fractures
  • Allows adequate penetrance of the host defense
    mechanisms and IV antibiotics to protect further
    against possible infection

24
Type 1 Open Fractures
  • Routine operative debridement might cause
    increased soft tissue trauma, periosteal
    stripping and osseous devascularization

25
Type 1 Open Fractures
  • Children have better healing potential than
    adults
  • Differences in the malleability strength of the
    bone
  • Better vascular supply to the extremities
  • Thicker periosteum

26
In the old orthopedic literature
  • Cases of gas gangrene in children with open
    fractures managed non-operatively
  • Before the routine use of antibiotics

27
Infection Rate with Operative Management
  • Literatures infection rate for type 1 open
    fractures treated operatively is an average of
    1.9

28
Infection Rate with Operative Management
29
Infection Rate with Operative Management
30
Organisms Cultured from Open Fractures
  • The majority of bacteria cultured are normal skin
    flora
  • Staphylococcus epidermidis
  • Proprionibacterium acnes
  • Corynebacterium species

31
Organisms Cultured from Open Fractures
  • Farm related injuries increase the risk of
  • Clostridium perfringens
  • Exposure to fresh water increases the risk of
  • Pseudomonas aeruginosa
  • Aeromonas hydrophilia

32
Organisms Cultured from Open Fractures
  • The frequent growth of S. aureus P. aeruginosa
    from patients who have an infection contrasts
    with the infrequent growth of these organisms on
    initial wound culture
  • Suggests that these infections are acquired in
    the hospital

33
Importance of Antibiotics
  • Prospective, double blind, randomized study
  • Infection rate was
  • 13.9 in placebo group
  • 9.7 in group treated with Penicillin
    Streptomycin
  • 2.3 in group treated with a 1st generation
    cephalosporin

Patzakis et al. The Role of Antibiotics in the
Management of Open Fractures. The Journal of
Bone and Joint Surgery 197456532-541.
34
Importance of Antibiotics
  • Meta-analysis demonstrated a significant
    reduction in wound infections in patients who
    received antibiotics for all types of open
    fractures
  • 13.4 of patients who were not treated with
    antibiotics developed an infection
  • 5.5 of treated patients developed an infection
  • NNT 13 8-25

35
Which Antibiotic?
  • Most common pathogens causing infections after
    open fractures
  • Staphylococcus aureus
  • Facultative gram-negative bacilli
  • In type I open fractures
  • 1st generation cephalosporin sufficient
  • In type II III
  • Combinations therapy with a cephalosporin and an
    aminoglycoside OR 3rd generation cephalosporin

36
Timing of Antibiotics is Important
  • One study with over 1000 open fractures found
    that starting antibiotics within 3 hours of
    injury lowered the infection rate
  • Infection rate 4.7 if antibiotics w/in 3 hours
  • Infection rate 7.4 if antibiotics started gt3h
    after injury
  • Of note, surgical debridement was performed for
    all open fractures in this study

37
Guidelines for Antibiotic Length?
  • No standardized protocol for length of Abx
    following open fractures
  • One report published which demonstrated no
    difference b/w 1 5 days of IV Abx
  • In the adult literature, anywhere from 1-3 days
    of antibiotics is the recommendation

38
Non Operative Management of Type 1 Open Fractures
  • What does the literature say these days?

39
  • Reviews the results of non operative management
    of type I open fractures in children
  • Retrospective chart review (1998-2003)
  • 40 patients followed until healed
  • clinically radiographically
  • 1 deep infection occurred
  • overall infection rate 2.5

40
  • 0 infection rate in the 32 upper extremity type
    I open fractures
  • 0 infection rate in the 23 patients under 12
    years

41
Details of Study 1
  • 40 patients diagnosed with type 1 open fracture
  • 33 boys, 7 girls
  • Age 10 years range 4-15y
  • Fracture distribution
  • 8 tibia
  • 18 diaphyseal radius ulna
  • 14 distal radius ulna
  • Mechanism
  • Most low-moderate energy
  • Falls from bikes, skateboards, rollarblades,
    scooters
  • 7 kids hit by motor vehicle

42
Details of Study 1
  • Treatment Initiated in the ED
  • Initiation of IV antibiotics
  • Cleansing and/or irrigation of the open wound
    with Betadine saline
  • Protecting the wound with Xeroform sterile
    gauze
  • Tetanus prophylaxis if needed
  • Closed reduction immobilization

43
Details of Study 1
  • Patients were admitted to hospital for 48-72
    hours for observation, continued IV antibiotics
    and wound management
  • Patients were discharged w/o abx
  • but 4/40 were sent home on 1 week of Keflex, at
    the treating surgeons discretion

44
Details of Study 1
  • Patients were followed until fracture union
  • Clinically no longer tender at fracture site
  • Radiologically bridged by sufficient callus

45
Details of Study 1
  • Definitions
  • Deep infection proceeded to debridement
  • Increasing pain, drainage from the wound and
    radiologic changes within the bone
  • Superficial infections
  • Inflammation of the skin/subcutaneous tissue w/o
    radiologic evidence of osteomyelitis

46
Results of Study 1
  • Average hospital stay 2.5 days (1-5)
  • No documented fevers
  • No patients developed malunion/nonunion
  • No patients developed osteomyelitis
  • No wound complications during admission
  • No superficial infections
  • 1 deep infection of the tibia (at 3 months)

47
Results of Study 1
48
Results of Study 1
49
Results of Study 1
50
Results of Study 1
51
Results of Study 1
52
Results of Study 1
53
Results of Study 1
54
How does this healing compare to fracture healing
after OR irrigation?
55
How does this healing compare to fracture healing
after OR irrigation?
56
Results of Study 1
57
Results of Study 1
58
Results of Study 1
59
Results of Study 1
60
Results of Study 1
  • The 1 infection
  • 15 yr male, comminuted midshaft tibia
  • Fall down the stairs
  • Small nidus of dead bone found anterior to the
    fracture site---gtcaused a draining sinus to form
    over the anterior tibia
  • Sinus tract was excised the dead bone debrided
    in the OR
  • Patient made a full recovery

61
Conclusions Study 1
  • Non operative management of Pediatric type I open
    fractures is safe and effective
  • Non operative management does not appear to
    affect the healing potential
  • Children over age 12 with lower extremity type I
    open fractures are at risk for failing
    non-operative management
  • Should consider traditional irrigation and
    debridement of the wound in the OR

62
  • Evaluates the results of non operative management
    of grade 1 open fractures treated in the ED or
    with a lt24hour admission (for IV antibiotics)
  • Retrospective chart review (2000-2006)
  • 25 patients followed until healed (clinically and
    radiographically)
  • 1 patient had persistent draining from the wound
    site fever (overall infection rate 4)

63
Details of study 2
  • 25 patients diagnosed with type 1 open fracture
  • 20 boys, 5 girls
  • Age range 2-15y
  • Fracture distribution
  • 5 tibial shaft /- fibula
  • 18 radius ulna
  • 2 Monteggia fracture/dislocations

64
Details of study 2
  • 14 patients were admitted (lt24h)
  • 11 were treated exclusively in the ED

65
Details of study 2
  • Treatment Initiated in the ED
  • Initiation of IV antibiotics
  • Irrigation of the wound with sterile saline
  • Protecting the wound with Xeroform or Betadine
    soaked gauze
  • Tetanus prophylaxis if needed
  • Closed reduction immobilization

66
Details of study 2
  • IV antibiotics used
  • 20/25 patients received Ancef
  • Others
  • Ampicillin/sulbactam
  • Ceftriaxone
  • Gentamicin

67
Details of study 2
  • Patients who were admitted overnight remained on
    IV antibiotics until discharge
  • At discharge oral antibiotics were given to 20 of
    25 patients
  • 19 received Keflex
  • 1 received Clindamycin
  • Duration ranged from 1-7 days

68
Details of study 2
  • Follow up schedule
  • 7-10 days radiograph wound check (windowing)
  • 14-17 days radiograph in cast
  • 6-8 weeks radiograph out of cast
  • Followed until healed
  • Non-tender, full ROM at joint above below
  • Bridging bone on radiograph

69
Results of study 2
  • 1 patient diagnosed clinically with an infection
    (culture negative)
  • 8 yr boy
  • Tibia fracture (from football tackle)
  • At F/U on day 6erythema serosanguineous
    drainage from wound
  • Admitted and treated with 2 days of IV Clinda
  • Complete resolution of drainage/erythema
  • Discharged with 1 week course of oral Clinda
  • Fracture union at 11 weeks (no further
    complications)

70
Results of study 2
  • Average time to union
  • Tibia fractures 67 days
  • Forearm fractures 45 days
  • Monteggia fracture/dislocations 29 days

71
  • Conclusions
  • Non-operative management of grade 1 open
    fractures is safe in pediatrics
  • Eliminates any possible general anesthetic risk
  • Significantly decreases the cost of caring for
    these patients in the health care system
  • OR costs
  • Cost of prolonged hospital admissions
  • Social costs of a hospitalized child

72
  • Current protocol
  • Treat low energy grade 1 open fractures
  • sustained in a clean environment with no gross
    contamination
  • In the ED as an outpatient
  • Conscious sedation and reduction
  • Superficial cleansing
  • Single dose of IV Abx
  • 3-5 days of oral antibiotics

73
Adult Literature
  • There is precedent for non-operative treatment of
    grade 1 open fractures

74
  • 0 infection rate in 91 open grade 1 fractures

75
Details of Study 3
  • Retrospective review (1990-1997)
  • 91 patients with isolated Type I open fractures
  • 78 adults, 13 children
  • 60 males, 31 females
  • Exclusion criteria
  • multiple injuries
  • gunshot wounds
  • hand injuries
  • compartment syndrome
  • Intra-articular fractures

76
Details of Study 3
  • All received antibiotics and were followed until
    fracture union
  • Charts were reviewed for
  • Type of fracture
  • Mechanism of injury
  • Type of treatment
  • Length of hospital stay
  • Complications encountered

77
Details of Study 3
78
Details of Study 3
79
Details of Study 3
80
Details of Study 3
81
Details of Study 3
  • All patients received antibiotics (within 6h)
  • Adults 1g cefazolin
  • Children 1g (11), 750mg (1), 500 mg (1)
  • All were admitted for at least 48 hours
  • Wounds greater than a puncture site were
    irrigated with several liters of saline
  • Majority did not receive irrigation
  • Wounds were dressed with sterile gauze

82
Details of Study 3
  • 32 pts had surgery for definitive treatment of
    their fracture
  • 1 pt had surgery w/in 8 hours golden period
  • All others had surgery after 12 hours
  • Average time was 5 days 12h-15days
  • None of the wounds had evidence of infection
  • Open wound was not debrided unless it was
    included in the operative exposure

83
Results of Study 3
  • Hospital stay
  • 9 days on average
  • 11 days for those who had surgery
  • 4.5 days for those without surgery
  • Follow up
  • Averaged 7 months 2mo - 5y

84
Results of Study 3
  • Complications
  • Developed in 10 pts (8 in lower extremities)
  • 6/10 pts needed surgery for definitive treatment
  • Infection rate
  • 0

85
Conclusions Study 3
  • Immediate operative debridement may not be
    necessary in isolated, low-energy Type 1 open
    fractures with stable fracture patterns

86
Results of Study 3
  • Current Protocol
  • Low energy type 1 open fracture do not need
    operative debridement
  • Do not classify open fractures by the size of the
    soft tissue wound alone
  • Comminuted fractures are taken to the OR and
    reclassified after operative debridement

87
Guidelines for antibiotic length?
  • In the 2 pediatric studies we just reviewed
  • 1 dose of IV antibiotics was sufficient in 1
    study (20/25 d/cd on 1-7 days of PO Abx)
  • 48 hours of IV antibiotics was sufficient for
    the other study (only 4/40 were d/cd on PO Abx)

88
Calgary Consensus
  • Call on call surgeon for personal preference
  • 1 dose of IV Ancef, then 3-7 days PO antibiotics
  • Routine windowing of the cast is not done
  • Surgeon dependent
  • Have the patient return to the ED if there are
    any problems within the first 3 days for urgent
    evaluation (pain, fever, tachycardia, odour)
  • The size of the wound by itself is not indication
    for non-operative debridement

89
Back to the Objectives
  1. Review the different types of open fractures
  2. Discuss the current treatment of open fractures
  3. Review the literature supporting non-operative
    management of Type 1 open fractures

90
Summary
  • The literature suggest that treating type 1 open
    fractures with IV antibiotics and closed
    reductions is safe
  • But no randomized controlled trials
  • Different surgeons ---gt different approaches,
    therefore discuss with the on call surgeon first
  • Use of antibiotics is not advocated as a
    substitute for proper clinical judgment
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