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Management of Open Fractures. Christine Kennedy Pediatric Emergency Fellow October 22, 2009. Objectives. Review the different types of open fractures Discuss the current treatment of open fractures Review the literature supporting non-operative management of Type 1 open fractures.

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management of open fractures

Management of Open Fractures

Christine Kennedy

Pediatric Emergency Fellow

October 22, 2009

objectives
Objectives
  • Review the different types of open fractures
  • Discuss the current treatment of open fractures
  • Review the literature supporting non-operative management of Type 1 open fractures
introductory case
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….
slide6
Case
  • Question was…Does this need to go to the OR?
  • Ortho consulted…advised 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 reduction…wound started to ooze on my foot…
open fracture classification gustilo and anderson
Open Fracture ClassificationGustilo and Anderson
  • Type I
    • Clean wound <1 cm in length
    • # is simple, transverse or oblique with little comminution
  • Type II
    • Laceration >1cm without extensive soft tissue damage, flaps or avulsions
  • Type III
    • Extensive soft tissue damage, crushing or a traumatic amputation
      • Subtypes 3A, 3B, 3C
open fracture classification
Open Fracture Classification
  • Type 3 subtypes
    • 3A: Adequate soft tissue coverage
    • 3B: Inadequate soft tissue coverage
    • 3C: Arterial injury requiring repair

3B

open fracture classification2
Open Fracture Classification

Type I

Type I

Type IIIc

Type IIIb

open fracture classification gustilo and anderson1
Open Fracture ClassificationGustilo and Anderson
  • Type I Infection rate 0-2%
    • Clean wound <1 cm in length
    • # is simple, transverse or oblique with little comminution
  • Type II Infection rate 2-7%
    • Laceration >1cm 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. 1990;72:299-304.

open fracture vs abrasion1
Open Fracture vs Abrasion

Open fracture

  • disruption of the dermis with communication into the subcutaneous tissue contiguous with the bone
open fracture vs abrasion2
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
how do the orthopedic surgeons decide
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
how common are open fractures
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 2004;24:1-6.

management of open fractures1
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
management of open fractures2
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
management of open fractures3
Management of Open Fractures
  • Type 1
    • Operative vs non-operative, why the controversy?
type 1 open fractures
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
type 1 open fractures1
Type 1 Open Fractures
  • Allows adequate penetrance of the host defense mechanisms and IV antibiotics to protect further against possible infection
type 1 open fractures2
Type 1 Open Fractures
  • Routine operative debridement might cause increased soft tissue trauma, periosteal stripping and osseous devascularization
type 1 open fractures3
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
in the old orthopedic literature
In the old orthopedic literature…
  • Cases of gas gangrene in children with open fractures managed non-operatively
  • Before the routine use of antibiotics
infection rate with operative management
Infection Rate with Operative Management
  • Literature’s infection rate for type 1 open fractures treated operatively is an average of 1.9%*
organisms cultured from open fractures
Organisms Cultured from Open Fractures
  • The majority of bacteria cultured are normal skin flora
    • Staphylococcus epidermidis
    • Proprionibacterium acnes
    • Corynebacterium species
organisms cultured from open fractures1
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
organisms cultured from open fractures2
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
importance of antibiotics
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 1974;56:532-541.

importance of antibiotics1
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]
which antibiotic
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
timing of antibiotics is important
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 >3h after injury
  • Of note, surgical debridement was performed for all open fractures in this study
guidelines for antibiotic length
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
non operative management of type 1 open fractures
Non Operative Management of Type 1 Open Fractures
  • What does the literature say these days?
slide39
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%
slide40
0% infection rate in the 32 upper extremity type I open fractures
  • 0% infection rate in the 23 patients under 12 years
details of study 1
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
details of study 11
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
details of study 12
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 surgeon’s discretion
details of study 13
Details of Study #1
  • Patients were followed until fracture union
    • Clinically: no longer tender at fracture site
    • Radiologically: bridged by sufficient callus
details of study 14
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
results of study 1
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)
results of study 112
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--->caused 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
conclusions study 1
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
slide62
Evaluates the results of non operative management of grade 1 open fractures treated in the ED or with a <24hour 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%)
details of study 2
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
details of study 21
Details of study #2
  • 14 patients were admitted (<24h)
  • 11 were treated exclusively in the ED
details of study 22
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
details of study 23
Details of study #2
  • IV antibiotics used
    • 20/25 patients received Ancef
    • Others
      • Ampicillin/sulbactam
      • Ceftriaxone
      • Gentamicin
details of study 24
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
details of study 25
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
results of study 2
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 6:erythema & 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)
results of study 21
Results of study #2

Average time to union

  • Tibia fractures: 67 days
  • Forearm fractures: 45 days
  • Monteggia fracture/dislocations: 29 days
slide71
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
slide72
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
adult literature
Adult Literature
  • There is precedent for non-operative treatment of grade 1 open fractures
details of study 3
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
details of study 31
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
details of study 36
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
details of study 37
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
results of study 3
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]
results of study 31
Results of Study #3
  • Complications
    • Developed in 10 pts (8 in lower extremities)
    • 6/10 pts needed surgery for definitive treatment
  • Infection rate
    • 0%
conclusions study 3
Conclusions Study #3
  • Immediate operative debridement may not be necessary in isolated, low-energy Type 1 open fractures with stable fracture patterns
results of study 32
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
guidelines for antibiotic length1
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/c’d on 1-7 days of PO Abx)
    • ~48 hours of IV antibiotics was sufficient for the other study (only 4/40 were d/c’d on PO Abx)
calgary consensus
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
back to the objectives
Back to the Objectives
  • Review the different types of open fractures
  • Discuss the current treatment of open fractures
  • Review the literature supporting non-operative management of Type 1 open fractures
summary
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 ---> different approaches, therefore discuss with the on call surgeon first
  • Use of antibiotics is not advocated as a substitute for proper clinical judgment