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Management of Open Fractures

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

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

  2. 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

  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. 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…

  5. Post-reduction X-Rays

  6. Case-Follow up at day 39

  7. 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

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

  9. Open Fracture Classification

  10. Open Fracture Classification Type I Type I Type IIIc Type IIIb

  11. 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.

  12. Open Fracture vs Abrasion

  13. Open Fracture vs Abrasion Open fracture • disruption of the dermis with communication into the subcutaneous tissue contiguous with the bone

  14. 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

  15. 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

  16. 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.

  17. 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

  18. 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

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

  20. 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

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

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

  23. 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

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

  25. Infection Rate with Operative Management • Literature’s infection rate for type 1 open fractures treated operatively is an average of 1.9%*

  26. Infection Rate with Operative Management

  27. Infection Rate with Operative Management

  28. Organisms Cultured from Open Fractures • The majority of bacteria cultured are normal skin flora • Staphylococcus epidermidis • Proprionibacterium acnes • Corynebacterium species

  29. 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

  30. 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

  31. 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.

  32. 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]

  33. 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

  34. 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

  35. 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

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

  37. 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%

  38. 0% infection rate in the 32 upper extremity type I open fractures • 0% infection rate in the 23 patients under 12 years

  39. 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

  40. 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

  41. 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

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

  43. 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

  44. 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)

  45. Results of Study #1

  46. Results of Study #1

  47. Results of Study #1

  48. Results of Study #1

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