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Open Fracture Wound Care

Open Fracture Wound Care. Mitchell Goldflies. Overview. Would evaluation Initial surgical management “Why I&D should be D&I” Dressing and wound coverings Wound VAC Antibiotic Bead pouch Definitive closure. First Take a deep breath Ask about Wound Limb Timing contamination. Then

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Open Fracture Wound Care

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  1. Open Fracture Wound Care Mitchell Goldflies

  2. Overview • Would evaluation • Initial surgical management “Why I&D should be D&I” • Dressing and wound coverings Wound VAC Antibiotic Bead pouch • Definitive closure

  3. First Take a deep breath Ask about Wound Limb Timing contamination Then Order Antibiotics Ensure proper overall trauma “Step away from the open fracture” When the ER Calls. . .

  4. IV Antibiotics • Tetanus prophylaxis • Antibiotics: choice and duration by grade • I/II –cephalosporin • III – ceph+ aminoglycoside • Soil, farm – add penicillin • Fresh or salt water- add penicillin

  5. Compartment Syndrome • CAN occur with open fractures • Blick, Brumback, Polka jbjs 1986 • 198 open fractures • 9.1% compartment syndrome

  6. Grading Open Fractures It’s not all about size! 4 contributing factors • Degree of Soft tissue damage • Comminution • Contamination • Time from injury

  7. Utility of MangledExtremity ScoringSystems

  8. Low sensitivity of all scores Poor predictors of amputation Bosse JBJS 83A (1) 2001 “A Prospective Evaluation of the Clinical Utility of the Lower Extremity Injury-severity Scores”

  9. Consensus on Scoring Systems • Not Vaild as Predictors • Useful: Emphasis factors important in decision making • Shock • Pt age • Other injuries

  10. “The Insensate Foot Following Severe Lower Extremity Trauma: An Indication for Amputation?” • Bosse, et al; JBJS 87-a, 2005 • 55 pts with increase foot post trauma • 29 salvaged • 55% had NORMAL plantar sensation 2 years after injury

  11. Additional Infection RiskHost-related Factors • Age • Co-mobility • Obesity • Diabetes • RA and Steroid Use • Mal-nutrition • Malignancy

  12. Wound Size Shape Location Edges contamination Extremity Pluses Perfusion Sensation Motor Other injuries Open Fracture Evaluation

  13. Timing • Delay thought to increase risk of infection • Recent studies indicate minor delays do not increase risk of infection 6-8 hours

  14. Surgical Managemet Think “D&I” not “I&D”!!!

  15. Debridement • Initial procedure is most important • Goals • Remove all foreign material • Remove nonviable host tissue • Decrease bacterial load • Create clean, living wound

  16. Debridement Principles • Experienced surgeon • Gentile Tissue handling • Extend wound- longitudinal! Very long incision, at least 3:1

  17. Increased Injury Trauma Requires Decreased Surgical Trauma

  18. Debridement Principles Systematic, sharp debridment • Layer by layer • Surface to deep • Save skin in key areas • Fat and fascia are expendable • Dead muscle MUST go • Non-viable bone should usually go

  19. Avoid the Dreaded “three “Ds” • Dead bone • Dead muscle • Dead space

  20. Wound Irrigation • Volume… lots • Delivery Method • High or low pressure? • Pulsatile or continous? • Choice of solution • Antiseptics • Antibiotics • detergents

  21. Surgical Treatment • Debridement • Irrigation • Stabilization! • Wound Coverage • Peri-operative anitbiotics

  22. Role of Stability • Stabilized open fractures are less susceptible to infection

  23. Stability • Provisional External fixation good option • Allows thorough 2nd D&I • Always a safe option • ORIF safe Grade I and II upper extremity fxs • IM nail Grade I, II +/- IIIA tibia safe

  24. Options “Loose” Skin closure Avoids retraction Antibiotic Bead Wound VAC Avoid Wet-Dry My Choices Exposed bone or hardware… Bead pouch Exposed muscle… Wound VAC Temporary Wound Coverage

  25. Antibiotic Bead Pouch Rationale • Deliver a high local concentration of antibiotics with low systemic levels • Reduce wound desiccation • Reduce dressing changes • Lessen contamination • Lessen patient discomfort

  26. Antibiotic Bead Pouch Effectievnes • Animal Studies • Equally or more effective than systemic antibiotics • Human Studies • Most retrospective • Used in conjunction with systemic antibiotics

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