Basic Principles of Open Fracture Management in the Emergency Room

Fracture management begins after initial trauma survey and

resuscitation is complete

Antibiotics

o initiate early IV antibiotics and update tetanus prophylaxis as

indicated

Control bleeding

o direct pressure will control active bleeding

o do not blindly clamp or place tourniquets on damaged extremities

Assessment

o soft-tissue damage

o neurovascular exam

Dressing

o remove gross debris from wound

o place sterile saline-soaked dressing on the wound

Stabilize

o splint fracture for temporary stabilization

decreases pain, further injury from bone ends, and

disruption of clots

Basic Principles of Open Fracture Management in the Operating Room

Aggressive debridement and irrigation

o thorough debridement is critical to prevention of deep infection

o low pressure lavage more effective in reducing bacterial counts than

 high pressure lavage

o saline shown to be most effective irrigating agent

on average, 3L of saline are used for each successive Gustilo type

Type I: 3L

Type II: 6L

Type III: 9L

o bony fragments without soft tissue attachment can be removed

Fracture stabilization

o can be with internal or external fixation, as indicated

Staged debridement and irrigation

o perform every 24 to 48 hours as needed

Early soft tissue coverage or wound closure is ideal

o timing of flap coverage for open tibial fractures remains controversial

o increased risk of infection beyond 7 days

Can place antibiotic bead-pouch in open dirty wounds

o beads made by mixing methylmethacrylate with heat-stable antibiotic

powder

Antibiotic Treatment

Gustilo Type I and II

 o 1st generation cephalosporin

o clindamycin or vancomycin can also be used if allergies exist

Gustilo Type III

o 1st generation cephalosporin and aminoglycoside

Farm injuries or possible bowel contamination

o add penicillin for anaerobic coverage (clostridium)

Duration

o initiate as soon as possible

studies show increased infection rate when antibiotics are

delayed for more than 3 hours from time of injury

o continue for 24 hours after initial injury if wound is able to be

closed primarily

o continue until 24 hours after final closure if wound is not closed

during initial surgical debridement

Bone Gap Reconstruction

Reconstruction options

o Masquelet technique

o distraction osteogenesis

o vascularized bone flap

Tetanus Prophylaxis

Initiate in emergency room or trauma bay

 Two forms of prophylaxis

o toxoid dose 0.5 mL, regardless of age

o immune globulin dosing

<5-years-old receives 75U

5-10-years-old receives 125U

>10-years-old receives 250U

o toxoid and immunoglobulin should be given intramuscularly with two

different syringes in two different locations

Guidelines for tetanus prophylaxis depend on 3 factors

o complete or incomplete vaccination history (3 doses)

o date of most recent vaccination

o severity of wound