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Acute Management of Open Fractures: Proposal of a New Multidisciplinary

Algorithm

Article  in  Orthopedics · October 2012

DOI: 10.3928/01477447-20120919-08 · Source: PubMed

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 n trauma update
Section Editors: David J. Hak, MD, MBA & Philip F. Stahel, MD

Acute Management of Open Fractures:

Proposal of a New Multidisciplinary Algorithm
Cyril Mauffrey, MD, FRCS; James R. Bailey, MD; Richard J. Bowles, MD; Connie Price, MD; Duke Hasson, MD;
David J. Hak, MD, MBA; Philip F. Stahel, MD, FACS

open fractures during the de- • Determine whether the

Abstract: Despite the frequency of open fractures, their bridement process based on
management remains one of the greatest and most debated
muscle, bone, soft tissue, and
orthopedic challenges. The current challenges that health
vascular injury and has been
care faces financially and clinically offer an opportunity to
designed to aid in predicting
develop a universal reliable, reproducible, evidence-based
the outcome and treatment
protocol. The authors review the current evidence concern-
based on the complexity of
ing the acute management of open fractures and suggest a
modern treatment algorithm. the injury. In this article, the
authors review the current
evidence concerning the acute
patient’s needs exceed a
facility’s capacity.
• Arrange appropriately for
the patient’s interhospi-
tal transfer (who, what,
when, and how).
• Assure that optimum
care is provided and that
the level of care does not

T he acute management of
open fractures has long
been a topic of debate and
classification and on clas-
sic articles that are several
decades old.2,3 Since then,
management of open frac-
tures and propose a modern
algorithm for treatment from
deteriorate at any point
during the evaluation,
resuscitation, or transfer
controversy among orthope- the epidemiology of bacteria the emergency department to process.
dic surgeons. Complications has changed, and little has the operating room. The decision about wheth-
associated with incomplete or been done to adapt our prac- er to keep or transfer the pa-
inappropriate treatment carry tice. The Orthopedic Trauma Management in the tient must be made at this
significant consequences for Association has been work- Emergency Department time. The receiving center
the patient and treating sur- ing on a new classification When seeing the patient should have experience in
geon. The acute treatment of scheme for open fractures that in the emergency depart- dealing with these complex
these injuries has been based is currently being validated.4 ment, physicians and other injuries and have a microvas-
on the Gustilo and Anderson1 This scheme aims to classify health care providers should cular or plastic surgeon avail-
follow the Advanced Trauma able for early care planning.
Life Support guidelines es- The receiving center should
Drs Mauffrey, Price, Hasson, Hak, and Stahel are from the Denver
Health Medical Center, Denver, Colorado; Dr Bailey is from the Naval
tablished by the American also have a dedicated operat-
Medical Center, San Diego, California; and Dr Bowles is from Beth Israel College of Surgeons and its ing room time where ortho-
Deaconess Medical Center, Boston, Massachusetts. Committee on Trauma. These pedic and plastic surgeons
Drs Mauffrey, Bailey, Bowles, Price, Hasson, Hak, and Stahel have no principles are: can collaborate early. Radio-
relevant financial relationships to disclose.
The views expressed in this article are those of the authors and do not
• Assess the patient’s con- graphs or photographs of the
necessarily reflect the official policy or position of the Department of the dition rapidly and accu- injury should be taken, and
Navy, Department of Defense, or the US government. rately. the wounds should be dressed
Correspondence should be addressed to: Cyril Mauffrey, MD, FRCS, • Resuscitate and stabilize appropriately, using a normal
Denver Health Medical Center, 777 Bannock St, Denver, CO 80204 (cyril.
mauffrey@dhha.org).
the patient according to saline-soaked dressing. The
doi: 10.3928/01477447-20120919-08 priority. patient’s tetanus immuniza-

OCTOBER 2012 | Volume 35 • Number 10 877

n trauma update
tion status should be checked
and, if necessary, a tetanus
vaccine administered. Antibi-
otics should be administered
as soon as possible after injury.
Antibiotic Prophylaxis
Versus Placebo
The occurrence of infec-
tion in an open fracture is a
dramatic complication lead-
ing to significant morbidity,
to include delayed union, non-
union, multiple additional sur-
geries, or amputation. The risk
of infection is multifactoral
and often host, injury, and sur-
geon or management depen-
dent. Antibiotic prophylaxis
is an aspect of open-fracture
management where the gold
standard remains unclear. In
fact, the ideal antibiotics for
infection prophylaxis, as well
as their timing and duration,
are still debated.
The difficulty lies in the
fact that decisions are based
on level I articles that are
now several decades old, and
the epidemiology of bacte-
rial contamination of open
fractures has since changed.
A landmark article by Gustilo
and Anderson1 revealed that
in more than two-thirds of
158 open fracture wounds, a
positive bacterial culture was
identified. Stratification of in-
fection rates per open fracture
types was 2% for type I frac-
tures, 2% to 15% for type II
fractures, and 5% to 50% for
type III fractures. Most clini-
cians agree that patients should
begin intravenous antibiotics
within 3 hours after injury.
This has been shown to reduce
the rate of infection from 7.4%
to 4.7% when compared with
878 ORTHOPEDICS | Healio.com/Orthopedics
prophylaxis started more than
3 hours after the injury.5
Prophylactic antibiotic ther-
apy should be considered an
adjunct to, and not a substitute
for, a systematic open fracture
management protocol that in-
cludes early and aggressive de-
bridement and irrigation, frac-
ture stabilization, and wound
coverage. Nonetheless, pro-
phylactic antibiotics are essen-
tial because, in their absence,
infection can be expected to oc-
cur in 20% of open fractures.2
This was investigated by
several authors. A randomized
trial by Patzakis et al3 revealed
that a first-generation cephalo-
sporine, such as cephalotin, re-
duced the infection rate more
efficiently than a placebo or a
combination of streptomycin
and penicillin. More com-
parative studies, such as those
by Bergman6 or Braun et al,7
reached similar conclusions
when comparing penicillin,
dicloxacillin, or cloxacillin
use for 2 days with use of a
placebo. A metanalysis on this
specific topic was executed by
the Cochrane group, confirm-
ing the efficiency of prophy-
lactic antibiotics vs a placebo
in open fractures.8 The result
was a reduction of infection
rate from 13.4% to 5.5%, with
the addition of intravenous an-
tibiotics.
In summary:
• Patients should be started
on intravenous antibiotics
within 3 hours of injury.
• Antibiotics are an adjunct
to a thorough debridement,
not a substitute.
• Level I data support the
use of antibiotics in open
fractures.
Organism-specific
Antibiotics
The role of wound culture
in open fracture has been chal-
lenged. Lee9 confirmed that
infections following open frac-
tures were caused in only 8% of
cases by organisms identified
at the predebridement stage,
whereas 7% of open fractures
with negative cultures dur-
ing the predebridement phase
eventually developed an infec-
tion. Valenziano et al10 reached
similar conclusions.
Bacteriological studies fo-
cusing on wound cultures in
open fractures have taught us
that, among patients who de-
veloped a deep infection, pa-
tients who were given prophy-
laxis against gram-negative
bacteria grew primarily gram-
positive bacteria, whereas
patients who were given pro-
phylaxis against gram-positive
bacteria grew gram-negative
bacteria from deep infected
tissue.11
Among 4 Level I trials
studying antibiotic prophy-
laxis in open fractures,3,6,7,11
all highlighted a prevalence of
Staphylococcus aureus as the
number one cause of surgical
site infection, and one11 re-
ported the rate of methicillin-
resistant S aureus (MRSA)
as being nearly one-third of
the total staphylococcal in-
fections. With increasing use
of antibiotics in the general
population, we are faced with
a new concern that was prob-
ably not present in clinical
trials from prior decades: the
changing epidemiology of the
colonizing organisms.
It is essential to pro-
vide coverage against gram-
positive bacteria in open frac-
tures; however, Carsenti-Etesse
et al11 raised concern about the
potential development of gram-
negative bacterial infection in
this setting. In 2000, Patzakis
et al5 compared the use of cip-
rofloxacin alone vs a combina-
tion of cefamandole and gen-
tamicin. For open type I and II
fractures, no differences in the
infection rates were noted be-
tween the 2 groups. However,
when type II open fractures
were isolated, the infection
rate decreased from 31% in the
ciprofloxacin group to 7.7% in
the group of patients who were
prescribed gram-positive and
gram-negative prophylaxis.
This fact is supported by the
recently published East guide-
lines12 (Level I) emphasizing
the importance of additional
gram-negative coverage for
type III fractures.
Moreover, it is only follow-
ing the initial debridement that
the severity and type of open
fracture can be accurately de-
termined and classified. This
is often underestimated at the
time of arrival in the emergency
department. Hence, although
antibiotics should be given in
the emergency department as
soon as the patient arrives, and
ideally within 3 hours from the
injury, the current authors be-
lieve that final antibiotic pro-
phylaxis protocol should not
be based on the initial open
wound size but rather should
be chronologically based, fol-
lowing a clear algorithm with
a prophylaxis tailored to the
surgical management of the
open wound, the fracture, the
associated bone, and vascular
and muscle injury.

Another controversial topic
is the total duration of anti-
biotic prophylaxis for open
fractures. Dellinger et al13
performed a randomized trial
comparing 24 hours vs 5 days
of cefonicid. The infection rate
in both groups was compa-
rable, with no added benefits
in patients who were provided
with a prolonged prophylaxis.
Others still believe that con-
tinuing the antibiotic prophy-
laxis until 24 to 72 hours after
injury, at least for type III frac-
tures, is beneficial in reducing
the infection rate.14
In summary:
• Systematic culture of
open fractures is not rec-
ommended.
• S aureus is the top cause
of surgical site infection.
• MRSA is found in one-
third of S aureus infec-
tions.
• Level I evidence exists to
add gram-negative cover-
age (gentamicin) in type
III fractures.
• Antibiotics prophylaxis can
be discontinued 24 hours
after injury or surgery.
Timing of Debridement
In 2009, the British
Orthopaedic Association and
the British Association of
Plastic, Reconstructive and
Aesthetic Surgeons modified
the guidelines on debride-
ment timing of open tibia frac-
tures from within 6 hours to
within 24 hours from injury.15
Historically, the main drive
for emergent debridement was
Gustillo and Anderson’s1 clas-
sic article, which concluded
that it was essential to man-
age the wound with urgent de-
OCTOBER 2012 | Volume 35 • Number 10 879
bridement and thorough irri-
gation to reduce the risk of in-
fection. This mantra has been
strongly criticized because
several confounding factors
were present in their study. As
a consequence, it is not fea-
sible to reach significant con-
clusions as to which factors
contributed to the reduction in
infection rates.
More recently, some ar-
ticles have emerged in sup-
port of debridement within 24
hours. Patzakis and Wilkins16
reviewed the infection rates
of patients with open fractures
treated with irrigation and
debridement within 12 hours
from injury or in a delayed
fashion (more than 12 hours
from injury); the infection
rate in both groups was 7%.
Charalambous et al17 studied
a cutoff of 6 hours after in-
jury for the timing of initial
irrigation and debridement,
and no statistically significant
difference between early and
delayed treatment groups was
noted in terms of infection
rates. Basic science studies
support the common thought
that thoroughness of debride-
ment is more important than
its timing: a well-done de-
bridement by an experienced
surgeon is better than an inad-
equate debridement performed
within 6 hours.18 Schlitzkus
et al19 identified that fracture
grade, revised trauma score,
and male sex were all indepen-
dent predictors of wound com-
plications but timing of initial
debridement was not.
In summary:
• Grossly contaminated
wounds or sewage/farm-
yard injuries might bene-
fit from irrigation and de-
bridement within 6 hours.
• Other nonlimb-threatening
open fractures can undergo
irrigation and debridement
within 24 hours.
Surgical Technique
In 2010, the British
Orthopaedic Association and
the British Association of
Plastic, Reconstructive and
Aesthetic Surgeons working
party on the management of
open tibial fractures16 agreed on
a protocol that is now followed
nationwide across the United
Kingdom. This includes antibi-
otic prophylaxis, but also a well-
defined step-by-step approach
for initial wound debridement
that includes removal of all
dead tissue. Systematic debride-
ment occurs in the following
sequence: (1) application of a
soapy solution; (2) preparation
of the limb with a chlorhexi-
dine alcohol solution, avoiding
direct contact of the chlorhexi-
dine with the open wound; (3)
wound extension, ideally fol-
lowing potential fasciotomy
incisions; and (4) systematic
assessment of the tissues, from
superficial to deep and from the
periphery to the center of the
wound. Next, to ensure bone vi-
ability during the debridement
process, deflation of the tour-
niquet should be performed to
assess bleeding of the bony seg-
ment. At this stage, nonviable
fragments or loose fragments
of bone with no attachment to
soft tissue should be discarded.
Finally, once the debridement
has been performed, thorough
irrigation can be achieved.
It is only following this rad-
ical and systematic approach
n trauma update
that the injury can be classified
and a multidisciplinary treat-
ment plan elaborated by the
orthopedic and microvascular
surgery teams.
In summary:
• Wash the limb with soapy
solution, then prep with
chlorhexidine alcohol,
avoiding the traumatic
wound.
• Perform a systematic de-
bridement.
• Classify the injury and
plan definitive reconstruc-
tion after debridement.
• If definitive fixation is de-
layed, plan for vacuum-
assisted closure or a bead
pouch.
• Release the tourniquet to
assess bone end viability.
• Perform a “tug test” to as-
sess bone fragments that
require excision.
Management of the
Traumatic Wound
Wounds that can be closed
primarily should be closed.
Placement of temporary anti-
biotic beads reduces infection
rates in type III open fractures.
Primary or Delayed Closure
No good evidence exists
to guide the decision of ear-
ly vs delayed closure of the
skin wound. A review of the
Cochrane Database by Eliya
and Banda20 found that no
randomized, controlled trials
compared primary vs delayed
wound closure. In the absence
of data, it seems reasonable to
advocate mitigating the risk of
infection in open fractures by
delaying wound closure until
the risk of wound infection has
been declared.
n trauma update
fractures for chronic osteomy-
elitis. Henry et al23 performed
a similar nonrandomized study
and reached similar conclu-
sions with a lower infection
rate in the group managed
with antibiotic beads and in-
travenous antibiotics than in
the group managed with intra-
venous antibiotics alone (both
groups had early irrigation and
debridement).
The use of more modern
antibiotic carriers is a chal-
lenge for the industry. McKee
et al24 studied the efficacy
of calcium sulphate loaded
with tobramycin vs PMMA
loaded with tobramycin to
reduce and treat chronic non-
hematogenous osteomyeli-
tis or an infected nonunion.
They reported a similar rate
of eradication of infection but
a slightly superior number of
returns to the operating room
in the PMMA group, reach-
ing statistical significance.24
To the current authors’ knowl-
Figure: Proposed evidence-based algorithm for initial treatment of open edge, calcium sulphate use as
fractures. Abbreviations: ED, emergency department; I&D, irrigation and de- a carrier for antibiotics is not
bridement; IV, intravenous; OR, operating room; Post Op, postoperatively; approved by the US Food &
q8H, every 8 hours; VAC, vacuum-assisted closure. Drug Adminstration.
Vacuum-assisted Therapy
Antibiotic Beads studied a consecutive series Negative-pressure wound
A classic trial in arthroplas- of 1085 severe open fractures therapy, in which vacuum suc-
ty and infection was performed and examined infection rates tion is applied across an air-
by Lidwell et al21 and pub- in a group managed with in- tight topical dressing, has been
lished in the British Medical travenous antibiotics alone vs used in the treatment of chron-
Journal in 1982. The authors a second group managed with ic and surgical wounds. The
assessed factors that most sig- the addition of polymethyl- negative pressure is thought
nificantly reduced the risk of methacrylate (PMMA)-loaded to aid the drainage of excess
infection in 8000 patients un- gentamicin beads. The infec- fluid, reduce infection rates,
dergoing hip or knee replace- tion rate was 12% in the for- and increase localized blood
ment and quantified them in- mer group vs 3.7% in the latter flow. It is also known as topi-
dividually. Of note, infection group. Statistical significance cal negative-pressure therapy,
rates were reduced 11-fold was achieved for type IIIB and vacuum-assisted closure, and
when antibiotic-loaded cement IIIC fractures for acute infec- sealed-surface wound suction.
was used. Ostermann et al22 tion and for type II and IIIB A systematic review in 2008
880 ORTHOPEDICS | Healio.com/Orthopedics
by Ubbink et al25 found only
a small number of flawed tri-
als, and thus little evidence to
support the use of negative-
pressure wound therapy in the
treatment of wounds.
The Figure highlights the
authors’ multidisciplinary al-
gorithm for the management
of open fractures. If antibiot-
ics were not administered en
route, they should be admin-
istered immediately on arrival
to the emergency department,
and ideally within 3 hours of
the injury. The authors propose
systematic coverage against
gram-positive bacteria us-
ing intravenous cephazolin, 1
gram every 8 hours for patients
weighing less than 80 kg and
2 grams for patients weighing
more than 80 kg, continued for
24 hours after the first debride-
ment. Intravenous vancomycin
is added for patients with a his-
tory of MRSA infection. For
grossly contaminated wounds
or farmyard/sewage injuries,
cephazolin is replaced with
600 mg of clindamycin intra-
venously every 8 hours for 24
hours after initial debridement.
Intraoperative assessment
of the injury during the de-
bridement will determine the
final antibiotic regime. If the
wound edges are not closeable
or muscle necrosis or bone loss
is present, a single intravenous
dose of 5 mg/kg of gentamicin
should be added at the time of
the initial debridement.
At the time of definitive
skeletal stabilization and skin
closure, patients should be giv-
en a single intravenous dose of
cefazolin 1 g,80 kg or 2 g.80
kg. One gram of vancomycin
intravenously should be added

to this regime if the patient has
a previous history of MRSA
infection. If none of the pre-
viously mentioned findings
are present during debride-
ment, the initial 24 hours of
cephazolin plus or minus the
vancomycin (if previous his-
tory of MRSA infection exists)
will suffice. Patients with ana-
phylaxis to penicillin should
receive intravenous clindamy-
cin (600 mg preoperatively, 4
times a day) in place of cepha-
losporin. Fluoroquinolones
offer no advantages compared
with a combination of cepha-
losporin and gentamicin and
may actually have a detrimen-
tal effect of fracture healing
and increase the infection rate
in type III fractures.12
Conclusion
The authors present an evi-
dence-based treatment algo-
rithm for acute management of
open fractures. It is the au-
thors’ belief that a standard-
ized, evidence-based decision
tree will help streamline and
improve care, specifically at
teaching institutions with mul-
tiple staff and residents
(Figure). Open fractures
should be taken care of by
well-trained, experienced or-
thopedic surgeons who are
aware of the intricacies and
potential complications of this
complex injury. A clear algo-
rithm should be implemented
in every institution dealing
with such trauma, and ideally
a multidisciplinary approach
should be the gold standard,
with early involvement of the
orthopedist, microvascular sur-
OCTOBER 2012 | Volume 35 • Number 10 881
View publication stats
geon, and infectious disease
department. Centers that do
not have the capacity to man-
age such injuries should have a
clear pathway of referral. This
algorithm is currently being
used for decision making at
Denver Health Medical Center,
Denver, Colorado. F, Desplaces N, et al.
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Coming next issue...
sports medicine update
n trauma update
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