Open Fracture Management for the Trauma Team

Outline
Historical Perspective Definition Treatment Goals Mechanism and Classification Initial Evaluation and Management

Richard B. Islinger, MD Director of Orthopaedic Trauma

Outline
Surgical Management Definitive Wound Management Complications Case Studies

Historical Perspective
Hippocrates
Described wound management of open fractures Recognized that associated purulent material needed to be allowed to drain
Would assist drainage with steel (knife) Promoted leaving wound open

Historical Perspective
Galen
Recognized purulence and admired it
Felt it was essential to repair process Searched for medicaments that might enhance purulence
Viewed as desirable for the wound to heal

Historical Perspective
Pare, Desault, Larrey
Described debridement of wounds
To remove dead tissue and provide drainage Found that early debridements were better Enhanced wound healing

Historical Perspective
Contemporary Military Conflicts
Civil War, WW1, WW2, Korean War, Vietnam War, Persian Gulf War
Cornerstone of initial wound treatment
Thorough Debridement and leaving wound open This having to be re-learned at times Antisepsis and Antibiotics beneficial In addition to primary debridement

Definition
Open Fracture (compound fracture)
A break in the skin and underlying soft tissue leading directly into or communicating with the fracture and its hematoma

Treatment Goals
Restore limb and patient function
As early and as fully as possible Surgeon must prevent Infection
Infection is most common event leading to:
Malunion, Nonunion, and Loss of Function

Mechanism
Violent force to human body expressed as
K=MV2/2
All of K is absorbed by bodys soft tissue before bone is fractured
Therefore significant soft tissue injury needs to be recognized!

Open Fracture Classification

Allows comparison of results in scientific publication Provides guidelines for prognosis and treatment Gustillo and Anderson system
Most widely used

Open Fracture Classification

Too much emphasis on wound size
Crush injury (small wound) Sharp injury (large wound)

Should emphasize
Degree of soft tissue injury Degree of contamination

Open Fracture Classification

Type 1
Low energy, inside-out mechanism Clean wound, Minimal muscle damage

Open Fracture Classification

Type 2
Moderate soft-tissue damage with higher energy Outside-in injury Some necrotic muscle, some bone stripping

Open Fracture Classification

Type 3A
High energy, outside-in injury Extensive muscle devitalization and bony stripping Fracture displaced or comminuted Bone coverage with existing soft tissue not a problem

Open Fracture Classification

Type 3B
High energy, outside-in injury Extensive muscle devitalization and bony stripping Fracture displaced or comminuted Requires a local flap or free tissue transfer for Bone coverage and closure

Open Fracture Classification

Type 3C
High energy Major vascular injury requiring repair for salvage of extremity

Open Fracture Classification

Type 3
All:
Shotgun wounds, high-velocity GSWs, segmental fractures with displacement, fracture with segmental loss, farmyard injury or highly contaminated environment, fracture caused by crushing force of fast-moving vehicle

Open Fracture Classification

Interobserver agreement poor
125 randomized open fractures
Orthopaedic faculty 60% agreement Orthopaedic Trauma Fellowship trained- 66% agreement
Brumback et al, JBJS, 76A,1162-1166,1994

Open Fracture Classification

Fracture type
Should not be determined in the E.R., it should be determined in the O.R. at the time of surgical debridement

Low Velocity GSW Fracture

Less that 2000 ft/sec
Generally, not treated like open fractures Requires evaluation of neurovascular status
If normal, can be managed with local debridement
Without formal deep debridement and irrigation IV Antibiotics Can approach fracture fixation as if a closed fracture
Geisslar et al, J Orth Trauma,4:39-41,1990

Low Velocity GSW Fracture

Prospective trial
No antibiotics vs. IV ancef Q8 hours x 72 hours 67 low velocity GSW fractures
Not requiring operative stabilization No difference in infection rates
Dickey et al, J Ortho Trauma,3:6-10,1989

Low Velocity GSW Fracture

Prospective trial
Acute vs Delayed IM nailing of femoral shaft fractures from low velocity GSW
No difference in:
Infection, Delayed union, or Nonunion rates
Hollmann et al, J Orth Trauma,4:64-69,1990

Initial Patient Management

ABCs Deliberate and orderly assessment of entire patient
Control hemorrhage
Direct pressure, tourniquet

Re-align fracture and limb

Initial Patient Management

When a wound occurs in the same limb segment as a fracture, the fracture must be considered open until proven otherwise!
Careful physical examination
to look offers the prospect to know - not to look is to guess

Initial Patient Management

Local irrigation with 1-2 Liters Sterile compressive dressing and splint
Betadine soaked Repeat wound examinations associated with higher infection rate Tscherne et al, Fractures with Soft Tissue Injuries. 1984

Do not culture wound in ER

Initial Patient Management

Pre-debridement wound cultures
retrospective study, 245 open fractures
8% of organisms grown caused deep infection 7% of negative cultures became infected Of those infected, cultures grew infecting organism only 22% of the time concluded cultures of no value and not be done
Lee, Clin Orth, Jun 1997,(339)p71-5

Initial Patient Management

Antibiotics
Minimal contamination, low energy
Ancef 1 gm IV Q8

Moderate contamination, higher energy

Add Gentamicin (5mg/kg) IV Q 24

Soil contamination/severe contamination

Add Penicillin 4x106 units IV Q6
Patzakis, Management of Open Fractures, ICL,31:6264, 1982

Initial Patient Management

Most common infecting organisms
Staphylococcus Aureus Gram Negatives
Pseudomonas, Enterobacter, and Enterococcus

Initial Patient Management

Tetanus Prophylaxis
Clostridium Tetani (soil, animal feces)
If not immunized or not had booster within 5 years
Tetanus Toxoid

Clostridium Perfringens/Septicum
highly contaminated environments

If wound severely contaminated

tetanus immune globulin (250-500 IU) IM

Bleck, Principles and Practice of Infect Dis, New York, 1995,pp.2173-2178

Initial Patient Management

Radiographs
Minimize amount of patient transfers
coordinate plain x-rays, CT scan, etc

Surgical Debridement
Timing
the sooner the better! within 6-8 hours from time of injury
nationally recognized time period

Good Quality Plain X-rays

AP/Lateral of fracture AP/Lateral of both joints above and below fracture

Surgical Debridement
Retrospective Study
47 Grade II/III open fractures
initial debridement
less that 5 hours - 7% infection rate greater than 5 hours - 38% infection rate overt signs of infection manifested at 4.8 months
Kindsfater et al, J Orth Trauma, Apr 1995,9(2) p121-7

Surgical Debridement
I&D is a misnomer
should be listed as Debridement and Irrigation Debridement Goals
remove foreign material detection and removal of nonviable tissue reduction of bacterial contamination creation of wound that can heal without infection

Surgical Debridement
Best if down with tourniquet deflated
can interfere with evaluation of viability of muscle

Surgical Debridement
Evaluate muscle for:
Color, Consistency, Contractility, and Capacity to bleed necrotic muscle is culture medium for infection
especially anaerobic

extensile incision
extend wound in longitudinal direction
both proximally and distally expose: fracture, damaged tissue, and healthy tissue

when in doubt, take it out

Surgical Debridement
Tendons
leave if clean, and preserve paratenon
blood supply

Surgical Debridement
Knife debridement best Goal: Leave only clean viable tissue remaining
Nonunion or delayed union is a far less challenging complication than:
an infected nonunion

Bone
if devoid of soft tissue attachments
then must be removed

preserve soft tissue attachments to remaining bone

Surgical Debridement
The surgeon who does the initial debridement
should not be the surgeon
who will be responsible for the soft tissue coverage

Surgical Irrigation
>10 Liters Normal Saline results in lower incidence of infection Pulse lavage more effective that bulb syringe with NS
Gustillo et al, JBJS, 72A229-304,1990

100 fold decrease in Staph Aureus in wound

Anglen et al, J Ortho Trauma,8:390-396

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Surgical Irrigation
Addition of antibiotics to NS Pulse Lavage
does not decrease bacterial count of hardware when compared to NS Anglen et al, J Ortho Trauma,8:390-396

Post-Debridement Cultures
More accurate in predicting infection
infecting organism present in 42% (vs. 8% of pre-debridement cxs.) of initial culture

addition of Bacitracin/Polymyxin to NS
effective for final irrigation in wounds
Rosenstein et al, JBJS 71A:427-430, 1989

Optional

Lee, Clin Orthop, June 1997,(339)p71-5

does provide objective data to aid in clinical decision making

Antibiotic Beads
Provides high local concentration of antibiotics in the wound made in the O.R.
PMMA with Tobramycin made into bead shapes
threaded on large non-absorbable suture placed directly in wound covered with impervious dressing
creating bead pouch

Antibiotic Beads
Prospective study, 1085 open fractures
group 1: systemic antibiotics only
overall infection rate 12%

group 2: systemic antibiotics, tobramycinPMMA beads

overall infection rate 3.7%

more effective in grade II/III open fx wounds

Ostermann et al, JBJS(Br), Jan 1995, 77(1)p93-7

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Skeletal Stabilization
Splint
Good option if operative fixation not required

Skeletal Stabilization
External Fixation
easily and rapidly applied excellent stability obtained reasonable anatomic reduction possible

Internal fixation
usually appropriate if wound clean, and soft tissue coverage available

External Fixation
Great option in dirty wounds, or extensive soft tissue injury

Skeletal Stabilization
External Fixation
minimal additional soft-tissue trauma required risk of infection minimized ability to convert to internal fixation
when wound clean with adequate soft tissue coverage available

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Definitive Management
Peri-operative antibiotics for 48 hours
after each surgical debridement
Minimal contamination, low energy
Ancef 1 gm IV Q8

Definitive Management
Prospective randomized study
75 grade II/III open fractures
all patients treated with D&I, Ancef, and Gent.
Group 1- Gent 5mg/kg divided twice daily doses Group 2 - Gent 6 mg/kg once daily dose

Moderate contamination, higher energy

Add Gentamicin (5mg/kg) IV Q 24

Soil contamination/severe contamination

Add Penicillin 4x106 units IV Q6
Patzakis, Management of Open Fractures, ICL,31:6264, 1982

all patients monitored for renal toxicity No difference in infection rates, rates of healing etc.
Daily dosing found to be safe, effective, and cost efficient
Sorger et al, Clin Orthop, Sep 1999,(336)p197-204

Definitive Management
If on Gentimicin greater than 3 days
need to check blood levels check Trough 18 hours after 3rd dose
should be less than 2

Definitive Management
Repeat Debridement and Irrigation
should be repeated every 48 hours until clean
and can be closed or covered with soft tissue
Moore et al, Clin Orthop,248:227-230,1989

Primary closure rarely indicated

needs to truly be Grade I When in doubt, leave it open
Leave all open fractures open

avoid toxic side effects

renal, etc

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Definitive Management
Wound Closure options
Delayed Primary Closure Local Soft Tissue Flap Free Tissue Transfer

Definitive Management
Retrospective Study, 1085 open fractures
115 Grade II, 239 Grade III
all treated with D&I Q48 hours and appropriate Antibiotics

Best if wound is covered or closed within 57 days

decreased infection rate
Cole et al, Clin Orthop, Jun 1995,(315)p84-103

No Infection
wounds closed at average 7.6 days

Yes Infection
wounds closed at average 17.9 days
Ostermann, Orthopedics, May 1994, 17(5)p397-9

Complications
Infection Rates with appropriate care
Type 1 - 7% Type 2 - 11% Type 3A - 18% Type 3B/C - 56% all open fractures average - 16%
comparable to other contemporary studies
Dellinger et al, Arch Surgery 123:1320-1327,1987

Complications
Compartment Syndrome
open fractures are associated with high energy injuries
high energy injury associated with compartment syndromes
Therefore: Open fractures are often accompanied by compartment syndrome Dont miss it!

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Case Study #1
31 y.o. female, ejected from MVA
Grade 3B open distal tibia fracture Initial IV ancef, Gentamicin, PCN, Td booster Operative D&I within 8 hours
external fixation, aggressive tissue debridement, Abx Beads subsequent D&Is twice more

Case Study #1
Free Tissue Transfer by Plastics Surgery
within 7 days

Delayed internal fixation at 3 weeks awaiting bone grafting at 7 weeks No sign of infection at this time

Case Study #2
26 yo male MCA high energy
Grade 3B open tibia fracture, Grade 3B open talus fracture Initial IV ancef, Gentamicin, PCN, Td booster Operative D&I within 8 hours
external fixation aggressive tissue debridement, Abx Beads subsequent D&Is three more times
10 days

Case Study #2
Free Tissue Flap Deep Infection
Osteomyelitis 3 months

Radical Bony/Tissue Debridement

Followed by Bone Transport Currently in Limb Salvage Mode

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Case Study #2

Case Study #2

Thank You

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