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Open Fractures – Pearls and Pitfalls

Authors: Richard B. Moleno, DO, MS (@rbmoleno, EM Resident Physician, UTSW/Parkland Memorial Hospital) and Michael Venezia, DO, MPH (Orthopaedic Surgery Resident Physician, Largo Medical Center) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF)

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Background

Open fractures are something ED physicians deal with quite frequently. They can range from a tiny break in the skin to limbs hanging by a small piece of skin and tissue. Some common mechanisms by which these injuries occur include falls, motor vehicle collisions, motor vehicle versus pedestrian, and crush injuries. A thorough physical exam should be performed on all of these patients, paying special attention to mechanism of injury, examining the wound to look for contamination, and confirming intact neurovascular status. Following the primary survey, make sure to complete the secondary survey so that additional injuries are not missed. Plain films should be obtained of all injured areas, and tetanus status should be updated if indicated.

Diagnoses that cannot be missed include vascular compromise and compartment syndrome. Compartment syndrome teachings classically recite the 5 P’s; however, these perform poorly when studied with inadequate sensitivities. The most important clinical exam finding in these patients is pain out of proportion and pain with passive stretch of the affected area. Decreased two point discrimination in the affected limb can be beneficial in evaluating for compartment syndrome.  A compartment pressure >30 mm Hg raises concern, and a pressure within 30 mm Hg of the diastolic blood pressure (ΔP) indicates compartment syndrome. Immediate involvement of an orthopaedic or general surgeon should be obtained so that fasciotomies can be performed. If vascular compromise is suspected, an ankle-brachial index (ABI) should be obtained.  A normal ABI is > 0.9.  Abnormal ABIs with suspected vascular compromise should be investigated with angiography.

Traditional teachings state that all patients should receive antibiotics and go to the operating room within 6 hours for washout and/or open reduction internal fixation (ORIF).1 To better understand treatment principles, we will first review how to classify open fractures.

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Classification

The most well known grading system for open fractures is the Gustilo-Anderson classification. It is based on the size of the skin defect and degree of soft tissue injury and contamination.2

Type I – Laceration is <1cm and there is no evidence of contamination

Type II – Laceration >1cm with moderate contamination

Type III

  • A: severe soft tissue injury but adequate bone coverage, highly contaminated (5-10%)
  • B: severe soft tissue injury, massive contamination, bone is exposed, and there is periosteal stripping (10-50%)
  • C: same as IIIB but with an arterial injury requiring repair (25-50%)

You can also calculate the Mangled Extremity Severity Score (MESS) score, which estimates viability of an extremity after trauma to determine need for salvage versus empiric amputation. Patients with a MESS ≥ 7 are likely to require amputation secondary to their limb trauma. It takes into account the following:

  • Extent of skeletal and soft-tissue damage
  • Extent and severity of limb ischemia
  • Associated shock
  • Age

 

Management

Initial management of all patients should start with the ABCs. Once you arrive at circulation, you should attempt to control hemorrhage by direct pressure or a tourniquet if the patient is in severe shock or with otherwise uncontrollable bleeding. You should resuscitate the patient and correct coagulopathies with crystalloids, packed red cells, and other blood products as needed.3

Reduction of grossly deformed fractures may be attempted in the Emergency Room, primarily for neurovascular compromise and comfort of the patient. All neurovascular-compromised patients require urgent reduction and further vascular workup. A patient with an ankle-brachial index of <0.9 should be evaluated with angiography.5

All grossly contaminated wounds should be irrigated, covered in sterile saline soaked permeable dressing, and splinted. Further management is to be made at this time with consultation and imaging. Preoperative cultures have been shown to be ineffective in the quest for definitive organisms and are not recommended.

Tetanus prophylaxis and antibiotics should be initiated in all patients, with tetanus based on their prior status and antibiotics as described below.

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Antibiotics

Open fractures are significant injuries that can lead to many complications if not treated appropriately and in a timely manner. The current literature shows that in the absence of timely antibiotics, infection can occur in up to 24% of cases.5 Studies have shown that delay in antibiotic administration >3 hours can result in an increased infection rate (7.4% versus 4.7%).6

Recommended antibiotics vary based on grading of the open fracture. Gustilo-Anderson types I-II should be treated with a first generation cephalosporin, with the addition of an aminoglycoside for type III fractures. If there is any concern for clostridial exposure (e.g. farm injuries), the recommendation is to add Penicillin G. Of note, this classification is truly an intraoperative grading that cannot be accurately diagnosed in the trauma bay until the severity of soft tissue wounds has been assessed during debridement. Most institutions will err on the side of caution if there is any question of it being a higher energy fracture and cover it empirically as a type III. Currently there is no data to support prophylactic coverage of MRSA, despite the notable increase in prevalence in recent years.7

The latest literature available demonstrates that timing to antibiotic coverage is the most important determining factor in infection with regards to open fractures. Although the currently used algorithm for antibiotic regimen has not changed in many years, there have been no studies that show any alternative regimens with higher success and lower infection rates.

 

Ultimate Disposition and Treatment

All these patients need orthopedic surgery consultation. The current treatment algorithm is very controversial, as prior recommendations were for urgent irrigation and debridement within 6 hours of injury. Recent studies have shown no documented increased risk of infection with delayed irrigation and debridement beyond 6 hours.8 The current recommendation is that most grade I-II open fractures should be treated as urgent and not delayed beyond 24 hours if medically possible. General consensus for type III injuries is to provide an urgent irrigation and debridement as soon as possible. Intraoperative guidelines for irrigation have been shown to be most effective using normal saline, with the amount based on the grade of the fracture: 3L for type I, 6L for type II, and 9L for type III.9

 

References/Further Reading

  1. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453-8.
  2. Egol KA, Koval KJ, Zuckerman JD. Handbook of Fractures. Lippincott Williams & Wilkins; 2010.
  3. Tintinalli J, Stapczynski J, Ma OJ et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, Seventh Edition. McGraw-Hill; 2010.
  4. Available at: http://lifeinthefastlane.com/ortho-library/open-fractures/. Accessed October 31, 2015.
  5. Melvin, J. Stuart, et al. “Open tibial shaft fractures: I. Evaluation and initial wound management.” Journal of the American Academy of Orthopaedic Surgeons1 (2010): 10-19.
  6. Patzakis MJ, Wilkins J: Factors influencing infection rate in openfracture wounds. Clin Orthop 1989;243:36–40.
  7. Saveli, Carla C., et al. “The role of prophylactic antibiotics in open fractures in an era of community-acquired methicillin-resistant Staphylococcus aureus.” Orthopedics (Online)8 (2011): 611.
  8. Crowley DJ, Kanakaris NK, Giannoudis PV. Debridement and wound closure of open fractures: The impact of the time factor on infection rates.Injury 2007; 38:879-889.
  9. http://www.ncbi.nlm.nih.gov/pubmed/25159242

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