EM@3AM: Open Fracture

Author: Ryan Sumpter (MS4, Uniformed Services University, Bethesda, MD); Rachel Bridwell, MD (@rebridwell, EM Resident Physician, San Antonio, TX) // Reviewed by: Brit Long, MD (@long_brit, EM Attending Physician, San Antonio, TX) and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 22-year-old male is brought in by EMS to the ED after falling 20 feet from scaffolding at a construction site. He landed primarily on his right leg, which is now obviously deformed with broken skin and exposed bone distally. The patient denied loss of consciousness, medical problems, medications and has no other complaints. Triage vital signs (VS) include BP 144/84, HR 140, T 99.2, and SpO2 99% on room air. He is in obvious pain with a grossly deformed right ankle. Pulses are normal and equal bilaterally.

What’s the next step in your evaluation and treatment?

Answer:  Open fracture management and treatment^1-15

Epidemiology:

• Incidence reported at ranges of approximately 3.4-30.7 per 100,000 persons per year^1,2
  • Approximately 3% of fractures are open³
• Most commonly occur secondary to trauma, both high and low energy mechanisms
  • Majority of open fractures are low energy injuries with only 22.3% of open fractures being caused by high-energy injuries such as road traffic accidents or falls from a height¹
    • High-energy open fractures are more common in younger males
    • Low energy open fractures in older females
  • Mean age of those who sustain open tibial fractures is 43.3 years, though with a bimodal distribution²
    • Incidence of open fractures is similar between males between ages 15 and 19 years and females between 80 and 89 years at 53-54.5 per 100,000 persons per year⁴
  • Long bones most commonly affected, with open phalanx fractures being reported as 45% or more of all open fracture injuries, followed by open tibia-fibula fractures estimated at approximately 12%⁴

Clinical Presentation:

• Many open fractures present grossly deformed and often with exposed bone
  • Some open fractures may be more subtle, particularly in the pediatric population
    • Examine for any signs of focal bleeding, tenting of skin, or puncture marks
  • Open fractures are commonly classified in to Gustilo-Anderson categories⁵:
    • Type I: Laceration is < 1 cm and no evidence of contamination
    • Type II: Laceration > 1 cm 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%)
    • Mangled Extremity Severity Score (MESS)⁶
      • Skeletal and soft tissue damage
      • Limb ischemia
      • Age
      • Associated shock

Evaluation:

• Open fractures commonly designate significant trauma, thus patients should be managed as traumas, per ATLS guidelines
  • Open fractures may be very distracting and may draw attention away from life-threatening problems (non-patent airway, developing tension pneumothorax, cardiac tamponade, etc.)
  • Assessment of limb-threatening injuries falls under ‘C’ or ‘D’ portions of ATLS²
    • Hemorrhage control with tourniquet or direct pressure
    • Transfusion of blood components as needed
  • After initial stabilization, open fractures should be urgently addressed as well as completing a thorough history and physical exam focused on the mechanism, location, and timing of injury
    • If vascular compromise of a vessel is present, reduction of the fracture should be attempted as soon as possible
      • Hard signs (if any present, patient should go to OR):⁷
        • Absent of diminished distal pulses
        • Obvious arterial bleeding
        • Large expanding or pulsatile hematoma
        • Audible bruit, Palpable Thrill
        • Distal Ischemia (pain, pallor, paralysis, paresthesia, coolness)
          • Consider compartment syndrome, as 9% of open fractures present with compartment syndrome³
        • Soft signs:⁷
          • Small, stable hematoma
          • Injury to anatomically related nerve
          • Unexplained hypotension
          • History of hemorrhage
          • Proximity of injury to major vascular structures
          • Complex fracture
        • Thoroughly document neurological sensation in distal portions of affected extremity, along with surveying for anyother trauma or fractures
          • If there is concern for vascular injury, an ankle brachial index (ABI) may be obtained, or may go to CTA
          • If ABI is less than < 0.9, vascular surgery consult and CT angiogram are warranted⁸
            • Distal pulses normal, in 10-20% of significant arterial injuries³
        • Laboratory evaluation:
          • CBC, BMP, Coags if on anticoagulation, VBG
        • Imaging:
          • Radiographs including the joints above and below the fracture and 2 views; however, CT has shown relative increased sensitivity and specificity compared to plain films and is the gold standard, though is more expensive^9,10
            • Sensitivity and specificity of radiographs as compared to CT shown to be 89% and 95%, respectively¹⁰
          • CT Angiography useful when concerned about vascular injury
            • Presence of at least one hard or soft sign (as listed above) of arterial injury is risk factor for a positive CTA
            • Presence of multiple hard or soft signs, compared to one soft sign, increases risk almost threefold⁸
            • However, less than 7% of arterial injury found on CTA usually requires intervention⁸

Treatment:

• After initial trauma resuscitation and stabilization and attempt at reduction if needed:
  • Thorough irrigation with multiple liters of sterile saline and dressing with sterile saline-soaked gauze.
    • Recommendations are 3L for Type I, 6L for Type II, and 9L for Type III¹¹
  • Stabilize fracture with splint, brace, or traction and recheck distal pulses after
• Antibiotics
  • Starting antibiotics within < 3 hours in order to reduce possibility of infection rate primarily osteomyelitis¹¹
  • Classically, Types I and II open fractures should be treated with first-generation cephalosporin (Cefazolin 1 g or 25 mg/kg in children, Cephalexin), and type III fractures should have the addition of aminoglycoside (gentamicin 240 mg, 25 mg/kg in children)¹²
    • If severe PCN allergy, may prophylactically treat with Clindamycin 900 mg IV q8h + Levofloxacin 500 mg IV q24h¹³
    • Treatment of Type III fractures with ceftriaxone without the addition of an aminoglycoside has no increase in skin and soft tissue infection rates^13,14
      • May reduce renal and aural side effects from aminoglycosides
    • Recent RCT in open fracture in finger-tip amputation found no difference in infectious complications without prophylactic antibiotics¹⁵
      • Meticulous debridement and wound care is key
    • Facial fracture considerations: Amoxicillin-clavulanate/ampicillin-sulbactam or clindamycin if allergic¹⁶
      • Definitely give:
        • Facial fractures with open skin
        • Mandibular fractures open to oral cavity
      • Strongly consider:
        • Orbital wall fracture extending into frontal, ethmoid, maxillary sinus
      • Consider:
        • Frontal sinus fracture, Nasal bone fractures with mucosal disruption with resulting epistaxis
        • Lateral orbital wall fractures
      • Other considerations:
        • Seawater exposure: add doxycycline for Vibrio coverage³
        • Farm injuries: add penicillin G or metronidazole to cover Clostridium and other anaerobes³
      • Required tetanus prophylaxis if patient’s most recent tetanus is > 5 years or unknown
      • These patients require significant analgesia

Disposition:

• Following resuscitation and stabilization, tetanus prophylaxis, antibiotic prophylaxis, and irrigation: all patients with open fractures will require urgent consult to orthopedic surgery
  • Type I and II open fractures are urgent injuries that require surgery within 24 hours
  • Type III injuries require urgent surgical intervention of irrigation and debridement as soon as possible
    • Of IIIC injuries, 50% result in amputation³
  • Patients will likely require admission to ICU for management and monitoring for complications such as infection, neurovascular injury, or compartment syndrome

Pearls:

• Treat patients with open fractures as trauma patients, looking for concomitant life-threatening injuries as well as vascular injuries and compartment syndrome from the fracture
• Use the Gustilo-Anderson classification system in early consultation with orthopedics
• Began early prophylactic antibiotics early with first-generation cephalosporin for Types I-II open fractures, and aminoglycoside or ceftriaxone to treat Type III¹⁴

A 25-year-old man presents to the emergency department after he was thrown from a motorcycle when he was struck by a car. He was wearing a helmet and did not lose consciousness. He complains of right lower leg pain. On examination, he has a 5-centimeter wound over the anterior tibia. There is an obvious fracture of the midshaft of the tibia with bone ends visible in the wound and moderate muscle and skin damage but no large area of soft tissue loss. He is neurovascularly intact distally. Which of the following initial interventions has been shown to be most important in preventing complications of this injury?

A) Administer intravenous antibiotics

B) High-pressure irrigation with antibiotic solution

C) Obtain wound cultures in the emergency department

D) Perform surgical stabilization within six hours of injury

Answer: A

Open fractures are defined as fractures that communicate with the external environment due to skin and soft tissue injury. The incidence of infection in open fractures is increased over closed fractures and correlates with the severity of the injury. Several classification systems have been used to describe open fractures. The Gustilo-Anderson classification is one of the most commonly used. Type I fractures are low-energy fractures with minimal soft-tissue damage and are typically described as a wound of 1-centimeter or less. Type II fractures involve moderate soft tissue damage, and wounds are between 1 and 10 centimeters with minimal contamination. Type III fractures are high-energy fractures with large wounds and extensive soft tissue damage with variable contamination. Farm injuries and fractures with associated vascular injuries are included in some subclassifications. Immediate administration of intravenous antibiotics is indicated, as the risk of infection has been shown to be increased when antibiotics are given more than three hours after injury. The choice of antibiotic is determined by the fracture type. A first-generation cephalosporin is recommended for Gustilo-Anderson Type I and II fractures, an aminoglycoside or third-generation cephalosporin is added for Type III fractures, and penicillin is added for gross contamination with soil. Initial treatment in the emergency department also involves immobilizing the extremity and tetanus prophylaxis as indicated by immunization status. Gross debris should be removed, and a sterile, saline-soaked dressing should be applied. Debridement and stabilization of the fracture are performed urgently, within 24 hours of injury, in the operating room. Repeat debridements may be necessary, but early closure or coverage of the wound is preferred. Most Type I and II fractures can be closed primarily, but Type III fractures may need delayed soft tissue reconstruction for wound coverage.

High-pressure irrigation with antibiotic solution (B) is not indicated as high pressure can push debris further into the wound and antibiotics can be toxic to tissues. High volume, low-pressure irrigation with saline has been shown to be most effective. Obtaining wound cultures in the emergency department (C) is not useful for determining the choice of antibiotic or for predicting future infecting organisms and is not recommended. Performing surgical stabilization within six hours of injury (D) has not been shown to lower complications compared to within 24 hours of injury.

Rosh Review Free Qbank Access

Further Reading:

Additional FOAM Resources:

http://www.emdocs.net/open-fractures-pearls-and-pitfalls/

http://www.emdocs.net/mandibular-fractures-pearls-and-pitfalls/

https://litfl.com/open-fractures/

https://coreem.net/core/open-fractures/

http://www.tamingthesru.com/blog/ebcp/antibiotics-for-facial-fractures

https://rebelem.com/should-we-give-fingertip-amputations-with-exposed-bone-prophylactic-antibiotics/

References

1. Court-Brown CM, Bugler KE, Clement ND, Duckworth AD, McQueen MM. The epidemiology of open fractures in adults. A 15-year review. Injury. 2012;43(6):891-897. doi:10.1016/j.injury.2011.12.007
2. Elniel AR, Giannoudis P V. Open fractures of the lower extremity: Current management and clinical outcomes. EFORT open Rev. 2018;3(5):316-325. doi:10.1302/2058-5241.3.170072
3. Jedlicka N, Summers NJ, Murdoch MM. Overview of concepts and treatments in open fractures. Clin Podiatr Med Surg. 2012;29(2):279-290, viii. doi:10.1016/j.cpm.2012.01.006
4. Sop JL, Sop A. Open Fracture Management.; 2019. http://www.ncbi.nlm.nih.gov/pubmed/28846249. Accessed December 21, 2019.
5. Agel J, Evans AR, Marsh JL, et al. The OTA open fracture classification: a study of reliability and agreement. J Orthop Trauma. 2013;27(7):379-384; discussion 384-5. doi:10.1097/BOT.0b013e3182820d31
6. Loja MN, Sammann A, DuBose J, et al. The mangled extremity score and amputation: Time for a revision. In: Journal of Trauma and Acute Care Surgery. Vol 82. Lippincott Williams and Wilkins; 2017:518-523. doi:10.1097/TA.0000000000001339
7. Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline D. Tintinalli’s Emergency Medicine : A Comprehensive Study Guide.
8. Monazzam S, Goodell PB, Salcedo ES, Nelson SH, Wolinsky PR. When are CT angiograms indicated for patients with lower extremity fractures? A review of 275 extremities. In: Journal of Trauma and Acute Care Surgery. Vol 82. Lippincott Williams and Wilkins; 2017:133-137. doi:10.1097/TA.0000000000001258
9. Avci M, Kozaci N. Comparison of X-ray imaging and computed tomography scan in the evaluation of knee trauma. Med. 2019;55(10). doi:10.3390/medicina55100623
10. Open Fractures Management – Trauma – Orthobullets. https://www.orthobullets.com/trauma/1004/open-fractures-management. Accessed December 21, 2019.
11. Lee CK, Hansen SL. Management of Acute Wounds. Surg Clin North Am. 2009;89(3):659-676. doi:10.1016/j.suc.2009.03.005
12. Anderson A, Miller AD, Brandon Bookstaver P. Antimicrobial prophylaxis in open lower extremity fractures. Open Access Emerg Med. 2011;3:7-11. doi:10.2147/OAEM.S11862
13. Rodriguez L, Jung HS, Goulet JA, Cicalo A, Machado-Aranda DA, Napolitano LM. Evidence-based protocol for prophylactic antibiotics in open fractures: Improved antibiotic stewardship with no increase in infection rates. J Trauma Acute Care Surg. 2014;77(3):400-408. doi:10.1097/TA.0000000000000398
14. Rubin G, Orbach H, Rinott M, Wolovelsky A, Rozen N. The use of prophylactic antibiotics in treatment of fingertip amputation: A randomized prospective trial. Am J Emerg Med. 2015;33(5):645-647. doi:10.1016/j.ajem.2015.02.002
15. Mundinger G, Borsuk D, Okhah Z, et al. Antibiotics and Facial Fractures: Evidence-Based Recommendations Compared with Experience-Based Practice. Craniomaxillofacial Trauma Reconstr. 2014;08(01):064-078. doi:10.1055/s-0034-1378187

Acknowledgements:

We are military service members. This work was prepared as part of our official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the United States Military, Department of Defense or its Components, or the United States Government.