Text of Adeel Husain PGY 3 Loma Linda University Dept of Orthopaedic Surgery Open Fractures
Slide 1
Adeel Husain PGY 3 Loma Linda University Dept of Orthopaedic
Surgery Open Fractures
Slide 2
Definition Break in the skin and underlying soft tissue leading
directly into or communicating with the fracture and its
hematoma
Slide 3
Last century, high mortality with open fractures of long bones
Early amputation in order to prevent death WWI, mortality of open
femur fractures > 70% 1939 Trueta closed treatment of war
fractures Included open wound treatment and then enclosure of the
extremity in a cast Greatest danger of infection lay in muscle, not
bone Trueta J: "Closed" treatment of war fractures, Lacet
1939;1:1452-1455 History
Slide 4
1943 PCN on the battlefield quickly reduced rate of wound
sepsis Delayed closure of wounds Hampton: closure btwn 4 th and 7
th day Larger defects continued to be left open to heal by
secondary intention Hampton OP Jr: Basic principles in management
of open fractures; JAMA 1955; 159:417-419 History
Slide 5
Advances shifted the focus Preservation of life and limb
preservation of function and prevention of complications However,
amputation rates still exceed 50% in the most severe open tibial
fractures assoc with vascular injury* Lange RH, Bach AW, Hansen ST
et al: Open tibial fractures with associated vascular injuries:
prognosis for limb salvage. J Trauma; 25(3):203- 208 History
Slide 6
Epidemiology 3% of all limb fractures 21.3 per 100,000 per
year
Slide 7
Open fracture classification Allows comparison of results
Provides guidelines on prognosis and treatment Fracture healing,
infection and amputation rate correlate with the degree of soft
tissue injury Gustilo upgraded to Gustilo and Anderson AO open
fracture classification Host classification of open fractures
Slide 8
Gustilo and Anderson Classification Model is tibia, however
applied to all types of open fractures Emphasis on wound size Crush
injury assoc with small wounds Sharp injury assoc with large wounds
Better to emphasize Degree of soft tissue injury Degree of
contamination
Slide 9
Type 1 Open Fractures Inside-out injury Clean wound Minimal
soft tissue damage No significant periosteal stripping
Slide 10
Type 2 Open Fractures Moderate soft tissue damage Outside-in
Higher energy Some necrotic muscle Some periosteal stripping
Slide 11
Type 3a Open Fractures High energy Outside-in Extensive muscle
devitalization Bone coverage with existing soft tissue
Slide 12
Type 3b Open Fractures High energy Outside in Extensive muscle
devitalization Requires a flap for bone coverage and soft tissue
closure Periosteal stripping
Slide 13
Type 3c Open Fractures High energy Increased risk of amputation
and infection Any grade 3 with major vascular injury requiring
repair
Slide 14
Why use this classification? Grades of soft tissue injury
correlates with infection and fracture healing Grade123A3B3C
Infection Rates 0-2%2-7%10-25%10-50%25-50% Fracture Healing (weeks)
21-2828-2830-35 Amputation Rate 50%
Slide 15
Gustilo and Anderson Bowen and Widmaier* 2005 Host
classification predicts infection after open fracture Gustilo and
Anderson classification and the number of comorbidities predict
infection risk 174 patients with open fractures of long bones
Sorted into three classes based on 14 immunocompromising factors
Age>80, current nicotine use, DM, malignancy, pulmonary
insufficiency, systemic immunodeficiency, etc Bowen TR, Widmaier
JC. Host classification predicts infection after open fracture.
Clin Orthop Relat Res. 2005;433:205-11.
Slide 16
What they found Patients with any compromising risk factor has
increased risk of infection May benefit from additional therapies
that decrease the risk of infection. Bowen TR, Widmaier JC. Host
classification predicts infection after open fracture. Clin Orthop
Relat Res. 2005;433:205-11. ClassCompromising factorsInfection
rates A04% B1-215% C3 or more31%
Slide 17
Gustilo Classification: a simple and useful tool, but is it
accurate? 1994 Brumback et al. 125 randomized open fractures 245
surgeons of various levels of training 12 cases of open tibia
fractures, videos used Interobserver agreement poor Range 42-94%
for each fracture Ortho attendings - 59% agreement Ortho Trauma
Fellowship trained attendings - 66% agreement Brumback RJ, Jones AL
(1994) Interobserver agreement in the classification of open
fractures of the tibia. The results of a survey of two hundred and
forty-five orthopaedic surgeons. J Bone and Joint Am;
76(8):11621166.
Slide 18
So. Fracture type should not be classified in the ER Most
reliably done in the OR at the completion of primary wound care and
debridement
Slide 19
Microbiology Most acute infections are caused by pathogens
acquired in the hospital 1976 Gustilo and Anderson most infections
in their study of 326 open fxs developed secondarily When left open
for >2wks, wounds were prone to nocosomial contaminants such as
Pseudomonas and other GN bacteria Currently most open fracture
infections are caused by GNR and GP staph Gustilo RB, Anderson JT:
Prevention of Infection in the Treatment of One Thousand and
Twenty-five Open Fractures of Long Bones; JBJS, 58(4):453-458, June
1976
Slide 20
Nocosomial infection?!!!! Only 18% of infections were caused by
the same organism initially isolated in the perioperative cultures*
Carsenti-Etesse et al. 1999 92% of open fracture infections were
caused by bacteria acquired while the patient was in the hospital**
*Patzakis MJ, Wilkins J, Moore TM: Considerations in reducing the
infection rate in open tibial fractures. Clin Orthop Relat Res.
1983 Sep;(178):36-41. *Patzakis MJ, Bains RS, Lee J, Shepherd L,
Singer G, Ressler R, Harvey F, Holtom P: Prospective, randomized,
double-blind study comparing single antibiotic therapy,
ciprofloxacin, to combo antibiotic therapy in open fracture wounds.
J Orthop Trauma. 2000 Nov;14(8):529-33. **Carsenti-Etesse H, Doyon
F, Desplaces N, Gagey O, Tancrede C, Pradier C, Dunais B,
Dellamonica P. Epidemiology of bacterial infection during
management of open leg fractures. Eur J Clin Microbiol Infect Dis.
1999;18:315-23. Cover the wounds quickly
Slide 21
Common bacteria encountered with open fractures Blunt Trauma,
Low Energy GSWStaph, Strept Farm WoundsClostridia Fresh
WaterPseudomonas, Aeromonas Sea WaterAeromonas, Vibrios War Wounds,
High Energy GSWGram Negative
Slide 22
What systemic antibiotic? 1 st Gen CephGentPCN Grade 1 Grade 2
+/- Grade 3 +/- Farm/War Wounds (Gustilo, et al; JBJS 72A
1990)
Slide 23
Antibiotic comparisons No difference btwn clindamycin and
cefazolin* Patzakis et al. ** For type 1&2, cipro =
cefamandole+gentamicin For type 3, cipro worse (31% vs 7.7%
infection) Cipro and other fluoroquinolones inhibit osteoblast
activity and fracture healing*** *Benson DR, Riggins RS, Lawrence
RM, Hoeprich PD, Huston AC, Harrison JA. Treatment of open
fractures: a prospective study. J Trauma. 1983;23:25-30. **Patzakis
MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F,
Holtom P. Prospective, randomized, double-blind study comparing
single-agent antibiotic therapy, ciprofloxacin, to combination
antibiotic therapy in open fracture wounds. J Orthop Trauma.
2000;14:529-33. ***Holtom PD, Pavkovic SA, Bravos PD, Patzakis MJ,
Shepherd LE, Frenkel B. Inhibitory effects of the quinolone
antibiotics trovafloxacin, ciprofloxacin, and levofloxacin on
osteoblastic cells in vitro. J Orthop Res. 2000;18:721-7.
***Huddleston PM, Steckelberg JM, Hanssen AD, Rouse MS, Bolander
ME, Patel R. Ciprofloxacin inhibition of experimental fracture
healing. J Bone Joint Surg Am. 2000;82:161-73.
Slide 24
When and for how long? Start abx as soon as possible* Less than
3 hours 4.7 % infection rate Greater than 3 hours 7.4% No
difference btwn 1 and 5 days of post op abx treatment** Mass Gen
recommended treatment:*** Cefazolin Q 8 until 24 hours after wound
closed Gentamicin or levofloxacin added for type 3 *Patzakis MJ,
Wilkins J. Factors influencing infection rate in open fracture
wounds. Clin Orthop Relat Res. 1989;243:36-40. **Dellinger EP,
Caplan ES, Weaver LD, Wertz MJ, Brumback R, Burgess A, Poka A,
Benirschke SK, Lennard S, Lou MA. Duration of preventive antibiotic
administration for open extremity fractures. Arch Surg.
1988;123:333-9. ***Okike K, Bhattacharyya T: Trends in the
management of open fractures. A critical analysis. J Bone Joint
Surg. 2006 Dec;88(12):2739-48.
Slide 25
Local antibiotic therapy High abx conc within the wound and low
systemic conc Reduces risk of systemic side effect Vancomycin or
aminoglycosides Heat stable Available in powder form Active against
suspected pathogens Eckman JB Jr, Henry SL, Mangino PD, Seligson D.
Wound and serum levels of tobramycin with the prophylactic use of
tobramycin- impregnated polymethylmethacrylate beads in compound
fractures. Clin Orthop Relat Res. 1988; 237:213-5.
Slide 26
Antibiotics - locally Prevents secondary contamination by
nocosomial pathogens Useful adjunct to systemic abx Potential for
abx impregnated bone graft, bone graft substitute, and abx coated
IMN Ostermann PA, Seligson D, Henry SL: Local antibiotic therapy
for severe open fractures. A review of 1085 consecutive cases; J
Bone Joint Surg Br. 1995 Jan;77(1):93-7. AntibioticInfection Rate
IV Abx12% IV Abx + local aminoglycoside impregnated PMMA beads
3.7%
Slide 27
Antibiotic Beads Pros Very high levels of antibiotics locally
Dead space management Cons Requires removal Limited to heat stable
antibiotics Increased drainage from wound
Slide 28
Goals of treatment 1. preserve life 2. preserve limb 3.
preserve function Also. Prevent infection Fracture stabilization
Soft tissue coverage
Slide 29
Stages of care for open fractures
Slide 30
Initial assessment & management ABCs Assess entire patient
Careful PE, neurovasc Abx and tetanus Local irrigation 1-2 liters
Sterile compressive dressings Realign fracture and splint Do not
culture wound in the ED* 8% of bugs grown caused deep infection
cultures were of no value and not to be done Recheck pulse, motor
and sensation Lee J. Efficacy of cultures in the management of open
fractures. Clin Orthop Relat Res. 1997;339:71-5.
Slide 31
Can I take pictures with my phone and send it to my senior?
Documents characteristics accurately Prevents multiple examinations
Decreases contamination* Communication via digital photography was
more useful than verbal communication** 1.3-megapixel camera is
comparable with higher resolution cameras when viewing color images
on computer desktop*** *Tscherne H, Gotzen L, editors Fractures
with soft tissue injuries. New York: Springer; 1984 **Tipmongkol V,
Thepkamnoet H, Tangtrakulwanich B: Using Digital Wound Photography
to Improve Communication among Orthopaedic Health Care
Professionals in Orthopeadic Patients. The Thai Journal of
Orthopaedic Surgery: 33 No.2: S16-20 AAOS 2010 Podium Present
***Andres BM. Response to letter to the editor re: A comparison of
digital cameras -- features essential for the orthopaedic surgeon.
Clin Orthop 2004; 428:309.
Slide 32
Primary surgery Objectives of initial surgical management
Preservation of life and limb Wound debridement Definitive injury
assessment Fracture stabilization Stages of open fracture
management in the OR
Slide 33
Surgical emergency! 1898 Friedrich guinea pigs Take to the OR
within 6-8 hours* 1973 Robson: bacteria multiply in contaminated
wounds ** 10 5 organisms/gram of tissue is the infection threshold
Reached at 5.17 hours 1995 Kindsfater et al: 47 G2/3 fxs at 4.8
months out. Less than 5 hrs 7% infection Greater than 5 hrs 38%
infection However G3 fxs were treated later *Friedrich PL. Die
aseptische Versorgung frischer Wundern. Arch Klin Chir.
1898;57:288-310. **Robson MC, Duke WF, Krizek TJ. Rapid bacterial
screening in the treatment of civilian wounds. J Surg Res.
1973;14:426-30.
Slide 34
Or not?.... Calling the 6 hour rule into question 1993 Bednar
and Parikh. No significant difference * 3.4% vs 9%; 82 open
femoral/tibial fxs 2004 Ashford et al. No significant difference **
11% vs 17%; pts from the austrailian outback 2004 Spencer et al....
No significant difference *** 10.1% vs 10.9%; 142 open long bone
fxs from UK 2003 Pollack and the LEAP investigators. No
correlation**** 315 open long bone fxs 2005 Skaggs et al.No
significant difference ***** children with all types of open
fractures; 554 open fractures *Bednar DA, Parikh J. Effect of time
delay from injury to primary management on the incidence of deep
infection after open fractures of the lower extremities caused by
blunt trauma in adults. J Orthop Trauma. 1993;7:532-5. **Ashford
RU, Mehta JA, Cripps R. Delayed presentation is no barrier to
satisfactory outcome in the management of open tibial fractures.
Injury. 2004;35:411-6. ***Spencer J, Smith A, Woods D. The effect
of time delay on infection in open long-bone fractures: a 5-year
prospective audit from a district general hospital. Ann R Coll Surg
Engl. 2004;86:108-12. ****Pollack AN, Castillo RC, Jones AL, Bosse
MJ, MacKenzie EJ, and the LEAP Study Group. Time to definitive
treatment significantly influences incidence of infection after
open high-energy lower-extremity trauma. Read at the Annual Meeting
of the Orthopaedic Trauma Association; 2003 Oct 9-11; Salt Lake
City, UT. *****Skaggs DL, Friend L, Alman B, Chambers HG, Schmitz
M, Leake B, Kay RM, Flynn JM. The Effect of Surgical Delay on Acute
Infection Following 554 Open Fractures in Children. JBJS-A 2005.
87:8-12 No significant difference before or after 6 hours!!!
Slide 35
Do we even need to do operative debridement? Orcutt et al... No
significant difference, BUT* 50 type 1 &2 open fractures less
infection in nonoperative group (3% vs 6%) Less delayed union in
nonop group (10% vs 16%) Yang et al.0% infections ** 91 type 1 open
fractures treated without I&D *Orcutt S, Kilgus D, Ziner D. The
treatment of low-grade open fractures without operative
debridement. Read at the Annual Meeting of the Orthopaedic Trauma
Association; 1988 Oct 28; Dallas, TX. **Yang EC, Eisler J.
Treatment of Isolated Type 1 Open Fractures: Is Emergent Operative
Debridement Necessary? Clin Orthop Relat Res 2003. 410: 289-294. Do
we even need to debride low grade open fractures?
Slide 36
However, after review of all literature.. Okike et al. states.
Thorough operative debridement is the standard of care for all open
fractures. Even if the benefits of formal I&D were
insignificant for low grade fractures, operative debridement is
still required for proper wound classification. Open fractures
graded on the basis of superficial characteristics are often
misclassified. Huge risk not to explore and debride! Okike K,
Bhattacharyya T: Trends in the management of open fractures. A
critical analysis. J Bone Joint Surg Am. 2006
Dec;88(12):2739-48.
Slide 37
URGENTLY debride, not EMERGENTLY Time to OR is probably less
important than:* Adequacy of debridement Time to soft tissue
coverage Timing depends on.** Is patient stable? Is the OR
prepared? Is appropriate assistance available? Ortho trained scrub
techs, assistant surgeons, xray techs, and other OR staff 2005
Skaggs et al:*** If after 10pm, keep until the morning! Or at least
within 24 hours. Unless. neurovasc compromise horrible soft tissue
contamination compartment syndrome *Okike K, Bhattacharyya T:
Trends in the management of open fractures. A critical analysis. J
Bone Joint Surg. 2006 Dec;88(12):2739-48. **Werner CM, Pierpont Y,
Pollak AN: The urgency of surgical dbridement in the management of
open fractures. J Am Acad Orthop Surg. 2008 Jul;16(7):369-75.
***Stewart DJ, Kay RM, Skaggs DL: Open Fractures in Children.
Principles of Evaluation and Management. JBJS-A. 2005;87:2784-2798.
Within 24 hours Within 6 hours
Slide 38
I&D in the OR Trauma scrub Soap and saline to remove gross
debris Zone of injury Skin wound is the window through which the
true wound communicates with the exterior Extend the traumatic
wound Excise margins Resect muscle and skin to healthy tissue
color, consistency, capacity to bleed and contractility Bone ends
are exposed and debrided Irrigate Serial debridements? If needed, 2
nd or 3 rd debridement after 24- 48 hours should be planned
Slide 39
The Irrigation Amount No good data, copious is better Animal
studies show improved removal of particulate matter and bacteria
but effect plateaus Irrigation bags typically contain 3 L of fluid
Anglen recommends:* 3L (one bag) for type 1 6L (two bags) for type
2 9L (three bags) for type 3 *Anglen JO. Wound Irrigation in
Musculoskeletal Injury. JAAOS 2001. 9: 219-226.
Slide 40
How to deliver the irrigation? (what animal studies show) Bulb
Syringe vs Pulsatile Lavage Pulsatile lavage Detrimental for early
bone healing this is no longer present at 2 wks * More soft tissue
destruction ** More effective in removing particulate matter and
bacteria *** High or low pressure? Higher pressure Better bone
cleaning Worse soft tissue cleaning Slows bone healing *Dirschl DR,
Duff GP, Dahners LE, Edin M, Rahn BA, Miclau T. High Pressure
Pulsatile Lavage Irrigation of Intraarticular Fractures: Effects on
Fracture Healing. JOT 1998. 12(7): 460-463. **Boyd JI, Wongworawat
MD. High-Pressure Pulsatile Lavage Causes Soft Tissue Damage. CORR
2004. 427: 13-17 ***Bhandari M, Schemitsch EH, Adili A, Lachowski
RJ, Shaughnessy SG. High and Low Pressure Pulsatile Lavage of
Contaminated Tibial Fractures: An in vitro Study of Bacterial
Adherence and Bone Damage. JOT 1999. 13: 526-533.
Slide 41
Antibiotics in the irrigation? Antibiotics (bacitracin and/or
neomycin) Mixed results, controversial Costly bacitracin alone
around $500/washout ?? Causing resistance Wound healing problems?
Few reported cases of anaphylaxis Anglen: No proven value in the
care of open fracture woundssome risk, albeit small. No proven
benefit! *Anglen JO. Wound Irrigation in Musculoskeletal Injury.
JAAOS 2001. 9: 219-226.
Slide 42
Soaps in the irrigation? Surfactants (i.e. Soaps) Less bacteria
adhesion Emulsify and remove debris No significant difference in
infection or bone healing compared to bacitracin solution, but more
wound healing problems in bacitracin group Anglen JO. Comparison of
Soap and Antibiotic Solutions for Irrigation of Lower-Limb Open
Fracture Wounds: A Prospective, Randomized Study. JBJS-A 2005.
87(7):1415-1422.
Slide 43
Level 4 evidence based recommendations 1 st washout, highly
contaminated Soap solution Repeat washout of clean wounds Saline
Infected wounds Soap, then antibiotic *Anglen JO. Wound Irrigation
in Musculoskeletal Injury. JAAOS 2001. 9: 219-226.
Slide 44
Wound closure after contaminated fracture Timing and technique
is controversial OPEN WOUND should be left OPEN! Prevents anaerobic
conditions in wound: Clostridium Facilitates drainage Allows repeat
debridement Zalavras CG, Patzakis MJ:Open fractures: evaluation and
management. J Am Acad Orthop Surg. 2003 May-Jun;11(3):212-9.
Dubunked!
Slide 45
To close or not to close? Recently, renewed interest in primary
closure Collinge, OTA 2004 Moola, OTA 2005 Russell, OTA 2005
DeLong, J Trauma 2004/ Bosse, JAAOS 2002 Improved abx management
Better stabilization Less morbidity Shorter hospital stay, lower
cost NO increase in wound infection These wounds are at higher risk
of clostridia perfringens if they do get infected. 1999 Delong et
al: 119 open fxs No significant difference delayed/nonunion and
infection rates btwn immediate and delayed closure Immediate
closure is a viable option DeLong WG Jr, Born CT, Wei SY, Petrik
ME, Ponzio R, Schwab CW: Aggressive treatment of 119 open fracture
wounds. J Trauma. 1999 Jun;46(6):1049-54. infection rate7% Overall
delayed/nonunion rate16% GradePercent of primary closures 188% 286%
3a75% 3b33% 3c0%
Slide 46
Contraindications to primary closure Inadequate debridement
Gross contamination Farm related or freshwater immersion injuries
Delay in treatment >12 hours Delay in giving abx Compromised
host or tissue viability
Slide 47
When to cover the wound? ASAP after wound adequately debrided
Only 18% of infections are caused by the same organism isolated in
initial perioperative culture* Suggests hospital acquired etiology
of infection Fix and Flap** For Type IIIB & IIIC open tibia
fractures Early if not immediate flap coverage Patzakis MJ, Bains
RS, Lee J, et al. Prospective, randomized, double-blind study
comparing single-agent antibiotic therapy, ciprofloxacin, to
combination antibiotic therapy in open fracture wounds. JOT 2000.
14: 529-533. **Gopal S, Majumder S, Batchelor A, Knight S, De Boer
P, Smith RM. Fix and flap: the radical orthopaedic and plastic
treatment of severe open fractures of the tibia. JBJS-B 2000.
82(7): 959 966. Timing of flap placementInfection rate < 72
hours6% > 72 hours30%
Vacuum assisted wound closure Recommended for temporary
management Mechanically induced negative pressure in a closed
system Removes fluid from extravascular space Reduced edema
Improves microcirculation Enhances proliferation of reparative
granulation tissue Open cell polyurethane foam dressing ensures an
even distribution of negative pressure -Webb LX: New techniques in
wound management: vacuum-assisted wound closure. J Am Acad Orthop
Surg. 2002 Sep-Oct;10(5):303-11. -Dedmond BT, Kortesis B, Punger K,
Simpson J, Argenta A, Kulp B, Morykwas M, Webb L. The use of
Negative Pressure Wound Therapy in the Temporary Treatment of Soft
Tissue Injuries associated with High Energy Open Tibial Shaft
Fractures. JOT. 2007
Slide 50
Types of fracture stabilization Splint Good option if operative
fixation not required Internal fixation Wound is clean and soft
tissue coverage available External fixation Dirty wounds or
extensive soft tissue injury
Slide 51
Fracture stabilization Gustilo type 1 injury can be treated the
same way as a comparable closed fracture Most cases involve
surgical fixation Outcome is similar to closed counterparts
Slide 52
Fracture stabilization Gustilo type 2&3 usually displaced
and unstable dictate surgical fixation Restore length, alignment,
rotation and provide stability ideal environment for soft tissue
healing and reduces wound infection reduces dead space and hematoma
volume Inflammatory response dampened Exudates and edema is reduced
Tissue revascularization is encouraged
Slide 53
When to use plates? Open diaphyseal fractures of arm &
forearm Open diaphyseal fractures lower extremity NOT recommended
Open tibial shaft plating assoc high infection rate* Open
periarticular fractures Treatment of choice in both upper and lower
extremities Bach AW, Hansen ST Jr.: Plates versus external fixation
in severe open tibial shaft fractures. A randomized trial. Clin
Orthop Relat Res. 1989 Apr;(241):89-94.
Slide 54
When to use IM nails? Treatment of choice for most diaphyseal
fractures of the lower extremity Inserted without disrupting the
already injured soft tissue envelope Preserves the remaining extra
osseous blood supply to cortical bone Malunion is uncommon
Slide 55
To ream or not to ream? Does reaming cause additional damage to
the endosteal blood supply? Solid IM nails without reaming has a
lower risk of infection that tubular nails with a large dead space*
However reamed IM nails are biomechanically stronger and can
reliably maintain fracture reduction if statically locked 2000
Finkemeier et al. reamed vs unreamed interlocked nails of open
tibias NO statistical difference in outcome and risk of
complication** *Melcher GA, Claudi B, Schlegel U, Perren SM,
Printzen G, Munzinger J.Influence of type of medullary nail on the
development of local infection. An experimental study of solid and
slotted nails in rabbits;.J Bone Joint Surg Br. 1994
Nov;76(6):955-9. **Keating JF, O'Brien PJ, Blachut PA, Meek RN,
Broekhuyse HM: Locking intramedullary nailing with and without
reaming for open fractures of the tibial shaft. A prospective,
randomized study. J Bone Joint Surg Am. 1997 Mar;79(3):334-41.
**Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF: A
prospective, randomized study of intramedullary nails inserted with
and without reaming for the treatment of open and closed fractures
of the tibial shaft. J Orthop Trauma. 2000
Mar-Apr;14(3):187-93.
Slide 56
When to use external fixation? Diaphyseal fractures not
amenable to IM nails Ring fixators for periarticular fractures
Temporary joint spanning ex fix is popular for knee, ankle, elbow
and wrist If temporary, plan for conversion to IM nail within 3
weeks
Slide 57
Ex-fix: Weigh the pros and cons! Historically was definitive
treatment Now, more commonly as temporary fixation Can be applied
almost always and everywhere Severe soft tissue damage and
contamination Advantages: Easy and quick Relatively stable fixation
No further damage done Avoids hardware in the open wound
Disadvantages: Pin track infections Malalignment Delayed union Poor
patient compliance
Slide 58
Skin cover and soft tissue reconstruction Do these early! 1994
Osterman et al.* Retrospective 1085 fractures, 115 G2 and 239 G3
All treated with appropriate IV Abx and I&D No infection if
wounds closed at 7.6 days Yes infection if wounds closed at 17.9
days *Ostermann PA, Seligson D, Henry SL: Local antibiotic therapy
for severe open fractures: A review of 1085 consecutive cases. J
Bone Joint Surg Br 1995;77:9397. Infection risk increases if wound
open > 7 days
Slide 59
Reconstructive ladder: options for wound coverage Primary
closure Secondary intention Skin graft Local flap Regional flap
Distant flap Free flap Tissue expansion Type 1 open fx Type 3B open
fx Type 2/3A open fx
Slide 60
Flap coverage for type 3b
Slide 61
Type 3c, a bad injury! Devastating damage to bone and soft
tissue Major arterial injuries that require repair Poor functional
outcome Consensus btwn ortho, vascular and plastics Salvage is
technically possible in most cases However it is not always the
correct choice esp type 3c tibia fractures
Slide 62
We can do both, salvage & amputate. Vascular surgery can
revascularize with bypass graft Generally before fracture
stabilization Plastics can provide soft tissue coverage However, in
the tibia, the severity to soft tissue envelope and bone may result
in infected nonunion If salvage. long course of repeated surgical
procedures Painful and psychologically distressing Functional
outcome may be poor and no better than amputation
Slide 63
How to decide, salvage or amputate? Important factors in
decision making:* General condition of the patient (shock) Warm
ischemia time (>6hours) Age (>30 years) Cut to crush ratio
(blunt injuries has a large zone of crush) Howe HR Jr, Poole GV Jr,
Hansen KJ, Clark T, Plonk GW, Koman LA, Pennell TC: Salvage of
lower extremities following combined orthopedic and vascular
trauma. A predictive salvage index. Am Surg. 1987
Apr;53(4):205-8.
Slide 64
Gunshot injuries Energy dissipated at impact = damage severity
High velocity rifles and close range shotguns Worst, high energy of
impact Huge secondary cavitation Secondary effects of shattered
bone fragments Bullets lodged in joints should be removed avoid
lead arthropathy and systemic lead poisoning
Slide 65
Low velocity GSW
Slide 66
Low velocity GSW open fractures Geisslar et al. * If
neurovascular status normal, do local debridement NO formal I&D
needed IV Abx Approach fx fixation as if closed Dickey et al.** No
abx vs IV Ancef x 3d 67 low velocity GSW fxs Not requiring
operative fixation No difference in infection rates *Geisslar ett
al, J Ortho Trauma, 4;39-41,1990 **Dickey et al, J Ortho Trauma,
3;6-10,1989 Treat open fractures from low velocity GSW as closed
fractures without Abx
Slide 67
Pitfalls and complications Infection delayed union, nonunion,
malunion and loss of function Plan ahead to avoid delayed union and
nonunion Predict nonunion in severe injuries with bone loss Bone
grafting usually delayed 6 weeks when soft tissues have soundly
healed Autogenous bone grafting is usual strategy Fibular transfer,
free composite graft or distraction osteogenesis for complex
defects Recombinant human BMP in open tibia fracture reduces risk
of delayed union
Slide 68
Advances BMPs 40% decreased infection rate with BMP in type 3
open tibia fractures* Antibiotic Laden Bone Graft**
Tobramycin-impregnated calcium sulfate pellets with demineralized
bone matrix Animal study: successful in preventing infection *BESTT
Study Group, Govender S, Csimma C, Genant H, Valentin-Opran A.
Recombinant Human Bone Morphogenetic Protein-2 for Treatment of
Open Tibial Fractures: A prospective, controlled, randomized study
of four hundred and fifty patients. JBJS-A 2002. 84(12): 2123-2134.
**Beardmore AA, Brooks DE, Wenke JC, Thomas DB. Effectiveness of
local antibiotic delivery with an osteoinductive and
osteoconductive bone-graft substitute. JBJS-A 2005. 87(1):
107-112.
Slide 69
Summary A = good evidence (level 1 studies) B = fair evidence
(level 2/3 studies) C = poor quality evidence (level 4/5 studies) I
= insufficient or conflicting evidence Okike K, Bhattacharyya T:
Trends in the management of open fractures. A critical analysis. J
Bone Joint Surg. 2006 Dec;88(12):2739-48.
