11. open fractures and osteomyelitis

Question 1

fracture type 1

Answer 1

from inside to outside
bone pokes in and out
less than 1cm wound
simple fractures, low impact
low contamination and low levels of infection
minimum soft tissue injury

Question 2

fracture type 2

Answer 2

outside to inside - usually external trauma
simple or comminuted fractures
mild soft tissue damage
mild contamination

Question 3

fracture type 3

Answer 3

severe soft tissue damage and bone damage
high contamination, higher frequencies of infection
high energy/impact trauma
highly comminuted

Question 4

type 3a

Answer 4

can be corrected/closed with surgery
adequate soft tissue covering for fracture bone

Question 5

type 3b

Answer 5

cant close wound- exposed soft tissue and bone exposure
inadequate soft tissue covering
periosteal stripping

Question 6

type 3c

Answer 6

vasculature compromised , may need amputation, poor prognosis
severe soft tissue damage, arterial blood supply damaged

Question 7

what does open fracture mean? what is the contamination status

Answer 7

bone is exposed to the environment
not all contaminated fractures will become infected

Question 8

are open fractures medical emergencies?

Answer 8

No
assess neurovascular structures
assses the life threating injuries first , cover fracture to minimize infection from nosocomial organisms

Question 9

most open fractures are contaminated with nosocomal organisms- therefore to minimize this you should

Answer 9

apply a sterile dressing and splint to prevent further soft tissue damage and infection

Question 10

what is the goal of initial wound management for an open fracture

Answer 10

go from contaminated and avascular wound—> to a cleaner and improved blood supply

Question 11

what are the fundamentals of wound management

Answer 11

lavage!!! cant do enough

debridement- be conscious of how much you remove (fatty tissue can remove a lot if unsure) BUT soft tissue like muscle and skin, may want to leave if unsure bc its a main source of blood supply to the bone
-bones,tendons/ligaments LEAVE! unless absolutely needed

sterile bandage

Question 12

what are you removing during debridement

Answer 12

dead bone-sequestrum
dead soft tissue
dirt/debris

Question 13

layers of bandage/dressing

Answer 13

primary- highly absorptive, moisture retaining, wet to dry, dry to dry

secondary- absorbs, compressive, support

tertiary- protects from the outside environment/contamination

Question 14

Abx treatment for open fractures

Answer 14

start immediately
use a broad spectrum initially until culture comes back
Ideally start Abx after culture and sensitivity but cant wait- when you get the results then change Abx
ideally IV for the first 72 hrs

Question 15

type 1 fracture abx choice

Answer 15

1 generation cephalexin
gram +
usually aerobic gm+

Question 16

type 2 and 3 abx choice

Answer 16

abx against gram + and -

Question 17

fracture repair, when is it done

Answer 17

it can be done immediately after debridement or once the patient is stable

if done after debridement, start all over with sterile equipment, gloves etc

Question 18

what are the advantages of external fixation in open wounds

Answer 18

minimum disruption to soft tissue-maintain good blood supply
easy to remove without another surgery
can adjust stiffness/stability
easy access to the wound- could do wound care

Question 19

when would you use bone grafts

Answer 19

when absolutely needed, cant be infected- need optimal blood supply

type 1 and type 2 have adequate soft tissue covering and can be done at the time of repair

type 3 would be done 4-6 weeks after repair

Question 20

open wound management-dressing

Answer 20

sterile dressing applied with each bandage change
repeated debridement and lavage wound
more frequent bandage changes at the beginning esp type 3 fractures

Question 21

wound-skin- closure options type 3 fracture

Answer 21

delayed primary closure, skin graft
secondary intention

Question 22

what is osteomyelitis

Answer 22

inflammatory condition usually caused by an infection of the entire bone, periosteum, medullary canal, cortex)

Question 23

what is hematogenous osteomyelitis vs post-traumatic osteomyelitis

Answer 23

hematogenous- through circulation

post-traumatic- it was introduced at the time of fracture or fracture repair

Question 24

what is the pathogenesis of osteomyelitis?

Answer 24

1. there is an ischemic event: during fracture event-loss of blood supply or we caused the ischemia by removal of ST or compromised vasculature with implant
2. colonization of bacteria

Question 25

bacterial glycocalyx and osteomyelitis

Answer 25

bacteria colonize the implants- they release glycocalyx and are silent to the immune system-
build a biofilm on the implants
hematogenous drugs are ineffective

Question 26

what is chronic post traumatic osteomyelitis

Answer 26

this is when infection becomes apparent weeks to months after surgery - stopped abx and bacterial went crazy

or bacteria were silent on the implant and then began to go crazy

Question 27

clinical signs of chronic post-traumatic osteomyelitis

Answer 27

pain, swelling,
drainage
lameness

Question 28

sequestrum is

Answer 28

piece of dead bone

Question 29

culture and sensitivity

Answer 29

take the sample from deep tissue- tissue sample is the best and swap
tissue of bone sample

Question 30

treatment for osteomyelitis

Answer 30

must debride dead tissue, bone -remove the implant and take a culture,

if bone isn’t healed- must control infection and rigid stabilization the fracture

Question 31

Abx treatment of osteomyelitis

Answer 31

based on culture and sensitivity
initially parenteral
long term oral- 6-8 weeks

usually GM- and anerobic
1st gen cephalosporin
b-lactamase resistant pen
clindamycin