11. open fractures and osteomyelitis Flashcards
fracture type 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
fracture type 2
outside to inside - usually external trauma
simple or comminuted fractures
mild soft tissue damage
mild contamination
fracture type 3
severe soft tissue damage and bone damage
high contamination, higher frequencies of infection
high energy/impact trauma
highly comminuted
type 3a
can be corrected/closed with surgery
adequate soft tissue covering for fracture bone
type 3b
cant close wound- exposed soft tissue and bone exposure
inadequate soft tissue covering
periosteal stripping
type 3c
vasculature compromised , may need amputation, poor prognosis
severe soft tissue damage, arterial blood supply damaged
what does open fracture mean? what is the contamination status
bone is exposed to the environment
not all contaminated fractures will become infected
are open fractures medical emergencies?
No
assess neurovascular structures
assses the life threating injuries first , cover fracture to minimize infection from nosocomial organisms
most open fractures are contaminated with nosocomal organisms- therefore to minimize this you should
apply a sterile dressing and splint to prevent further soft tissue damage and infection
what is the goal of initial wound management for an open fracture
go from contaminated and avascular wound—> to a cleaner and improved blood supply
what are the fundamentals of wound management
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
what are you removing during debridement
dead bone-sequestrum
dead soft tissue
dirt/debris
layers of bandage/dressing
primary- highly absorptive, moisture retaining, wet to dry, dry to dry
secondary- absorbs, compressive, support
tertiary- protects from the outside environment/contamination
Abx treatment for open fractures
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
type 1 fracture abx choice
1 generation cephalexin
gram +
usually aerobic gm+
type 2 and 3 abx choice
abx against gram + and -
fracture repair, when is it done
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
what are the advantages of external fixation in open wounds
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
when would you use bone grafts
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
open wound management-dressing
sterile dressing applied with each bandage change
repeated debridement and lavage wound
more frequent bandage changes at the beginning esp type 3 fractures
wound-skin- closure options type 3 fracture
delayed primary closure, skin graft
secondary intention
what is osteomyelitis
inflammatory condition usually caused by an infection of the entire bone, periosteum, medullary canal, cortex)
what is hematogenous osteomyelitis vs post-traumatic osteomyelitis
hematogenous- through circulation
post-traumatic- it was introduced at the time of fracture or fracture repair
what is the pathogenesis of osteomyelitis?
- 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
- colonization of bacteria
bacterial glycocalyx and osteomyelitis
bacteria colonize the implants- they release glycocalyx and are silent to the immune system-
build a biofilm on the implants
hematogenous drugs are ineffective
what is chronic post traumatic osteomyelitis
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
clinical signs of chronic post-traumatic osteomyelitis
pain, swelling,
drainage
lameness
sequestrum is
piece of dead bone
culture and sensitivity
take the sample from deep tissue- tissue sample is the best and swap
tissue of bone sample
treatment for osteomyelitis
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
Abx treatment of osteomyelitis
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
