Open Fracture Management Flashcards
what are open fractures?
fractures with direct communication to the external environment
fractures with direct communication to the external environment
open fractures
most common location for open fractures
tibia and finger phalanx
associated conditions
additional injuries (30%)
compartment syndrome
percentage of open fractures associated with additional injuries
30%
the presence of an open wound does not preclude the occurrence of _____ in the injured limb
compartment syndrome
the size and nature of the external wound may not reflect the damage to the ____ structures
deeper
if concern for vascular insult, _____ should be obtained
ankle brachial index
normal ABI ratio
<0.9
vascular surgery consult and angiogram is warranted if ABI < ____
0.9
what do you do if ABI is <0.9
vascular consult and angiogram
consider ______ if concern for traumatic arthrotomy
saline load test or CT
consider saline load test or CT scan if concern for _____
traumatic arthrotomy
radiographs to obtain
obtain radiographs including joint above and below fracture
peri-articular injuries
evaluation for traumatic arthrotomy of the knee
CT
CT indications
peri-articular injuries
evaluation for traumatic arthrotomy of the knee
nonoperative treatment includes:
urgent IV antibiotics, tetanus prophylaxis, and extremity stabilization and dressing
nonoperative indications
initial treatment for all open fractures
a _____ should be treated as an open fracture until proven otherwise
soft tissue wound in proximity to a fracture
a soft tissue wound in proximity to a fracture should be treated as ____ until proven otherwise
an open fracture
operative management types
I&D, temporary fracture stabilization, local antibiotic administration and soft tissue coverage
definitive reconstruction and fracture fixation
consider ____ as soon as possible
ideal time of soft tissue coverage controversial, but most centers perform within 5-7 days
I&D
consider I&D as soon as possible
ideal time of soft tissue coverage controversial, but most centers perform within ____ days
5-7
infection rates of open fracture depend on _____, periosteal stripping and delay in treatment
zone of injury
infection rates of open fracture depend on zone of injury, _____ and delay in treatment
periosteal stripping
infection rates of open fracture depend on zone of injury, periosteal stripping and _____
delay in treatment
incidence of fracture-related infection range from _____% in type I open fractures to 30% in type III fractures
<1
incidence of fracture-related infection range from <1% in type I open fractures to _____% in type III fractures
30
indications for definitive reconstruction and fracture fixation
once soft tissue coverage is obtained and an adequate sterility is achieved
definitive treatment with internal fixation leads to significantly decreased _____, improved functional outcomes, and decreased time in the hospital compared to those definitively fixed with external fixation
time to union
definitive treatment with internal fixation leads to significantly decreased time to union, improved ____ outcomes, and decreased time in the hospital compared to those definitively fixed with external fixation
functional
when should antibiotics be initiated
as soon as possible
studies show increased infection rate when antibiotics are delayed for more than ____ hours from time of injury
3
continue antibiotics for 24 hours after initial injury if wound is able to be _____
closed primarily
continue antibiotics for 24 hours after final closure if _____
wound is not closed during initial surgical debridement
antibiotics for Gustilo type 1 and 2
1st generation cephalosporin
clindamycin or vancomycin can also be used if allergies exist
antibiotics for gustilo type 3
1st generation cephalosporin + aminoglycoside
some institutions use vancomycin + cefepime
antibiotics for farm injuries, heavy contamination, or possible bowel contamination
add high dose penicillin for anaerobic coverage (clostridium)
add high dose penicillin for anaerobic coverage (clostridium)
farm injuries, heavy contamination, possible bowel contamination
antibiotics for fresh water wounds
fluoroquinolones or 3rd or 4th generation cephalosporin
antibiotics for salt water wounds
doxycycline + ceftazidime or a fluoroquinolone
when to initiate tetanus prophylaxis
in the ED or trauma bay
tetanus toxoid and immunoglobulin should be given intramuscularly with ____ different syringes in ____ different locations
two
guidelines for tetanus prophylaxis depend on 3 factors
complete or incomplete vaccination history (3 doses)
date of most recent vaccination
severity of wound
methods of stabilization
splint, brace, or traction for temporary stabilization
decreases pain, minimizes soft tissue trauma, and prevents disruption of clots
remove gross debris from wound, do not remove any _____
bone fragments
place sterile _____ dressing on wound
saline soaked
recent meta-analysis (____ study) have recommended debridement within 24 hours to minimize risk of infection for type III fractures
goliath
recent meta-analysis (GOLIATH study) have recommended debridement within ____ hours to minimize risk of infection for type III fractures
24
recent meta-analysis (GOLIATH study) have recommended debridement within 24 hours to minimize risk of infection for type ____ fractures
3
recommended debridement within
within ____ hours for type IIIB open tibia fractures
12
recommended debridement within
within 12 hours for type ____ open tibia fractures
3B
taged debridement and irrigation
perform every ____ hours as needed
24-48
I&D technique: extend wound ____ in line with extremity to adequately expose open fracture
proximally and distally
low-pressure bulb irrigation vs. high-pressure pulse lavage
no difference in infection or union rates
studies have shown that saline with ____ had decreased primary wound healing problems when compared to antibiotic solutions
Castile soap
how many liters of saline for Gustilo type 1?
3
how many liters of saline for gustilo type 2?
6
how many liters of saline for gustilo type 3?
9
thorough ____ of devitalized tissue is critical to prevent deep infection
debridement
bony fragments without ____ attachments should be removed
soft tissue
bony fragments without soft tissue attachments should be ____
removed
performed at the time of initial debridement
temporary fracture stabilization
____ is temporary initial treatment of choice for majority of high energy open fractures of the lower extremity
external fixation
significantly contaminated wounds with large soft tissue defects
large bony defects
local antibiotics
indications for local antibiotics
significantly contaminated wounds with large soft tissue defects
large bony defects
local antibiotics technique
beads made by mixing methylmethacrylate with heat-stable antibiotic powder
vancomycin and tobramycin most commonly used
local antibiotics: beads made by mixing ____ with heat-stable antibiotic powder
vancomycin and tobramycin most commonly used
methylmethacrylate
most commonly used antibiotic powder in local antibiotic treatment
vancomycin and tobramycin
timing of flap coverage for open tibial fractures remains controversial, < _____ days is desired
7
soft tissue coverage: odds of infection increase by ____% for each day beyond day 7
16
soft tissue coverage: odds of infection increase by 16% for each day beyond day ____
7
studies have not shown any statistical difference between rate of ___ when ORIF is performed before fasciotomy closure, at fasciotomy closure, or after fasciotomy closure
infection
can proceed with bone grafting after wound is ____
clean and closed
_____ wound therapy may be utilized during debridement until definitive coverage can be achieved
negative-pressure
Definitive reconstruction and fracture fixation if no critical bone defect:
open reduction and internal fixation or intramedullary treatment depending on fracture location and morphology
definitive reconstruction and fracture fixation if critical bone defect:
Masquelet technique (“induced-membrane” technique)
distraction osteogenesis
vascularized bone flap/transfer
Masquelet technique 1st stage
I&D, cement spacer and temporizing fixation
Masquelet technique 2nd stage
placement of bone graft into “induced membrane” and definitive fixation
Studies show optimal time frame for bone grafting to be _____ weeks after placement of cement spacer
4-6
complications of open wounds
surgical site infection
osteomyelitis
Neurovascular injury
Compartment syndrome
osteomyelitis incidence ranges between ______% depending on the bone involved and fracture characteristics
1.8% to 27%
the most common site of post-surgical osteomyelitis following surgical treatment of open fractures
tibia
blast mechanism of injury
acute surgical amputation
delay in defintive soft tissue coverage greater than 7 days
more severe Gustillo-Anderson classification.
osteomyelitis risk factors
osteomyelitis risk factors
blast mechanism of injury
acute surgical amputation
delay in defintive soft tissue coverage greater than 7 days
more severe Gustillo-Anderson classification.
To minimize risk of infection, debridement recommended to be performed within ____ hours for all type III fractures and within 12 hours for type IIIB open tibia fractures
24
To minimize risk of infection, debridement recommended to be performed within 24 hours for all type III fractures and within ____ hours for type IIIB open tibia fractures
12
Infection rates higher in open injuries due to blunt or penetrating trauma?
blunt
____ rates higher in open injuries due to blunt trauma than penetrating trauma
infection
