Open fractures

Question 1

What is an open fracture

Answer 1

A fracture with direct communication to the external environment

Question 2

When should IV Abx be given by

Answer 2

Within 3 hours of time of injury

Question 3

Which abx are given in open fractures

Answer 3

Co-amoxiclav 1.2g 8hrly
if pen allergy: Clindamycin 600mg 6hrly
Tetanus prophylaxis

Question 4

What is the initial management of an open fracture

Answer 4

1. IV access, bloods taken
   - FBC
   - U+Es
   - LFTs
   - Clotting
   - G+S/ X match
2. Analgesia and antiemetic
3. IV abx - co-amoxiclav or clindamycin
4. Control bleeding - apply direct pressure do not blindly apply clamp/tourniquet
5. Soft tissue - assess neurovascular damage and damage to soft tissue
6. Photograph
7. Dressing - remove gross contamination and place saline soaked gauze and impermeable film cover
8. stabilise and splint. re assess neurovascular supply
9. refer to ortho on call

Question 5

WHen should neurovascular status be assessed

Answer 5

Before and after reduction

Question 6

What is the surgical management for open fractures

Answer 6

1. aggressive debridement and irrigation
   - low pressure lavage
   - remove any bony fragments without soft tissue attachments
   2, fracture stabilisation - internal or external
2. staged debridement - every 24/48hrs or as needed
3. Early soft tissue coverage/wound closure - aim for less than 7 days, decreases risk of infection
4. place abx bead pouch in dirty wounds

Question 7

Which abx are given at wound excision and how long are they given for

Answer 7

Co-amoxiclav 1.2g TDS and gentamycin 1.5mg/kg - started at wound incision and continued for 72hrs following surgery or until wound closure

Question 8

In what time frame should surgical management be done

Answer 8

Within 24 hours

Question 9

What would cause you to take a patient to theatre earlier than within the 24hrs

Answer 9

Compartment syndrome
Vascular injury
multiple injuries
Gross contamination - marine, farm

Question 10

When a wound is left open for >2 weeks which organisms is it more prone to

Answer 10

Pseudomonas

gram negative

Question 11

IF an open fracture has vascular damage how much time is there until it needs o be treated

Answer 11

6hrs from injury

Question 12

When are primary amputations performed

Answer 12

uncontrollable haemorrhage 
incomplete traumatic amputation 
4-6hrs ischaemia 
segmental muscle loss of 2 compartments
Bone loss greater than /3 of tibia

Question 13

When should definitive stabilisation and soft tissue coverage be done

Answer 13

Ideally within 72hrs

No more than 7 days

Question 14

Which abx should be given in definitive stabilisation and soft tissue coverage

Answer 14

Gentamycin and Teicoplanin at induction