Open Fractures + Osteomyelitis Flashcards
Open fracture
Fracture of bone with exposure to environment
All contaminated, but not all will become infected
Open fracture classification based on
Mechanism of injury
Degree of soft tissue damage
Configuration of fracture
Degree of contamination
Type I open fracture
Small <1 cm wound
Inside to outside (bone penetrates skin + retracts)
Low energy traumatic impacts
Least contamination/lowest infection/complication rate
Type II open fracture
Wound >1cm
Usually external trauma (outside to in)
Mild to moderate soft tissue damage
Simple or comminuted
Moderate contamination
Type III open fracture
Extensive soft tissue damage
Major contamination
High energy trauma
Highly comminuted
Outside to in
3 subtypes
Type IIIa open fracture
Adequate soft tissue coverage despite extensive laceration of flaps
No major reconstructive procedures required
Type IIIb open fracture
Soft tissue loss or inadequate soft tissue coverage
Type IIIc open fracture
Extensive soft tissue damage including blood supply and/or nerves
Management of open fractures
Prevent infection
Soft tissue + bone healing
Restoration of anatomy
Functional recovery
Evaluation of patients with open fractures
- Complete history/PE
- May have multiple injuries
- Life-threatening first
- Assess neurovascular structures
- Cover open wounds with sterile dressing (prevent nosocomial infection)
Wound management
Decrease contamination + improve blood supply
Lavage!!!!, debride, sterile bandage; ASEPTIC technique
Debridement
Fat/fascia - aggressive
Muscle/skin - conservative
If questionable - preserve + reevaluate
Bone/ligament/tendon - preserve unless absolutely necessary
**staged debridement
Antibiotic therapy for open wounds
Start immediately
Obtain culture + do sensitivity testing (culture from deep tissue)
General guidelines for Abx therapy of open wounds
Type I: usually aerobic, gram +; 1st gen cephalosporins
Type II, III: g + and -
Fracture repair
“New” surgery after debridment new instruments, gowns, gloves, etc
Construct healthy soft tissue envelop/reduction/alignment
Bone grafting
Type I/II - good soft tissue coverage; autogenous cancellous bone graft at time of repair
Type III - delayed grafting - 4-6 wk post-repair
Wound closure
Delayed primary closure, local skin grafts, axial pattern flaps, free skin grafts
Second intention healing
Vacuum assisted closure
Osteomyelitis
Inflammatory condition affecting bone (periosteum, cortex, medullary canal) usually due to infectious cause (bacterial, fungal - uncommon in NE, occasionally viral)
Route of osteomyelitis
Hematogenous
Post-traumatic
Pathogenesis of osteomyelitis
Ischemic event (fracture or surgery)
Concurrent bacterial colonization (hematogenous, direct inoculation, contiguous infection)
Factors predisposing to osteomyelitis
Hypovolemia
Malnutrition
Obesity
Endocrine disease
Immunosuppressive
Unstable fracture
Tissue metabolism
Foreign material
Dead space
Bacterial glycocalyx
Network of polysaccharides lying outside outer membrane of gram - cells and outside peptidoglycan of gram + cells (common in nature)
Exopolysaccharide polymers from bacteria - assist in adhesion to implant —> form biofilm
Biofilms
Modify local environment to favor microbe + protect from immune system
Concentrate nutrients, prevent identification of surface antigens
Antibiotic resistance: impedes perfusion of agent, quiescent growth pattern, harsh microenvironment
Chronic post-traumatic osteomyelitis
Most common form
Disease of ischemia
Weeks to yr after contamination
