Chapter 40: Open Fractures

Question 1

What is the interobserver agreement of Gustilo-Anderson open fracture classification scheme?

Answer 1

60%

Question 2

What is the psi for wound irrigation?

Answer 2

7-8 psi
1 liter bag @ 300PSI plus 16-18ga needle
Or 30mL syringe and 18ga needle

Question 3

Covering the wound reduces infection from 12% to what %?

Answer 3

5%

Question 4

What % of infections are caused by organisms cultured at time of initial presentation?

Answer 4

18% (most are hospital acquired)

Question 5

What % of traumatic appendicular fractures in dogs are open?
In cats?

Answer 5

Dogs 14%
Cats 29%

Question 6

Describe type 1, 2 and 3 on the Gustillo-Anderson Classification scheme for open fractures?

Answer 6

Type 1: Wound < 1cm (sharp fragments make wound, then often retract below level of skin)
Type 2: Wound >1cm without extensive soft tissue damage, flaps or avulsions (often wound was caused by outside forces)
Type 3: Extensive soft tissue damage (avulsion, degloving, bone loss) fractures with neurovascular injury, gunshots, traumatic partial amputations

There are 3 subtypes of Type 3:
IIIa: Adequate soft tissue available
IIIb: extensive loss of soft tissue, periosteal stripping, massive contamination
IIIc: arterial injury that will require repair (often we amputate in vet med)

Question 7

In humans, if antibiotics are started within 3 hours of injury, infection rate decreases to what % vs. >4 hours?

Answer 7

4.7% if within 3 hours
7.4% if >4 hours

Question 8

In humans:
For type I and II fractures, what empiric antibiotic is advised?
For type III?

Answer 8

I and II: 1st or 2nd gen cephalosporin
III: cephalosporin + fluoroquinolone

Question 9

Is there evidence that initial surgical debridement must happen in <6hr?

Answer 9

No - you should treat with wound care but don’t need sx that quick.

Question 10

VAC at what pressure reduced edema, increased blood flow, accelerated granulation tissue formation, and increased bacterial clearance?

Answer 10

-125mmHg

Question 11

In a type III open fracture, pedicle and muscle flaps can be used if you can’t reconstruct the soft tissues locally. What % do they reduce nonunion to (from initially 30%)?

Answer 11

Reduced to 5% with early coverage - even in infected wounds.

Question 12

For surgical approaches for different types of open fractures, what should you do?

Answer 12

Type I: Same as for closed fracture of the same type
Type II: Can sometimes treat same as closed - use your judgement
Type III: You may not be able to do internal fixation

** benefits of stability outweigh the potential harm of implants or need for future explant

Question 13

Cortical grafts in open/contaminated fractures are at risk of what?

Answer 13

becoming a sequestrum

Question 14

What are the complication rates for open fractures by type?
The nonunion rates?

Answer 14

Complications:
Type I 0-2%
Type II 2-10%
Type III 10-50%

Nonunions
Type I 0-5%
Type II 1-14%
Type III 2-37%