17 - Open Fractures

Question 1

Goals of open fracture treatment

Answer 1

• Convert contaminated wounds to clean wounds
• Early soft tissue healing
• Stabilize fractures
• NOTE: this is the same for all open wounds in the body

Question 2

Gustillo and Anderson classification

KNOW THIS CLASSIFICATION SYSTEM ***

Answer 2

• Mechanism of injuries (somewhat involves this)
• Level of contamination ***
• Configuration of fractures ***
• Degree of soft tissue damage ***
• NOTE: there are actually ICD billing codes that directly correlate to the Gustillo and Anderson classification system (Salter and Harris is the same way – not many others work this way)
• This classification system is actually useful clinically – incorporates rates of infection, amputation, etc. for each classification

Question 3

Types for Gustillo and Anderson classification

Answer 3

• Type I
• Type II
• Type IIIA
• Type IIIB
• Type IIIC

Question 4

Type I Gustillo and Anderson

Answer 4

• Clean puncture

Question 5

Type II Gustillo and Anderson

Answer 5

• Laceration > 1 cm
• Moderate contamination
• No extensive soft tissue damage
• Moderate comminution (fracture fragmentation of bone)
• Example: talus protruding through skin (extruded talus) due to extreme dorsiflexion, common mechanism is car accident where person slams on the break then crashes

Question 6

Type III-A Gustillo and Anderson

Answer 6

• Extensive laceration
• Adequate soft tissue coverage
• Severe comminution
• More contaminated
• Example: much larger lesion, same injury as type II (extruded talus), but a HIGHER amount of contamination “bumps” the injury up to a type IIIA

Question 7

Type III-B Gustillo and Anderson

Answer 7

• Massive contamination
• Extensive soft tissue loss
• Periosteal stripping *** (HALLMARK of III-B)
• Bone exposure
• Severe comminution
• NOTE: periosteal stripping is important here because losing periosteum decreases circulation to the bone, decreasing healing potential, and also eliminates possibility of skin graft being used to cover open wound because you can only skin graft over a wound if the periosteum is intact – if you have blood supply to the bone, you can put a skin graft over it (it won’t look great, but you would be more interested in function, not cosmesis)

Question 8

Type III-C Gustillo and Anderson

Answer 8

• Open fracture with arterial injury

- Arterial injury is a HALLMARK of III-C***

Question 9

Open fracture treatment plan

Answer 9

• Surgical emergency
• Golden period = 6 hours
• Multi-system evaluation
• Antibiosis and tetanus
• IRRIGATION AND DEBRIDEMENT = cornerstone of open fractures
• Stabilize fractures

Question 10

Surgical emergencies in podiatric medicine

Answer 10

• Open fracture
• Compartment syndrome
• Gas gangrene/necrotizing fasciitis
• Septic joint
• Fracture with neurovascular compromise

Question 11

Golden period

Answer 11

• If an open fracture is attended to before 6 hours, we just treat it as a contaminated wound
• If an open fracture is not attended to within 6 hours, it is considered an INFECTED wound

Question 12

Multisystem evaluation of patient

Answer 12

• A lot of open fractures can damage other structures or systems within the body
• No one ever died from an open fracture – they die from other things that you’ve missed
• If you treat the talus pushing out of the foot, but you miss the fact that the amount of force that body was under led to a lacerated spleen or other organ, you’ve just killed your patient

Question 13

Open fracture treatment plan

Answer 13

• Compartment syndrome (especially in crush injuries)
• Delayed closure (often required – can occasionally close a type I)
• Bone grafting
• Contaminated vs infected (6+ hours = infected)
• Rehabilitation

Question 14

Antibiotic protocols

Answer 14

• Limited duration of therapy (48 to 72 hours – don’t need 2 weeks of abx)
• The only time you would need to restart the antibiotics is if they need to go back to the OR for a delayed closure or if there is an obvious infection (drainage, erythema, etc.)
• Need to tell patients the minimum number of surgeries they may need is 2, maybe more
• Pen G in clostridium prone wounds (soil, dirt, farm injuries)

Question 15

Antibiotic therapy for type I open fractures

Answer 15

• Cefazolin (Ancef) 2 gm IV q 8 hrs.

Question 16

Antibiotic therapy for type II and III open fractures

Answer 16

• Combined therapy because these are more contaminated wounds
• Cefazolin (Ancef)
• Aminoglycosides 3-5 mg/kg/day

Question 17

STUDY: Anderson, A., Miller, A.D., & Bookstaver, P.B. (2011). Antimicrobial prophylaxis in open lower extremity fractures. Open Access Emergency Medicine, 3: 7-11.

Answer 17

• Level 1 study – Systematic review of randomized controlled trials
• Recommendation for I and II: Grade I and II open fractures treated with first generation cephalosporin within 3 hours of injury and continued for 24 hours
• Recommendation for III: Grade III treated with first generation cephalosporin and aminoglycoside within 3 hours and continued for 48-72 hours
• NOTE: the time frame for a I and II has been shortened to just 24 hours with just one antibiotic, which is slightly different protocol than presented before – you will follow your hospital’s guidelines for open fracture treatment

Question 18

Infection considerations

Answer 18

• Type I: 0-2%
• Type II: 2-7%
• Type III-A: 7%
• Type III-B: 10-50%
• Type III-C: 25-50%
• > 50% of Type III-C result in amputation
• NOTE: infection rates increase as the Gustillo and Anderson severity increases because there is increased contamination and increased size of wound

Question 19

Surgical principle – Debridement and lavage

Answer 19

• Initial debridement and pulse lavage
• Repeat debridement PRN
• Repeat antibiotic protocol
• Early coverage of wounds with delayed primary closure, grafts or flaps
• If tendon or bone looks avascular or necrotic, get it out – we can always do a bone graft or tendon graft to restore function at a later date
• If muscle looks unhealthy, need to get rid of it – Color (should be red), Condition (striations visible), Consistency (should be firm), Contractility (zap it with electrocautery to test)
• Goal: conservative but complete – repeat as much as needed
• “The solution to pollution is dilution” – this means irrigate, irrigate, irrigate (at least 2 L of fluid)

Question 20

How to determine if tissue is healthy

Answer 20

• Capillary refill time
• Pulses
• Temperature
• Color (cyanotic, white)
• Debride it a little (does it bleed?)
• UV lamp with injection

Question 21

Stabilization of fractures

Answer 21

• Intra-articular fractures: complication outweighs risk of infection
• Types of fixation: internal vs external
• Advantages for healing

Question 22

Indications for amputation

Answer 22

• Massive uncontrolled sepsis
• Necrosis and gangrene
• Primary amputation

Question 23

Bone grafting

Answer 23

• Type I and II: as soon as you’re sure there is no infection, you can put a bone graft in
• Type III: wait at least 6 weeks because there is so much contamination
• NOTE: may need to use an external fixator to maintain the gap (length) so that when the wound is ready, there has not been so much soft tissue retraction that the bone length is decreased

Question 24

Mangled Extremity Severity Score (MESS)

Answer 24

Retrospective and prospective trial revealed that a MESS value ≥ 7 predicted amputation with 100% accuracy

KNOW GREATER THAN 7 = AMPUTATION***

Question 25

Point system for MESS

Answer 25

``` A = skeletal/soft tissue injury B = ischemia C = shock D = age ```

Question 26

MESS A = skeletal/soft tissue injury point system

Answer 26

o Low energy (stab; simple fracture; “civilian” GSW) – 1 point o Medium energy (open or multiple fractures, dislocation) – 2 points o High energy (close-range shot gun or “military” GSW, crush injury) – 3 points o Very high energy (above + gross contamination, soft-tissue avulstion) – 4 points

Question 27

MESS B = ischemia point system

Answer 27

o Pulse reduced or absent but perfusion normal – 1 point o Pulseless; parasthesias, diminished capillary refill – 2 points o Cool, paralyzed, insensate, numb – 3 points o NOTE: scores are doubled for ischemia over 6 hours

Question 28

MESS C = shock point system

Answer 28

o Systolic BP always > 90 mm Hg – 0 points o Hypotensive transiently – 1 point o Persistent hypotension – 2 points

Question 29

MESS D = age point system

Answer 29

o 50 – 2 points

Question 30

CASE STUDY - patient presentation

Answer 30

o A 41-year-old male with past medical history of hypertension presented to the emergency department after sustaining a right ankle injury while playing basketball. He reported landing on an inverted foot after attempting a ‘dunk’ shot during the game. He then noted exposure of bone at the lateral aspect of his ankle. He denied losing consciousness or sustaining any other injuries. He did admit to having consumed moderate amounts of alcohol prior to the injury. o At presentation, he was in moderate distress due to pain, found to be alert and oriented to person, place and time. Vital signs were stable. o Examination of the right foot and ankle revealed medial dislocation of the foot on the ankle and a 15cm wound to the lateral aspect of the ankle. (Figs.1 and 2) At the proximal aspect of the wound, the distal fibula, talar dome and posterolateral talar body could be visualized.

Question 31

CASE STUDY - physical exam

Answer 31

o The base of the wound was beefy red and the wound margins viable o The open wound appeared relatively clean except for a sock embedded in the wound and was without debris or foreign bodies. o There was no evidence of neurovascular compromise. o Pedal pulses were palpable, capillary refill time was brisk and protective sensation intact.