Open
Definition
- Fracture with a break in the skin communicating with fracture haematoma or fracture
Classification
Gustilo and Anderson Classification of Open Fractures
Described 1976: treatment of 1025 open fractures
Modified 1984
| Grade | Wound | Description |
|---|---|---|
| I | < 1cm | Low Energy Low contamination, Clean wound Minimal tissue injury |
| II | 1-10cm | Moderate Energy Moderate contamination Moderate tissue injury |
| IIIa | > 10cm | High Energy Trauma regardless of size of wound Contaminated Extensive soft tissue laceratiosn or flaps, but maintain adequate soft tissue coverage of bone |
| IIIb | Needs flap/ graft for closure | |
| IIIc | Needs vascular repair to save limb | |
| Automatic Grade III Shotgun wound High-velocity gunshot wound Segmental fracture with displacement Diaphyseal segmental loss Wound occurring in a farmyard/ highly contaminated environment Crushing force from a fast-moving vehicle |
Management
- General Principles Trauma Management
- Resuscitation & Assessment
- Appropriate antibiotics
- Debridement/ Irrigation
- Bony stabilization
- Soft tissue envelope
- Definitive bony procedure
- Bone grafting as needed
- Gustilo JBJSA 1987
- Infection higher if < 10L washout
- Anglen 1984
- Pulse lavage 100x more effective than bulb
Antibiotics
Patzakis 1974
- Controlled, randomized, prospective trial
- Infection with pre-operative Cephalothin was 2.3% cf. 13.9% with no AB
- Finding initial swab correlating with infecting organism has been discredited
Gustilo
- Gram negative infection in Grade II ↑
- Hence add aminoglycoside if Grade II
- Tetanus
- Rationale of not swabbing open wounds
- No real correlation between road-side organisms & subsequent infection
- Which is typically hospital acquired
Tetanus Prophylaxis
Patient previously fully immunised
Wound not Tetanus-prone
- If < 10 years since TT: nothing
- If > 10 years since TT: single TT
Wound Tetanus-prone
- If < 5 years since TT: nothing
- If > 5 years since TT: single TT
Patient not adequately immunised or unknown
- Wound not Tetanus-prone
- Give 0.5ml TT
- Wound Tetanus-prone
- Give 250-500 units TIG
- + 0.5ml TT in other arm
- ± penicillin
Principles of Open/ Infected Fractures
- Management 5 fold
- Appropriate antibiotics
- Adequate debridement
- Soft tissue envelope preserved
- Skeletal stabilization
- Bone graft as needed
- Note can expand this as needed to TJR loose/ Infected/ Osteomyelitis