Adeel Husain PGY 3

1
Open Fractures

• Adeel Husain PGY 3
• Loma Linda University
• Dept of Orthopaedic Surgery

2
Definition

• Break in the skin and underlying soft tissue
  leading directly into or communicating with the
  fracture and its hematoma

3
History

• Last century, high mortality with open fractures
  of long bones
• Early amputation in order to prevent death
• WWI, mortality of open femur fractures gt 70
• 1939 Trueta closed treatment of war fractures
• Included open wound treatment and then enclosure
  of the extremity in a cast
• Greatest danger of infection lay in muscle, not
  bone

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History

• 1943 PCN on the battlefield quickly reduced rate
  of wound sepsis
• Delayed closure of wounds
• Hampton closure btwn 4th and 7th day
• Larger defects continued to be left open to heal
  by secondary intention

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History

• Advances shifted the focus
• Preservation of life and limb ? preservation of
  function and prevention of complications
• However, amputation rates still exceed 50 in the
  most severe open tibial fractures assoc with
  vascular injury

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Epidemiology

• 3 of all limb fractures
• 21.3 per 100,000 per year

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Open fracture classification

• Allows comparison of results
• Provides guidelines on prognosis and treatment
• Fracture healing, infection and amputation rate
  correlate with the degree of soft tissue injury
• Gustilo upgraded to Gustilo and Anderson
• AO open fracture classification
• Host classification of open fractures

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Gustilo and Anderson Classification

• Model is tibia, however applied to all types of
  open fractures
• Emphasis on wound size
• Crush injury assoc with small wounds
• Sharp injury assoc with large wounds
• Better to emphasize
• Degree of soft tissue injury
• Degree of contamination

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Type 1 Open Fractures

• Inside-out injury
• Clean wound
• Minimal soft tissue damage
• No significant periosteal stripping

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Type 2 Open Fractures

• Moderate soft tissue damage
• Outside-in
• Higher energy
• Some necrotic muscle
• Some periosteal stripping

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Type 3a Open Fractures

• High energy
• Outside-in
• Extensive muscle devitalization
• Bone coverage with existing soft tissue

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Type 3b Open Fractures

• High energy
• Outside in
• Extensive muscle devitalization
• Requires a flap for bone coverage and soft tissue
  closure
• Periosteal stripping

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Type 3c Open Fractures

• High energy
• Increased risk of amputation and infection
• Any grade 3 with
• major vascular injury requiring repair

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Why use this classification?

• Grades of soft tissue injury correlates with
  infection and fracture healing

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Gustilo and AndersonBowen and Widmaier

• 2005 Host classification predicts infection after
  open fracture
• Gustilo and Anderson classification and the
  number of comorbidities predict infection risk
• 174 patients with open fractures of long bones
• Sorted into three classes based on 14
  immunocompromising factors
• Agegt80, current nicotine use, DM, malignancy,
  pulmonary insufficiency, systemic
  immunodeficiency, etc

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What they found

• Patients with any compromising risk factor has
  increased risk of infection
• May benefit from additional therapies that
  decrease the risk of infection.

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Gustilo Classification a simple and useful
tool, but is it accurate?

• 1994 Brumback et al.
• 125 randomized open fractures
• 245 surgeons of various levels of training
• 12 cases of open tibia fractures, videos used
• Interobserver agreement poor
• Range 42-94 for each fracture
• Ortho attendings - 59 agreement
• Ortho Trauma Fellowship trained attendings - 66
  agreement

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So.

• Fracture type should not be classified in the ER
• Most reliably done in the OR at the completion of
  primary wound care and debridement

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Microbiology

• Most acute infections are caused by pathogens
  acquired in the hospital
• 1976 Gustilo and Anderson
• most infections in their study of 326 open fxs
  developed secondarily
• When left open for gt2wks, wounds were prone to
  nocosomial contaminants such as Pseudomonas and
  other GN bacteria
• Currently most open fracture infections are
  caused by GNR and GP staph

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Nocosomial infection?!!!!
Cover the wounds quickly

• Only 18 of infections were caused by the same
  organism initially isolated in the perioperative
  cultures
• Carsenti-Etesse et al. 1999
• 92 of open fracture infections were caused by
  bacteria acquired while the patient was in the
  hospital

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Common bacteria encountered with open fractures
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What systemic antibiotic?
(Gustilo, et al JBJS 72A 1990)
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Antibiotic comparisons

• No difference btwn clindamycin and cefazolin
• Patzakis et al.
• For type 12, cipro cefamandolegentamicin
• For type 3, cipro worse (31 vs 7.7 infection)
• Cipro and other fluoroquinolones inhibit
  osteoblast activity and fracture healing

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When and for how long?

• Start abx as soon as possible
• Less than 3 hours ? 4.7 infection rate
• Greater than 3 hours ? 7.4
• No difference btwn 1 and 5 days of post op abx
  treatment
• Mass Gen recommended treatment
• Cefazolin Q 8 until 24 hours after wound closed
• Gentamicin or levofloxacin added for type 3

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Local antibiotic therapy

• High abx conc within the wound and low systemic
  conc
• Reduces risk of systemic side effect
• Vancomycin or aminoglycosides
• Heat stable
• Available in powder form
• Active against suspected pathogens

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Antibiotics - locally

• Prevents secondary contamination by nocosomial
  pathogens
• Useful adjunct to systemic abx
• Potential for abx impregnated bone graft, bone
  graft substitute, and abx coated IMN

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Antibiotic Beads

• Cons
• Requires removal
• Limited to heat stable antibiotics
• Increased drainage from wound

• Pros
• Very high levels of antibiotics locally
• Dead space management

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Goals of treatment

• 1. preserve life
• 2. preserve limb
• 3. preserve function
• Also.
• Prevent infection
• Fracture stabilization
• Soft tissue coverage

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Stages of care for open fractures
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Initial assessment management

• ABCs
• Assess entire patient
• Careful PE, neurovasc
• Abx and tetanus
• Local irrigation 1-2 liters
• Sterile compressive dressings
• Realign fracture and splint
• Do not culture wound in the ED
• 8 of bugs grown caused deep infection
• cultures were of no value and not to be done
• Recheck pulse, motor and sensation

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Can I take pictures with my phone and send it to
my senior?

• Documents characteristics accurately
• Prevents multiple examinations
• Decreases contamination
• Communication via digital photography was more
  useful than verbal communication
• 1.3-megapixel camera is comparable with higher
  resolution cameras when viewing color images on
  computer desktop

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Primary surgery

• Objectives of initial surgical management
• Preservation of life and limb
• Wound debridement
• Definitive injury assessment
• Fracture stabilization

Stages of open fracture management in the OR
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Surgical emergency!

• 1898 Friedrich guinea pigs
• Take to the OR within 6-8 hours
• 1973 Robson
• bacteria multiply in contaminated wounds
• 105 organisms/gram of tissue is the infection
  threshold
• Reached at 5.17 hours
• 1995 Kindsfater et al
• 47 G2/3 fxs at 4.8 months out.
• Less than 5 hrs ? 7 infection
• Greater than 5 hrs ? 38 infection
• However G3 fxs were treated later

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Or not?.... Calling the 6 hour rule into
question
No significant difference before or after 6
hours!!!

• 1993 Bednar and Parikh. No significant
  difference
• 3.4 vs 9 82 open femoral/tibial fxs
• 2004 Ashford et al. No significant difference
• 11 vs 17 pts from the austrailian outback
• 2004 Spencer et al.... No significant difference
  
• 10.1 vs 10.9 142 open long bone fxs from UK
• 2003 Pollack and the LEAP investigators. No
  correlation
• 315 open long bone fxs
• 2005 Skaggs et al.No significant difference
  
• children with all types of open fractures 554
  open fractures

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Do we even need to do operative debridement?
Do we even need to debride low grade open
fractures?

• Orcutt et al... No significant difference, BUT
• 50 type 1 2 open fractures
• less infection in nonoperative group (3 vs 6)
• Less delayed union in nonop group (10 vs 16)
• Yang et al.0 infections
• 91 type 1 open fractures treated without ID

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However, after review of all literature..
Operative debridement is the standard of care!!!!

• Okike et al. states.
• Thorough operative debridement is the standard
  of care for all open fractures.
• Even if the benefits of formal ID were
  insignificant for low grade fractures, operative
  debridement is still required for proper wound
  classification.
• Open fractures graded on the basis of
  superficial characteristics are often
  misclassified.
• Huge risk not to explore and debride!

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URGENTLY debride, not EMERGENTLY

• Time to OR is probably less important than
• Adequacy of debridement
• Time to soft tissue coverage
• Timing depends on.
• Is patient stable?
• Is the OR prepared?
• Is appropriate assistance available?
• Ortho trained scrub techs, assistant surgeons,
  xray techs, and other OR staff
• 2005 Skaggs et al
• If after 10pm, keep until the morning! Or at
  least within 24 hours.
• Unless.
• neurovasc compromise
• horrible soft tissue contamination
• compartment syndrome

Within 24 hours
Within 6 hours
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ID in the OR

• Trauma scrub
• Soap and saline to remove gross debris
• Zone of injury
• Skin wound is the window through which the true
  wound communicates with the exterior
• Extend the traumatic wound
• Excise margins
• Resect muscle and skin to healthy tissue
• color, consistency, capacity to bleed and
  contractility
• Bone ends are exposed and debrided
• Irrigate
• Serial debridements?
• If needed, 2nd or 3rd debridement after 24-48
  hours should be planned

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The Irrigation

• Amount
• No good data, copious is better
• Animal studies show improved removal of
  particulate matter and bacteria but effect
  plateaus
• Irrigation bags typically contain 3 L of fluid
• Anglen recommends
• 3L (one bag) for type 1
• 6L (two bags) for type 2
• 9L (three bags) for type 3

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How to deliver the irrigation?(what animal
studies show)

• Bulb Syringe vs Pulsatile Lavage
• Pulsatile lavage
• Detrimental for early bone healing
• this is no longer present at 2 wks
• More soft tissue destruction
• More effective in removing particulate matter and
  bacteria
• High or low pressure?
• Higher pressure
• Better bone cleaning
• Worse soft tissue cleaning
• Slows bone healing

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Antibiotics in the irrigation?
No proven benefit!

• Antibiotics (bacitracin and/or neomycin)
• Mixed results, controversial
• Costly
• bacitracin alone around 500/washout
• ?? Causing resistance
• Wound healing problems?
• Few reported cases of anaphylaxis
• Anglen No proven value in the care of open
  fracture woundssome risk, albeit small.

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Soaps in the irrigation?

• Surfactants (i.e. Soaps)
• Less bacteria adhesion
• Emulsify and remove debris
• No significant difference in infection or bone
  healing compared to bacitracin solution, but more
  wound healing problems in bacitracin group

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Level 4 evidence based recommendations

• 1st washout, highly contaminated
• ? Soap solution
• Repeat washout of clean wounds
• ? Saline
• Infected wounds
• ? Soap, then antibiotic

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Wound closure after contaminated fracture
Dubunked!

• Timing and technique is controversial
• OPEN WOUND should be left OPEN!
• Prevents anaerobic conditions in wound
  Clostridium
• Facilitates drainage
• Allows repeat debridement

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To close or not to close?

• Recently, renewed interest in primary closure
• Collinge, OTA 2004
• Moola, OTA 2005
• Russell, OTA 2005
• DeLong, J Trauma 2004/
• Bosse, JAAOS 2002
• Improved abx management
• Better stabilization
• Less morbidity
• Shorter hospital stay, lower cost
• NO increase in wound infection
• These wounds are at higher risk of clostridia
  perfringens if they do get infected.

• 1999 Delong et al 119 open fxs
• No significant difference
• delayed/nonunion and infection rates btwn
  immediate and delayed closure
• Immediate closure is a viable option

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Contraindications to primary closure

• Inadequate debridement
• Gross contamination
• Farm related or freshwater immersion injuries
• Delay in treatment gt12 hours
• Delay in giving abx
• Compromised host or tissue viability

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When to cover the wound?

• ASAP after wound adequately debrided
• Only 18 of infections are caused by the same
  organism isolated in initial perioperative
  culture
• Suggests hospital acquired etiology of infection
• Fix and Flap
• For Type IIIB IIIC open tibia fractures
• Early if not immediate flap coverage

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Dressings

• Temporary closures rubber bands
• Wet to dry dressings
• Semi-permeable membranes
• Antibiotic bead pouch
• VAC

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VAC

• Vacuum assisted wound closure
• Recommended for temporary management
• Mechanically induced negative pressure in a
  closed system
• Removes fluid from extravascular space
• Reduced edema
• Improves microcirculation
• Enhances proliferation of reparative granulation
  tissue
• Open cell polyurethane foam dressing ensures an
  even distribution of negative pressure

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Types of fracture stabilization

• Splint
• Good option if operative fixation not required
• Internal fixation
• Wound is clean and soft tissue coverage available
• External fixation
• Dirty wounds or extensive soft tissue injury

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Fracture stabilization

• Gustilo type 1 injury can be treated the same way
  as a comparable closed fracture
• Most cases involve surgical fixation
• Outcome is similar to closed counterparts

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Fracture stabilization

• Gustilo type 23 usually displaced and unstable
• dictate surgical fixation
• Restore length, alignment, rotation and provide
  stability
• ideal environment for soft tissue healing and
  reduces wound infection
• reduces dead space and hematoma volume
• Inflammatory response dampened
• Exudates and edema is reduced
• Tissue revascularization is encouraged

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When to use plates?

• Open diaphyseal fractures of arm forearm
• Open diaphyseal fractures lower extremity
• NOT recommended
• Open tibial shaft plating assoc high infection
  rate
• Open periarticular fractures
• Treatment of choice in both upper and lower
  extremities

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When to use IM nails?

• Treatment of choice for most diaphyseal fractures
  of the lower extremity
• Inserted without disrupting the already injured
  soft tissue envelope
• Preserves the remaining extra osseous blood
  supply to cortical bone
• Malunion is uncommon

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To ream or not to ream?

• Does reaming cause additional damage to the
  endosteal blood supply?
• Solid IM nails without reaming has a lower risk
  of infection that tubular nails with a large dead
  space
• However reamed IM nails are biomechanically
  stronger and can reliably maintain fracture
  reduction if statically locked
• 2000 Finkemeier et al.
• reamed vs unreamed interlocked nails of open
  tibias
• NO statistical difference in outcome and risk of
  complication

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When to use external fixation?

• Diaphyseal fractures not amenable to IM nails
• Ring fixators for periarticular fractures
• Temporary joint spanning ex fix is popular for
  knee, ankle, elbow and wrist
• If temporary, plan for conversion to IM nail
  within 3 weeks

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Ex-fix Weigh the pros and cons!

• Historically was definitive treatment
• Now, more commonly as temporary fixation
• Can be applied almost always and everywhere
• Severe soft tissue damage and contamination

• Advantages
• Easy and quick
• Relatively stable fixation
• No further damage done
• Avoids hardware in the open wound

• Disadvantages
• Pin track infections
• Malalignment
• Delayed union
• Poor patient compliance

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Skin cover and soft tissue reconstruction

• Do these early!
• 1994 Osterman et al.
• Retrospective 1085 fractures, 115 G2 and 239 G3
• All treated with appropriate IV Abx and ID
• No infection if wounds closed at 7.6 days
• Yes infection if wounds closed at 17.9 days

Infection risk increases if wound open gt 7 days
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Reconstructive ladder options for wound coverage
Type 1 open fx
Type 2/3A open fx
Type 3B open fx
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Flap coverage for type 3b
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Type 3c, a bad injury!

• Devastating damage to bone and soft tissue
• Major arterial injuries that require repair
• Poor functional outcome
• Consensus btwn ortho, vascular and plastics
• Salvage is technically possible in most cases
• However it is not always the correct choice esp
  type 3c tibia fractures

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We can do both, salvage amputate.

• Vascular surgery can revascularize with bypass
  graft
• Generally before fracture stabilization
• Plastics can provide soft tissue coverage
• However, in the tibia, the severity to soft
  tissue envelope and bone may result in infected
  nonunion
• If salvage. long course of repeated surgical
  procedures
• Painful and psychologically distressing
• Functional outcome may be poor and no better than
  amputation

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How to decide, salvage or amputate?

• Important factors in decision making
• General condition of the patient (shock)
• Warm ischemia time (gt6hours)
• Age (gt30 years)
• Cut to crush ratio (blunt injuries has a large
  zone of crush)

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Gunshot injuries

• Energy dissipated at impact damage severity
• High velocity rifles and close range shotguns
• Worst, high energy of impact
• Huge secondary cavitation
• Secondary effects of shattered bone fragments
• Bullets lodged in joints should be removed
• avoid lead arthropathy and systemic lead poisoning

65
Low velocity GSW lt2000 ft/sec

• Low velocity handguns
• Less severe, not treated like open fractures
• Cavitation is not significant
• Secondary missile effects are minimal
• Bone fragments rarely stripped of soft tissue
  attachments and blood supply
• Soft tissue injuries not severe and skin wounds
  are small

66
Low velocity GSW open fractures
Treat open fractures from low velocity GSW as
closed fractures without Abx

• Geisslar et al.
• If neurovascular status normal, do local
  debridement
• NO formal ID needed
• IV Abx
• Approach fx fixation as if closed

• Dickey et al.
• No abx vs IV Ancef x 3d
• 67 low velocity GSW fxs
• Not requiring operative fixation
• No difference in infection rates

Dickey et al, J Ortho Trauma, 36-10,1989
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Pitfalls and complications

• Infection ? delayed union, nonunion, malunion and
  loss of function
• Plan ahead to avoid delayed union and nonunion
• Predict nonunion in severe injuries with bone
  loss
• Bone grafting usually delayed 6 weeks when soft
  tissues have soundly healed
• Autogenous bone grafting is usual strategy
• Fibular transfer, free composite graft or
  distraction osteogenesis for complex defects
• Recombinant human BMP in open tibia fracture
  reduces risk of delayed union

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Advances

• BMPs
• 40 decreased infection rate with BMP in type 3
  open tibia fractures
• Antibiotic Laden Bone Graft
• Tobramycin-impregnated calcium sulfate pellets
  with demineralized bone matrix
• Animal study successful in preventing infection

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Summary
A good evidence (level 1 studies) B fair
evidence (level 2/3 studies) C poor quality
evidence (level 4/5 studies) I insufficient or
conflicting evidence
Okike K, Bhattacharyya T Trends in the
management of open fractures. A critical
analysis. J Bone Joint Surg. 2006
Dec88(12)2739-48.
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Thank you