Open Fracture Wound Care

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Open Fracture Wound Care
Jeff Anglen, MD Professor and Chairman Orthopaedic
s Indiana University
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WWW.OTA.ORG
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Lecture Plan

• Issues
• Timing of open fracture wound treatment How
  emergent is it?
• What are the important principles that remain
  true?
• What is new in
• Antibiotic coverage
• Debridement techniques
• Irrigation methods
• Wound closure/coverage

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Open Fracture Care Timing
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Textbooks

• Open fractures are surgical emergencies.Any
  delaysjeopardize limb survival
• Skeletal Trauma, 1st edition, 1992

• Formal radical debridement and irrigation should
  be accomplished within 6 hours (nationally
  recognized standard).
• Millers Review of Orthopaedics, 4th edition,
  2004 (italic emphasis added)

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Open Fractures must go the OR within 6 hours, to
reduce the risk of infection
Based on animal studies from 1898 by P. Friedrich
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Recent Literature
NO Difference

• Khatod et al., Journal of Trauma 2003
• Spencer et al. JRCS England 2004
• Charalambous et at. - 2005
• Skaggs et al. JBJS 2005
• Crowley et al lit review of 40 studies 2007

Retrospective
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Conclusions

• The 6 hour rule is not supported
• Timing of surgical treatment is not an important
  factor in preventing infection (within limits)
• Low grade open fractures can wait until morning
• Some should probably still be treated emergently
• Grade III
• Gross contamination

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Enduring Principles

• Early administration of antibiotics
• Adequate debridement and wound care
• Early coverage or closure
• Appropriate skeletal stabilization

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IV Antibiotics Classic

• choice and duration by Gustilo grade
• I, II - cephalosporin for 3 days
• III - ceph aminoglycoside for 5 days
• Gram negative coverage
• soil, farm - add penicillin
• Clostridial coverage
• re-cover for repeat visits to the OR

30 year old data, poor study designs Conclusions
not supported by data
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Antibiotic approach - EBM
Hauser CJ, Adams CA Jr., Eachempati SR. 
Surgical Infection Society Guideline.  Surgical
Infections 7(4)379-405, 2006

• 24-48 hours of 1st generation Cephalosporin
• Begin as early as possible
• NO need for specific gram negative coverage
• NO need for clostridial coverage
• No benefit for repeat courses with OR

We Need Better Studies!
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Debridement

• Initial procedure is most important
• Goals
• remove all foreign material
• remove nonviable host tissue
• decrease bacterial load
• create clean, living wound

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Debridement

• Principles
• experienced surgeon
• limit tourniquet
• extend wound carefully!
• systematic, layer by layer
• save skin in key areas
• fat and fascia are expendable
• dead muscle has to go
• evolving situation

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Versajet
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Pros Cons

• Adjustable power
• Small size
• Gets into 3-D spaces and around contours well
• Eyelids, Fingers, web spaces, lips and scalps
• Ground in or fine particulate surface dirt on
  muscle

• Learning curve
• Expensive
• Not well suited for large areas or high volumes

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Wound Irrigation

• Volume
• Delivery Method
• high or low pressure
• pulsatile or continuous
• Choice of Solution
• Antiseptics
• Antibiotics
• detergents

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Wound Irrigation

• Volume
• Delivery Method
• pulsatile or continuous
• high or low pressure
• Choice of Solution
• Antiseptics
• Antibiotics
• detergents

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Wound Irrigation

• Volume
• Delivery Method
• pulsatile or continuous
• high or low pressure
• Choice of Solution
• Antiseptics
• Antibiotics
• detergents

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Wound Irrigation

• Volume
• Delivery Method
• pulsatile or continuous
• high or low pressure
• Choice of Solution
• Antiseptics
• Antibiotics
• detergents

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A prospective randomized comparison of soap and
antibiotic irrigation in open lower extremity
fractures
Journal of Bone and Joint Surgery
87-A(7)1415-1422, 2005
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The study

• Prospective
• Randomized
• Sample Size 200/group
• NO formal blinding
• 3 outcomes
• Infection
• Delayed or Nonunion
• Failure of wound healing

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The study protocols

• Group B
• 100,000 units of Bacitracin per3 Liter bag of NS

• Group C
• 80 cc. ofliquid Castile Soap per 3 liter bag of
  NS

400 patients 458 open fractures
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Outcomes - Infection

• Group B
• 18

• Group C
• 13

p.2
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Outcomes Delayed/Nonunion

• Group B
• 25

• Group C
• 23

p.72
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Outcomes Wound Healing

• Group B
• 9.5

• Group C
• 4

p.03
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Conclusion
Level 1 evidence

• Antibiotic solution offers no advantage over soap
  solution for irrigation of open fracture wounds,
  and may be detrimental to wound healing.

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Recommendations
Level 4 evidence

• 1st washout, highly contaminatedSoap solution
• Subsequent washouts of clean woundsSaline
• Infected woundsSoap, then antibiotic

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Dressings

• Temporary closures - rubber bands
• wet to dry dressings ( wet to wet)
• semi-permeable membranes
• antibiotic bead pouch
• VAC

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Not FDA Approved - Off Label Use
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VAC dressing
Picture of wound vac here
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Negative Pressure Wound Therapy - NPWT

• Mechanism of Action
• Removal of interstitial fluid (edema)
• Opens microcirculation
• Removes enzymes that inhibit cell
  adhesion/migration
• Mechanical tension on tissues
• Deform cytoskeleton
• Release of 2nd messengers
• Angiogenesis

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Comparison of NPWT to Wet-Dry Dressings

• Lalliss SJ, et al. OTA meeting 2007
• Goat wounds contaminated with photon-emitting
  Pseudomonas
• VAC ?q480 vs W?D bid
• VAC
• Fewer bacteria at all intervals
• Less wound edema at all intervals

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Parrett et al. Plast Reconst Surg 2006

• Open IIIB tibia fxs
• 92-95 42 free flaps
• 96-99 26 free flaps
• 2000-03 11 free flaps
• Infection rate unchanged
• Local flaps unchanged

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However.

• Bhattacharyya T, et al. OTA 2007
• 38 pts with IIIB open tibias routinely Rxd with
  VAC
• Risk of infection still related to delay to
  definitive coverage within 7 days
• 12 vs. 54, plt008

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Stannard et alOTA Basic Science Symposium 2008

• PRCT
• 59 patients so far, gt90 grade III
• Saline wet-to-moist VS. NPWT
• Total Infection rates
• Saline WtM 7/25 (5.4)
• NPWT 2/37 (28)
• P.03

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To Close or Not to Close

• Classic teaching delayed closure of all open fx
• New information
• Advances in open fracture care
• irrig debridement techniques
• Improved antibiotic management
• Better surgical stabilization methods
• Most acute infections are hospital acquired
  organisms
• Studies support primary closure in many cases

Weitz-Marshall and Bosse J Am Acad Orthop Surg
200210379-384
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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 antibiotic administration
• Compromised host or tissue viability

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Thanks