Management of Open Fractures

1
Management of Open Fractures

• Christine Kennedy
• Pediatric Emergency Fellow
• October 22, 2009

2
Objectives

1. Review the different types of open fractures
2. Discuss the current treatment of open fractures
3. Review the literature supporting non-operative
   management of Type 1 open fractures

3
Introductory Case

• 8 yr boy with a midshaft radius ulna
• Obvious deformity on clinical exam
• Small scab on volar surface of forearm
• not actively bleeding
• Xray.

4
(No Transcript)
5
(No Transcript)
6
Case

• Question wasDoes this need to go to the OR?
• Ortho consultedadvised to attempt a closed
  reduction and give a dose of Ancef
• If successful, mark wound area on cast, send home
  on Keflex and F/U in ortho clinic
• During the reductionwound started to ooze on my
  foot

7
Post-reduction X-Rays
8
Case-Follow up at day 39
9
Open Fracture ClassificationGustilo and Anderson

• Type I
• Clean wound lt1 cm in length
• is simple, transverse or oblique with little
  comminution
• Type II
• Laceration gt1cm without extensive soft tissue
  damage, flaps or avulsions
• Type III
• Extensive soft tissue damage, crushing or a
  traumatic amputation
• Subtypes 3A, 3B, 3C

10
Open Fracture Classification

• Type 3 subtypes
• 3A Adequate soft tissue coverage
• 3B Inadequate soft tissue coverage
• 3C Arterial injury requiring repair

3B
11
Open Fracture Classification
12
Open Fracture Classification
Type I
Type I
Type IIIc
Type IIIb
13
Open Fracture ClassificationGustilo and Anderson

• Type I Infection rate 0-2
• Clean wound lt1 cm in length
• is simple, transverse or oblique with little
  comminution
• Type II Infection rate 2-7
• Laceration gt1cm without extensive soft tissue
  damage, flaps or avulsions
• Type III Infection rate 10-25
• Extensive soft tissue damage, crushing or a
  traumatic amputation

Gustilo et al. Current Concepts Review The
Management of Open Fractures. Journal of Bone
and Joint Surgery. 199072299-304.
14
Open Fracture vs Abrasion
15
Open Fracture vs Abrasion

• Open fracture
• disruption of the dermis with communication into
  the subcutaneous tissue contiguous with the bone

16
Open Fracture vs Abrasion

• Abrasion
• Soft tissue injury into the dermis (not through
  the dermis)
• usually due to friction or shearing
• An abrasion on its own over a fracture does not
  communicate with the fracture because the sc
  tissue is intact
• The pattern of bleeding from an abrasion is
  pinpoint dermal bleeding
• If you squeeze an abrasion, you may get bleeding
  but the pattern is different than a laceration
  that extends into the deeper tissue

17
How do the Orthopedic Surgeons decide?

• Probing the wound is not recommended
• Pull on the skin adjacent to the wound to see if
  you can SEE any subcutaneous fat as evidence that
  the dermis is broken
• Contact the on call surgeon to discuss

18
How Common are Open Fractures?

• For forearm fractures (most common fracture
  pattern in children)
• 0.5-4.5 are open

Luhmann et al. Complications and Outcome of Open
Pediatric Forearm Fractures. J Pediatr Orthop
2004241-6.
19
Management of Open Fractures

• Traditionally
• Considered a true surgical emergency
• Required operative debridement and fracture
  stabilization
• Golden Period was 6-12 hours from time of
  patient arrival

20
Management of Open Fractures

• Now.
• Type II III
• Require surgical debridement
• Wounds with high energy injuries result in
  devitalized tissue, local edema ischemia
• This alters the ability of local host defenses to
  resist infection

21
Management of Open Fractures

• Type 1
• Operative vs non-operative, why the controversy?

22
Type 1 Open Fractures

• Maintain a relatively intact soft tissue envelope
  therefore the vascular supply to the zone of
  injury is preserved
• This decreases the risk factors for development
  of infection
• Devitalized tissue
• Ischemia
• Edema

23
Type 1 Open Fractures

• Allows adequate penetrance of the host defense
  mechanisms and IV antibiotics to protect further
  against possible infection

24
Type 1 Open Fractures

• Routine operative debridement might cause
  increased soft tissue trauma, periosteal
  stripping and osseous devascularization

25
Type 1 Open Fractures

• Children have better healing potential than
  adults
• Differences in the malleability strength of the
  bone
• Better vascular supply to the extremities
• Thicker periosteum

26
In the old orthopedic literature

• Cases of gas gangrene in children with open
  fractures managed non-operatively
• Before the routine use of antibiotics

27
Infection Rate with Operative Management

• Literatures infection rate for type 1 open
  fractures treated operatively is an average of
  1.9

28
Infection Rate with Operative Management
29
Infection Rate with Operative Management
30
Organisms Cultured from Open Fractures

• The majority of bacteria cultured are normal skin
  flora
• Staphylococcus epidermidis
• Proprionibacterium acnes
• Corynebacterium species

31
Organisms Cultured from Open Fractures

• Farm related injuries increase the risk of
• Clostridium perfringens
• Exposure to fresh water increases the risk of
• Pseudomonas aeruginosa
• Aeromonas hydrophilia

32
Organisms Cultured from Open Fractures

• The frequent growth of S. aureus P. aeruginosa
  from patients who have an infection contrasts
  with the infrequent growth of these organisms on
  initial wound culture
• Suggests that these infections are acquired in
  the hospital

33
Importance of Antibiotics

• Prospective, double blind, randomized study
• Infection rate was
• 13.9 in placebo group
• 9.7 in group treated with Penicillin
  Streptomycin
• 2.3 in group treated with a 1st generation
  cephalosporin

Patzakis et al. The Role of Antibiotics in the
Management of Open Fractures. The Journal of
Bone and Joint Surgery 197456532-541.
34
Importance of Antibiotics

• Meta-analysis demonstrated a significant
  reduction in wound infections in patients who
  received antibiotics for all types of open
  fractures
• 13.4 of patients who were not treated with
  antibiotics developed an infection
• 5.5 of treated patients developed an infection
• NNT 13 8-25

35
Which Antibiotic?

• Most common pathogens causing infections after
  open fractures
• Staphylococcus aureus
• Facultative gram-negative bacilli
• In type I open fractures
• 1st generation cephalosporin sufficient
• In type II III
• Combinations therapy with a cephalosporin and an
  aminoglycoside OR 3rd generation cephalosporin

36
Timing of Antibiotics is Important

• One study with over 1000 open fractures found
  that starting antibiotics within 3 hours of
  injury lowered the infection rate
• Infection rate 4.7 if antibiotics w/in 3 hours
• Infection rate 7.4 if antibiotics started gt3h
  after injury
• Of note, surgical debridement was performed for
  all open fractures in this study

37
Guidelines for Antibiotic Length?

• No standardized protocol for length of Abx
  following open fractures
• One report published which demonstrated no
  difference b/w 1 5 days of IV Abx
• In the adult literature, anywhere from 1-3 days
  of antibiotics is the recommendation

38
Non Operative Management of Type 1 Open Fractures

• What does the literature say these days?

39

• Reviews the results of non operative management
  of type I open fractures in children
• Retrospective chart review (1998-2003)
• 40 patients followed until healed
• clinically radiographically
• 1 deep infection occurred
• overall infection rate 2.5

40

• 0 infection rate in the 32 upper extremity type
  I open fractures
• 0 infection rate in the 23 patients under 12
  years

41
Details of Study 1

• 40 patients diagnosed with type 1 open fracture
• 33 boys, 7 girls
• Age 10 years range 4-15y
• Fracture distribution
• 8 tibia
• 18 diaphyseal radius ulna
• 14 distal radius ulna
• Mechanism
• Most low-moderate energy
• Falls from bikes, skateboards, rollarblades,
  scooters
• 7 kids hit by motor vehicle

42
Details of Study 1

• Treatment Initiated in the ED
• Initiation of IV antibiotics
• Cleansing and/or irrigation of the open wound
  with Betadine saline
• Protecting the wound with Xeroform sterile
  gauze
• Tetanus prophylaxis if needed
• Closed reduction immobilization

43
Details of Study 1

• Patients were admitted to hospital for 48-72
  hours for observation, continued IV antibiotics
  and wound management
• Patients were discharged w/o abx
• but 4/40 were sent home on 1 week of Keflex, at
  the treating surgeons discretion

44
Details of Study 1

• Patients were followed until fracture union
• Clinically no longer tender at fracture site
• Radiologically bridged by sufficient callus

45
Details of Study 1

• Definitions
• Deep infection proceeded to debridement
• Increasing pain, drainage from the wound and
  radiologic changes within the bone
• Superficial infections
• Inflammation of the skin/subcutaneous tissue w/o
  radiologic evidence of osteomyelitis

46
Results of Study 1

• Average hospital stay 2.5 days (1-5)
• No documented fevers
• No patients developed malunion/nonunion
• No patients developed osteomyelitis
• No wound complications during admission
• No superficial infections
• 1 deep infection of the tibia (at 3 months)

47
Results of Study 1
48
Results of Study 1
49
Results of Study 1
50
Results of Study 1
51
Results of Study 1
52
Results of Study 1
53
Results of Study 1
54
How does this healing compare to fracture healing
after OR irrigation?
55
How does this healing compare to fracture healing
after OR irrigation?
56
Results of Study 1
57
Results of Study 1
58
Results of Study 1
59
Results of Study 1
60
Results of Study 1

• The 1 infection
• 15 yr male, comminuted midshaft tibia
• Fall down the stairs
• Small nidus of dead bone found anterior to the
  fracture site---gtcaused a draining sinus to form
  over the anterior tibia
• Sinus tract was excised the dead bone debrided
  in the OR
• Patient made a full recovery

61
Conclusions Study 1

• Non operative management of Pediatric type I open
  fractures is safe and effective
• Non operative management does not appear to
  affect the healing potential
• Children over age 12 with lower extremity type I
  open fractures are at risk for failing
  non-operative management
• Should consider traditional irrigation and
  debridement of the wound in the OR

62

• Evaluates the results of non operative management
  of grade 1 open fractures treated in the ED or
  with a lt24hour admission (for IV antibiotics)
• Retrospective chart review (2000-2006)
• 25 patients followed until healed (clinically and
  radiographically)
• 1 patient had persistent draining from the wound
  site fever (overall infection rate 4)

63
Details of study 2

• 25 patients diagnosed with type 1 open fracture
• 20 boys, 5 girls
• Age range 2-15y
• Fracture distribution
• 5 tibial shaft /- fibula
• 18 radius ulna
• 2 Monteggia fracture/dislocations

64
Details of study 2

• 14 patients were admitted (lt24h)
• 11 were treated exclusively in the ED

65
Details of study 2

• Treatment Initiated in the ED
• Initiation of IV antibiotics
• Irrigation of the wound with sterile saline
• Protecting the wound with Xeroform or Betadine
  soaked gauze
• Tetanus prophylaxis if needed
• Closed reduction immobilization

66
Details of study 2

• IV antibiotics used
• 20/25 patients received Ancef
• Others
• Ampicillin/sulbactam
• Ceftriaxone
• Gentamicin

67
Details of study 2

• Patients who were admitted overnight remained on
  IV antibiotics until discharge
• At discharge oral antibiotics were given to 20 of
  25 patients
• 19 received Keflex
• 1 received Clindamycin
• Duration ranged from 1-7 days

68
Details of study 2

• Follow up schedule
• 7-10 days radiograph wound check (windowing)
• 14-17 days radiograph in cast
• 6-8 weeks radiograph out of cast
• Followed until healed
• Non-tender, full ROM at joint above below
• Bridging bone on radiograph

69
Results of study 2

• 1 patient diagnosed clinically with an infection
  (culture negative)
• 8 yr boy
• Tibia fracture (from football tackle)
• At F/U on day 6erythema serosanguineous
  drainage from wound
• Admitted and treated with 2 days of IV Clinda
• Complete resolution of drainage/erythema
• Discharged with 1 week course of oral Clinda
• Fracture union at 11 weeks (no further
  complications)

70
Results of study 2

• Average time to union
• Tibia fractures 67 days
• Forearm fractures 45 days
• Monteggia fracture/dislocations 29 days

71

• Conclusions
• Non-operative management of grade 1 open
  fractures is safe in pediatrics
• Eliminates any possible general anesthetic risk
• Significantly decreases the cost of caring for
  these patients in the health care system
• OR costs
• Cost of prolonged hospital admissions
• Social costs of a hospitalized child

72

• Current protocol
• Treat low energy grade 1 open fractures
• sustained in a clean environment with no gross
  contamination
• In the ED as an outpatient
• Conscious sedation and reduction
• Superficial cleansing
• Single dose of IV Abx
• 3-5 days of oral antibiotics

73
Adult Literature

• There is precedent for non-operative treatment of
  grade 1 open fractures

74

• 0 infection rate in 91 open grade 1 fractures

75
Details of Study 3

• Retrospective review (1990-1997)
• 91 patients with isolated Type I open fractures
• 78 adults, 13 children
• 60 males, 31 females
• Exclusion criteria
• multiple injuries
• gunshot wounds
• hand injuries
• compartment syndrome
• Intra-articular fractures

76
Details of Study 3

• All received antibiotics and were followed until
  fracture union
• Charts were reviewed for
• Type of fracture
• Mechanism of injury
• Type of treatment
• Length of hospital stay
• Complications encountered

77
Details of Study 3
78
Details of Study 3
79
Details of Study 3
80
Details of Study 3
81
Details of Study 3

• All patients received antibiotics (within 6h)
• Adults 1g cefazolin
• Children 1g (11), 750mg (1), 500 mg (1)
• All were admitted for at least 48 hours
• Wounds greater than a puncture site were
  irrigated with several liters of saline
• Majority did not receive irrigation
• Wounds were dressed with sterile gauze

82
Details of Study 3

• 32 pts had surgery for definitive treatment of
  their fracture
• 1 pt had surgery w/in 8 hours golden period
• All others had surgery after 12 hours
• Average time was 5 days 12h-15days
• None of the wounds had evidence of infection
• Open wound was not debrided unless it was
  included in the operative exposure

83
Results of Study 3

• Hospital stay
• 9 days on average
• 11 days for those who had surgery
• 4.5 days for those without surgery
• Follow up
• Averaged 7 months 2mo - 5y

84
Results of Study 3

• Complications
• Developed in 10 pts (8 in lower extremities)
• 6/10 pts needed surgery for definitive treatment
• Infection rate
• 0

85
Conclusions Study 3

• Immediate operative debridement may not be
  necessary in isolated, low-energy Type 1 open
  fractures with stable fracture patterns

86
Results of Study 3

• Current Protocol
• Low energy type 1 open fracture do not need
  operative debridement
• Do not classify open fractures by the size of the
  soft tissue wound alone
• Comminuted fractures are taken to the OR and
  reclassified after operative debridement

87
Guidelines for antibiotic length?

• In the 2 pediatric studies we just reviewed
• 1 dose of IV antibiotics was sufficient in 1
  study (20/25 d/cd on 1-7 days of PO Abx)
• 48 hours of IV antibiotics was sufficient for
  the other study (only 4/40 were d/cd on PO Abx)

88
Calgary Consensus

• Call on call surgeon for personal preference
• 1 dose of IV Ancef, then 3-7 days PO antibiotics
• Routine windowing of the cast is not done
• Surgeon dependent
• Have the patient return to the ED if there are
  any problems within the first 3 days for urgent
  evaluation (pain, fever, tachycardia, odour)
• The size of the wound by itself is not indication
  for non-operative debridement

89
Back to the Objectives

1. Review the different types of open fractures
2. Discuss the current treatment of open fractures
3. Review the literature supporting non-operative
   management of Type 1 open fractures

90
Summary

• The literature suggest that treating type 1 open
  fractures with IV antibiotics and closed
  reductions is safe
• But no randomized controlled trials
• Different surgeons ---gt different approaches,
  therefore discuss with the on call surgeon first
• Use of antibiotics is not advocated as a
  substitute for proper clinical judgment