Management of compound fracture

Open fracture definition a fracture with direct communication to the external environment

Basic Principles of Open Fracture Management in the Emergency Room

Fracture management begins after initial trauma survey and resuscitation is complete Antibiotics initiate early IV antibiotics and update tetanus prophylaxis as indicated  Control bleeding direct pressure will control active bleeding do not blindly clamp or place tourniquets on damaged extremities Assessment soft-tissue damage neurovascular exam Dressing remove gross debris from wound  place sterile saline-soaked dressing on the wound Stabilize splint fracture for temporary stabilization decreases pain, further injury from bone ends, and disruption of clots

Basic Principles of Open Fracture Management in the Operating Room

Aggressive debridement and irrigation  thorough debridement is critical to prevention of deep infection low and high pressure lavage are equally effective in reducing bacterial counts  saline shown to be most effective irrigating agent on average, 3L of saline are used for each successive Gustilo type Type I: 3L Type II: 6L Type III: 9L bony fragments without soft tissue attachment can be removed Fracture stabilization can be with internal or external fixation, as indicated Staged debridement and irrigation perform every 24 to 48 hours as needed Early soft tissue coverage or wound closure is ideal  timing of flap coverage for open tibial fractures remains controversial increased risk of infection beyond 7 days  Can place antibiotic bead-pouch in open dirty wounds beads made by mixing methylmethacrylate with heat-stable antibiotic powder

Antibiotic Treatment

Gustilo Type I and II 1st generation cephalosporin  clindamycin or vancomycin can also be used if allergies exist Gustilo Type III 1st generation cephalosporin and aminoglycoside Farm injuries or possible bowel contamination add penicillin for anaerobic coverage (clostridium) Duration initiate as soon as possible studies show increased infection rate when antibiotics are delayed for more than 3 hours from time of injury continue for 24 hours after initial injury if wound is able to be closed primarily continue until 24 hours after final closure if wound is not closed during initial surgical debridement

Bone Gap Reconstruction

Reconstruction options Masquelet technique  distraction osteogenesis vascularized bone flap

Tetanus Prophylaxis

• Initiate in emergency room or trauma bay
• Two forms of prophylaxis 
  • toxoid dose 0.5 mL, regardless of age
  • immune globulin dosing
    • <5-years-old receives 75U
    • 5-10-years-old receives 125U
    • >10-years-old receives 250U
  • toxoid and immunoglobulin should be given intramuscularly with two different syringes in two different locations
• Guidelines for tetanus prophylaxis depend on 3 factors 
  • complete or incomplete vaccination history (3 doses)
  • date of most recent vaccination
  • severity of wound