Surviving Call: Open Fracture Management

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Surviving Call: Open Fracture Management

As the weather begins to warm and “trauma season” nears, I want to acknowledge everyone who is taking call as part of their practice. You are on the front lines of outreach for our specialty and provide an extremely important community service – Thank You!

Open fractures are incredibly common during this time of year, but the management is fraught with potential complications. Early treatment decisions ultimately have an outsized impact on a patient’s care, and decisions made in the emergency department can have long-lasting effects.

As a refresher, here are some suggestions for optimal management of open fractures:
  1. Start antibiotics immediately: The time to initiation of antibiotics is important, and initiation within one hour of injury has been shown to decrease infection rates. While many centers still use a first-generation cephalosporin with the addition of an aminoglycoside for the most severe fractures, protocols using piperacillin/tazobactam, vancomycin and cefepime, and ceftriaxone have been used with good results.
  2. The solution to pollution is a knife: The critical step in infection prevention is a thorough, thoughtful surgical debridement. Expose the entire zone of injury – this is not the time for minimally invasive surgery! If extension of a traumatic wound will result in untenable skin flaps, a defined surgical approach can also be used to effectively perform a debridement.
  3. Wash up: The Fluid Lavage of Open Wounds (FLOW) was an international multicenter trial comparing saline versus castile soap irrigation at multiple pressures (high- or low-pressure pulse lavage, gravity). The authors found a lower re-operation rate in the normal saline group, and found that the method of irrigation had no effect. No fancy soaps or antibiotics in your irrigation!
  4. Skeletal stability: Preventing further soft tissue damage is critical. If the wound is clean and will not require further debridement, proceeding with definitive fixation is appropriate. If further debridement will be necessary, provisional stabilization with a thoughtfully-placed external fixator (think hard about where to put those pins!) or a temporary internal fixator (I use a 3.5-mm locking plate) can be removed at the next debridement to allow full evaluation of the wound.
  5. Closure: Multiple studies have shown that closing open fracture wounds is beneficial and reduces infection rates. Even if you anticipate a second debridement, closing the wound is helpful and may obviate the need for a flap. If closure can’t be performed, a bead pouch OR negative-pressure wound therapy can be utilized – but don’t put beads beneath a VAC, as this leads to increased resistance and higher infection risk.
I refer to this checklist in my head every time I’m treating a patient with an open fracture. Hopefully, it helps keep your patients infection and complication-free!

Geoffrey S. Marecek, MD
[email protected]


DISCLAIMER: Statements of fact and opinion are the responsibility of the authors alone and do not imply an opinion or endorsement on the part of the officers or the members of WOA unless such opinion or endorsement is specifically stated. Materials may be reproduced only if Touches and the Western Orthopaedic Association are credited.

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