4. DEFINITION
– a fracture with direct communication to the external
environment
– described as a "compound" fracture
– a soft tissue wound in proximity to a fracture should be
treated as an open fracture until proven otherwise
7. TYPE 1
– Wound is less than 1cm
– Clean puncture wound
– There is little soft tissue
damage with no signs of
crushing injuries
– Low energy trauma
8. TYPE 2
– Wound is more than 1cm but
less than 10cm.
– There is no extensive soft tissue
damage.
– Moderate comminution
– Moderate contamination
9. TYPE 3
– Wound is more than 10cm
– High energy trauma
– High degree contaminated
– Comminuted fractures
A= with adequate soft tissue coverage
B=periosteal stripping
C=neurovascular injury that need to be
repaired regardless of degree of soft tissue
injury
16. TREATMENT OF OPEN
FRACTURES
– Antibiotics prophylaxis
– Prompt wound debridement
– Stabilization of the fracture
– Early definitive wound cover
17. TETANUS
– Two forms of prophylaxis
– toxoid dose 0.5 mL, regardless of age
– immune globulin dosing
– <5-years-old receive 75 U
– 5-10-years-old receive 125 U
– >10-years-old receive 250 U
– toxoid and immunoglobulin should be given intramuscularly with two
different syringes in two different locations
18. Guidelines for tetanus prophylaxis depend on 3
factors
– complete or incomplete vaccination history (3
doses)
– date of most recent vaccination
– severity of wound
19. Common organisms encountered
with open fracture
BLUNT
TRAUMA,
LOW
ENERGY
GSW
• Staphylococus
• Streptococcus
FARM
WOUNDS
• clostridia
FRESH
WATER
• Pseudomonas
Sea water
• vibrio
War
wounds,
High energy
GSW
• Gram negative
20.
21. INFECTION/ CONDITIONS/
LIKELY ORGANISMS
PREFERRED ALTERNATIVES COMMENTS
Compound fractures Iv cloxacillin 1gm q6d
Or
Cefazolin 1-2g q8H
If wound soiling or tissue
damage is severe andor
devitalized tissue is
present:
PLUS
Gentamicin 5mg/kg q24H
PLUS
Metronidazole 500mg q8h
Cefuroxime 1.5g as a
loading dose followed by
750mg q8h
In all cases, a patient’s
tetanus immunization
status should be assessed
Duration ( based on grade
of fracture)
Grade 1: 2weeks
Grade 2: 2-4 weeks
Grade 3:2-6 weeks
22. Malaysian national antibiotic guideline(NAG) , 2nd edition
Gun shot and other
penentrating wounds
Likely organisms:
Staphylococcus,
clostridium sp
Iv cloxacillin 1g
Or
Iv cefuroxime 1.5g
Plus
Iv Metronidazole
500mg
Iv Amoxycillin
/clavulanate 1.2
Or
Iv
ampilicillin/sulbactam
1.5g
Through surgical
debridement
23. LOCAL ANTIBIOTIC
THERAPHY
– High antibiotics concentration within the wound and low
systemic concentration.
- Reduces systemic side effects
– Vancomycin or aminoglycosides
-heat stable
-available in powder form
-active against suspected pathogens
26. WOUND DEBRIDEMENT AND
IRRIGATION
•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 attachments should be removed
*Staged debridement and irrigation
– perform every 24 to 48 hours as needed
31. FRACTURE STABILIZATION
1.Gustilo type 1 injury can be treated the same as closed
fracture.
Mostly involving surgical intervention
2. Gustilo type 2 and 3 usually displaced and unstable.
-Surgical intervention is a MUST !!!
-Surgical interventions is to create ideal environment for soft
tissue and reduces wound infection.
44. VASCULAR INJURY
– Absent peripheral pulses in an injured limb should be considered due to vascular
damage unless proven otherwise.
– Classical signs of arterial injury
1. Absent pulses
2. Active haemorrhage
3. Expanding haematoma
4. Bruits or thrills
** loss of total blood supply to a limb more than 8 hours will result in amputation.
51. TREATMENT FOR
OSTEOMYELITIS
ANTIBIOTICS (cover for staphylococcus infection)* most
common
- Iv Flucloxacillin and fuscidic acid ( can be changed once c&s
result is out)
- Continued until there is clinical and lab evidence of
improvement ( 1-2 weeks)
- Followed by oral antibiotics for 2-3 weeks
52. – Analgesics
– Splint the affected area
– Drainage – if there is subperiosteal abscess or pyrexia or local
tenderness for more than 24 hours even after started
adequate amount of antibiotics.
*ambulation is encouraged once the infection is subsides .
53.
54.
55. SUMMARY
1. Classify open fracture using Gustilo Anderson Classification.
2. Life threatening injuries should be treated first.
3. Administration of ATT injection
Antibiotics prophylaxis
wound debridement & irrigation
fracture stabilization
early definitive wound cover
Essential treatment of
open fracture
56. REFERENCE
– Apley, A., Solomon, L., Warwick, D., Nayagam, S. and Apley, A. (2005). Apley's
concise system of orthopaedics and fractures. London: Hodder Arnold.
– Kim, P. and Leopold, S. (2012). Gustilo-Anderson Classification. Clinical
Orthopaedics and Related Research®, 470(11), pp.3270-3274.
– Orthobullets.com. (2018). Open Fractures Management - Trauma -
Orthobullets. [online] Available at:
https://www.orthobullets.com/trauma/1004/open-fractures-management
[Accessed 8 Jul. 2018].
BASIC RULE :
3:1 rule when using crystalloids. If blood loss is 100cc the pt should receive 300cc of ns or ringer lactate.
1:1 rule for colloids
Fusidic acid is a bacterial protein synthesis inhibitor wt antibiotic activity against staphylococci , including MRSA.
It has good penentration into infected bone and joints.
Has activity against staphylococcus biofilms
