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Open Fracture

What It Is

• A fracture where the bone has violated the soft-tissue envelope and broken
through the skin
• Beware of threatened skin (e.g.: in tongue-type calcaneus fracture or ankle frac-
ture dislocation), which could convert into open fracture

Why It’s an Emergency

• Since the skin has been violated, there is a much higher risk for infection follow-
ing fracture treatment.
• Additionally, it usually requires higher energy for the bone to break the skin
(compared to a closed fracture of the same area), so there are often multiple other
soft-tissue injuries involved.

How “Emergent” Is It?

• Urgent. Although historically the treatment goal has been operative I+D within
6 h, recent literature has questioned if this truly affects infection rates or
outcomes.
• General consensus is currently:

° Immediate/emergent IV antibiotics (as soon as possible)


° Urgent operative debridement (but not necessarily emergently)
° For underequipped/non-trauma centers, time to transfer to an appropriate
level 1 facility has also been shown to correlate with outcomes

© Springer International Publishing Switzerland 2017 17


M.C. Makhni et al. (eds.), Orthopedic Emergencies,
DOI 10.1007/978-3-319-31524-9_5
18 J. Shillingford

Open fracture of tibia and fibula

When to be Suspicious

• Any violation of the skin within the zone of injury around the fracture
should be considered an open fracture until proven otherwise.
• Checking for “veinous oozing” out of laceration, or probing laceration, may pro-
vide information but these are not sensitive enough to be definitively diagnostic.

How to Diagnose

• Diagnosis is clinical—any break in skin around a fracture is presumed to be an


open fracture. No gold standard for diagnosis other than exploration in OR accom-
panied by I+D.
Open Fracture 19

How to Treat

• Immediate antibiotics:

° First-generation cephalosporin for all open fractures


° Consider adding aminoglycoside for Gustilo/Anderson grade 3
° Consider adding penicillin for farm injuries or possible bowel contamination
• Tetanus prophylaxis
• Immediate removal of gross contamination in ED (although no formal ED I+D)
• Coverage of wound with saline or betadine gauze—minimize exposures of
wound after initial evaluation
• Definitive treatment is thorough irrigation and debridement in OR

References

Hauser CJ, Adams Jr CA, Eachempati SR, Council of the Surgical Infection Society. Surgical
Infection Society guideline: prophylactic antibiotic use in open fractures: an evidence-based
guideline. Surg Infect (Larchmt). 2006;7(4):379–405.
Saveli CC, Belknap RW, Morgan SJ, Price CS. The role of prophylactic antibiotics in open frac-
tures in an era of community-acquired methicillin-resistant Staphylococcus aureus. Orthopedics.
2011;34(8):611–6. doi:10.3928/01477447-20110627-25. quiz 617.
Zalavras CG, Patzakis MJ. Open fractures: evaluation and management. J Am Acad Orthop Surg.
2003;11(3):212–9.

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