Management of Open Extremity Fractures

 

VBMC TRAUMA CARE SERVICES GUIDELINE

TITLE: Management of Open Fractures
PURPOSE: To establish institutional guidelines for the management of open fractures.

GUIDELINES:

Emergency Room:

  • Patient will receive the appropriate antibiotic within one hour of arrival to the ED.
  • Assess tetanus vaccination status and update if indicated
  • In coordination with trauma team assessment and resuscitation, obtain the appropriate imaging of the injured extremity.
  • Initial wound management of bedside normal saline irrigation with simple removal of any gross contamination/debris and placement of a sterile, normal saline-soaked dressing (pressure dressing for hemostatic control if necessary).
  • Reduce the injured extremity as necessary to correct malalignment and place in the appropriate splint or immobilization device.
  • Obtain orthopedic surgery consult.

Operative Treatment:

  • Patients with open fractures should be brought to the operating room for formal debridement within 24 hours of presentation whenever possible.
  • Patients with open fractures with gross contamination should brought to the operating room for formal debridement more quickly, as soon as clinically feasible, based on the patient’s condition and resources available.
  • Coordination with the Trauma Surgery Service will be necessary to ensure the patient’s clinical status is appropriate to proceed to the operating room.
  • After the initial operative debridement, timing for definitive fixation and/or repeat debridements will be at the discretion of the treating orthopedic surgeon. Consultation with the Orthopedic Trauma Service can be requested at any point to assume management but is contingent on the availability of an orthopedic traumatologist.
  • It is recommended that skin defects overlying open fractures should be closed at the time of initial debridement, which includes placement of a negative pressure wound vacuum dressing.
  • For open fractures with wounds requiring flaps, soft tissue transfers, or skin grafting (Gustilo Type IIIB), coverage should be completed within seven days from injury.

Antibiotic Management:

  • The appropriate antibiotic will be administered within one hour of arrival to the ED.
  • The antibiotic administration guideline (Figure 1) is based on the Gustilo-Anderson classification system of open fractures.
  • The antibiotic administration order pathway is available within EPIC EMR as an order set titled, “Open Fracture Antibiotics

Panel.” When initiating antibiotics, this order set will be used exclusively for all open fractures to ensure proper antibiotic utilization and duration of treatment.

  • Type I and II open fractures will receive 24 hours of antibiotics or discontinued within 24 hours of definitive wound closure.
  • Type III open fractures with receive 72 hours of antibiotics or discontinued within 24 hours of definitive wound closure.

 

RESOURCES/REFERENCES:

1. Gustilo RB, Anderson JT. Prevention of infection in the treatment of 1025 open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 1976;58(4):453–8

 

  1. Redfern J, Wasilko SM, Groth ME, McMillian WD, Bartlett CS. Surgical site infections in patients with Type 3 open fractures: comparing antibiotic prophylaxis with fefazolin plus gentamicin versus piperacillin/tazobactam. J Orthop Trauma. 2016;30(8):415-9
  2. Rodriguez L, Jung HS, Goulet JA, Cicalo A, Machado-Aranda DA, Napolitano LM. Evidence-based protocol for prophylactic antibiotics in open fractures: improved antibiotic stewardship with no increase in infection rates. J Trauma Acute Care Surg. 2014;77(3):400-7.
  3. Dunkel N, Pittet D, Tovmirzaeva L, Suva D, Bernard L, Lew D, Hoffmeyer Pm Uckay I. Short duration of antibiotic prophylaxis in open fractures does not enhance risk of subsequent infection. Bone Joint J. 2013;95-B(6):831-7
  4. Hoff WS, Bonadies JA, Cachecho R, Dorlac WC. East Practice Management Guidelines Work Group: update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma. 2011;70(3):751-4

 ACS TQIP best practice guidelines in the management of orthopaedic trauma. (2015). Retrieved December 23, 2021

https://www.facs.org//media/files/qualityprograms/trauma/tqip/ortho_guidelines.ashx

 

NOTE: Open femur fractures are considered Gustilo III regardless of the size of the soft tissue injury. 

 

 

Figure 1



Open Fracture Antibiotic and Tetanus Guideline