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
- 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
- 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.
- 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
- 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
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