Management of Open Fractures in the Emergency Department

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Author: Bill Mulkerin, MD
Stanford/Kaiser Emergency Medicine Residency

Open fractures often result from high-energy impacts, such as motorcycle crashes, motor vehicle collisions, and pedestrians being struck by motor vehicles.[1,2] These injuries are usually associated with poly-trauma.[1] Up to 9% of open fractures result in compartment syndrome.[3] Open fractures are most commonly classified by the Gustilo classification:

• Type I – clean wound less than 1cm
• Type II – laceration more than 1cm long, without extensive soft tissue damage, flaps, or avulsions 
• Type IIIA – adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration or flaps, or high-energy trauma irrespective of the size of the wound 
• Type IIIB – extensive soft tissue injury with periosteum stripping and bony exposure. This is usually associated with massive contamination. 
• Type IIIC – Exposed fracture with arterial damage that requires repair[4,5]

Reliability of the this classification system has been questioned, however, and some studies show inter-rater agreement when using this classification system to be as low as 60%.[6]

Management of open fractures in the emergency department should focus on identifying open fractures as early as possible. Especially in unstable poly-trauma patients, injured extremities are likely to be preliminarily stabilized and not reassessed.

Infection rates depend on severity of injury: type I open fractures infection rate of 0-2%, type II: 2-10%, type III: 10-50%.[5,7] Most wounds (65%) are contaminated, so antibiotics should be considered therapeutic rather than prophylactic.[5,7-9] It is critical to start antibiotics promptly, as a delay of more than three hours increases the risk for infection.[7,10] Appropriate antibiotic coverage should cover staphylococci and aerobic gram-negative bacilli, for example a first generation cephalosporin (e.g., cefazolin) plus an aminoglycoside (e.g., gentamicin or tobramycin). In farm injuries or vascular injuries, which may cause ischemia and low oxygen tension, ampicillin or penicillin should be added to cover for anaerobes such as clostridial myonecrosis (gas gangrene).[8]

Alternatives to aminoglycosides include quinolones, aztreonam, and third-generation cephalosporins.[9] Aminoglycoside-impregnated beads can also be used for local antibiotic delivery, with the most commonly used delivery vehicle being polymethylmethacrylate (PMMA) cement.[11] Of note, some clinicians use cefazolin as a single agent in type I open fractures, but this does not reliably cover gram negatives. The duration of antibiotic treatment is generally three days, although some investigators have proposed that one day may be enough.[12]

Operative treatment of open fractures is fracture stabilization and either primary or staged soft tissue closure. The definitive treatment of infection in open fractures is aggressive debridement and irrigation in the operating room. Low-pressure lavage has been shown to be more effective in reducing bacterial counts than high-pressure lavage, and saline has been shown to be the most effective irrigating agent.[13]

References:


1. Gustilo RB. Management of open fractures. An analysis of 673 cases. Minn Med. 1971;54:185–9.

2. Court-Brown CM, Rimmer S, Prakash U, et al. The epidemiology of open long bone fractures. Injury 1998;29:529–34.

3. Blick SS, Brumback RJ, Poka A, et al. Compartment syndrome in open tibial fractures. J Bone Joint Surg Am. 1986;68:1348–53.

4. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984 Aug;24(8):742-6.

5. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976 Jun;58(4):453-8.

6. Brumback RJ, Jones AL: Interobserver agreement in the classification of open fractures of the tibia: The results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg Am. 1994; 76:11621166.

7. Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res. 1989 Jun;(243):36-40.

8. Zalavras CG, Patzakis MJ. Open fractures: evaluation and management. J Am Acad Orthop Surg. 2003 May-Jun;11(3):212-9.

9. Patzakis MJ, Harvey JP Jr, Ivler D. The role of antibiotics in the management of open fractures. J Bone Joint Surg Am. 1974 Apr;56(3):532-41.

10. Gustilo RB.Use of antimicrobials in the management of open fractures. Arch Surg. 1979 Jul;114(7):805-8.

11. Zalavras CG, Patzakis MJ, Holtom PD, Sherman R. Management of open fractures. Infect Dis Clin North Am. 2005 Dec;19(4):915-29.

12. Dellinger EP, Caplan ES, Weaver LD, et al: Duration of preventive antibiotic administration for open extremity fractures. Arch Surg. 1988; 123:333-339.

13. Owens BD., White DW, Wenke JC. “Comparison of Irrigation Solutions and Devices in a Contaminated Musculoskeletal Wound Survival Model.” J Bone Joint Surg Am. 91, no. 1 (January 2009): 92–98.