Open Fractures: Understanding When To Wait, When To Fix, When to - - PowerPoint PPT Presentation

Open Fractures: Understanding When To Wait, When To Fix, When to Wash Out

Mani Kahn MD

No Disclosures

Open fractures are often high energy injuries

Short term Contamination

• Compromised soft tissue
• envelope

Compromised host

• Nerve injuries
• Vascular injuries
• Long term
• Wound healing
• Infection
• Delayed union
• Nonunion
• Loss of function
• Amputation

5-50% 7-60%

Open fractures are often high energy injuries

Short term

• Contamination
• Compromised soft tissue

envelope

• Compromised host
• Nerve injuries
• Vascular injuries

Long term

• Wound healing
• Infection
• Delayed union
• Nonunion
• Loss of function
• Amputation

5-50% 7-60%

Management

• Recognize the soft tissue injury
• Thorough debridement in the OR
• Temporizing (damage control) fixation
• Appropriate operative planning

Augment treatment…

• Appropriate early antibiotics
• High volume irrigation
• Effective wound care

Principles of debridement

• Exploration/extension of

wounds

• Careful inspection of

surfaces

• Preservation of critical

tissue

• Thorough removal of

foreign material and dead tissue

Surgical Urgency

• All open wounds are considered to be

contaminated

• Whether infection occurs is determined by 3

variables:

– Presence of bacteria – Presence of inert surfaces – Viability of host cells and tissues

Surgical Urgency

• systemic antibiotics may not be able to

effectively penetrate the site of infection to deliver antibiotic levels above the minimum inhibitory concentration

Timing of debridement “The 6 Hour Rule”

Friedrich 1898 Robson et al 1973

Obstacles to effective early debridement

• Multiply injured and under-resuscitated patients
• Protracted transport times
• OR availability
• Suboptimal conditions
• Trauma surgeon availability

National trends in timing of treatment

• f open tibia fractures

42

• % delay > 6 hrs

24

• % delay > 24 hrs

Male gender, older age

• Head or thoracic Injury AIS>
• 2

Presentation between

• 6 pm and 2 am

Level

• 1 university hospital setting

Namdari et al 2011

Delays >6 hrs do not appear to increase infection risk

Retrospective, prospective and meta-analysis studies No increased infection for open tibia fractures debrided >24 and >48 hours

Pollak et al 2010 Schenker et al 2012 Weber et al 2014 Duyos et al 2017

Infection risk factors

• Increasing Gustilo grade
• Lower extremity fractures

Harley et al 2002

Wound care/coverage

Bead

• pouch

Wound

• vac

Delayed primary closure

• Skin grafting
• Rotational flaps
• Free tissue transfer

Wound Closure

Stable tissue viability after multiple

• debridements

Low energy wounds that have been adequately

• debrided and cleaned can be closed

Recent level II evidence supports primary closure

• f all clean I, II, and IIIA fractures without

increased risk of infection or nonunion

Scharfenberger et al 2017

Provisional fixation: Damage control orthopedics

• Provisional fixation of fractures to allow for

improved physiology

• Provide stability and minimal soft tissue

damage with little surgical bleeding

• Avoid “second hit” of major orthopedic

procedure until patient is resuscitated

Indications for definitive fixation

• Adequate resuscitation

– lactate <2.5-4.0, base excess ≥-2 to -5, pH ≥7.3, UOP>30cc/kg/hr – Coagulopathy corrected

• Soft tissues permit
• Definitive coverage planned

Does Timing of Fixation and Wound Coverage Matter?

• 105 free flaps in 103 patients monitored for

infection

Liu et al Injury 2011

When to consider immediate ORIF

• Open upper extremity

fractures

Radoicˇic ́et al 2014 Harley et al 2002

When to consider immediate ORIF

Periarticular

• fractures

Distal femur fractures

• with bone loss

Axial injuries

• Early fixation in multiply

– injured patients

Shorter ICU stays

• Fewer complications
• Dugan et al 2013

Vallier et al 2013

Ex-fix or IMN for open tibia fractures?

• 143 tibia GI to GIIIb open tibia fractures

treated with unreamed IMN at time of debridement with 3% infection rate

• Staged ex-fix then IMN with higher infection

and nonunion rates compared with immediate IMN

Kakar 2007 Duyos 2017

References

Gustilo

• RB, Anderson JT (1976) Prevention of infection in the treatment of one thousand and twenty-Wve open

fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 58:453–458 Schenker

• ML, Yannascoli S, Baldwin KD, et al. Does timing to operative debridement affect infectious

complications in open long-bone fractures? A systematic review. J Bone Joint Surg Am. 2012;94A:1057–1064. Friedrich PL. Die

• aseptische Versorgung frischer Wunden, unter Mittheilung von Thier-Versuchen uber die

Auskeimungszeit von Infectionserregern in frischen Wunden. Archiv fur Klinsche Chirugie. 1898:288-310. Robson MC, Duke WF,

• Krizek TJ. Rapid bacterial screening in the treatment of civilian wounds. J Surg Res.

1973;14:426-30. Namdari

• S, Baldwin KD, Matuszewski P, Esterhai JL, Mehta S. Delay in surgical de ́bridement of open tibia

fractures: an analysis of national practice trends. J Orthop Trauma. 2011;25:140-4. Hauser

• CJ, Adams CA, Eachempati SR, et al. Surgical Infection Society guideline: prophylactic antibiotic use in open

fractures: an evidence- based guideline. Surg Infect. 2006;7:379–405. Scharfenberger

• et al Primary Wound Closure After Open Fracture: A Prospective Cohort Study Examining

Nonunion and Deep Infection. J Orthop Trauma Volume 31, Number 3, March 2017 Harley BJ, Beaupre LA, Jones CA,

• Dulai SK, Weber DW. The effect of time to definitive treatment on the rate of

nonunion and infection in open fractures. J Orthop Trauma. 2002;16:484-90. Radoicˇic

• ́ et al. Does timing of surgery affect the outcome of open articular distal humerus fractures Eur J Orthop

Surg Traumatol (2014) 24:777–782 Dugan

• et al Open supracondylar femur fractures with bone loss in the polytraumatized patient – Timing is

everything! Injury, Int. J. Care Injured 44 (2013) 1826–1831 Vallier

• et al. Do Patients With Multiple System Injury Benefit From Early Fixation of Unstable Axial Fractures? The

Effects of Timing of Surgery on Initial Hospital Course

Benefits of early debridement

• Early limb triage
• Reduction in bacterial load/removal of

nonviable tissue

• Shorten treatment course

Treatment Arm Time period Patients Infection rate (Type III) Retrospective 1955-1968 670 open fractures 12% (44%) Prospective 1969-1973 352 open fractures 2.5% (9%)

How far have we come?

• Infection Rate 4-63%

Schenker et al 2012

Indications for operative debridement

All wounds associated

• with

Fractures – traumatic – arthrotomy penetrating – the fascia, pleura, peritoneum, and vascular structures

Antibiotics: Timing counts!

Hauser et al 2006 Lack et al 2015

Nonunion risk factors

Increasing

• Gustilo grade

Presence of infection

• Harley et al 2002

Antibiotics

• Type I and Type II
• Type III
• High-risk anaerobic

(barnyard), vascular injury (low O2)

• First generation cephalosporin
• Add aminoglycoside
• Add PCN

Irrigation

High volume, low pressure saline

• +/- pulsatile

+/- antiseptic Type 1 – 3L Type 2 – 6L Type 3- 9L