17 MANAGEMENT OF OPEN FRACTURES 2024.pdf

MANAGEMENT OF OPEN FRACTURES DPM 2026 KEVIN SMITH, DPM FACFAS  CPMS Mission Statement To educate a diverse group of highly competent and compassionate podiatric health professionals to improve lives in a global community.  Lecture Objectives n Recognize the histor...

MANAGEMENT OF OPEN FRACTURES DPM 2026 KEVIN SMITH, DPM FACFAS  CPMS Mission Statement To educate a diverse group of highly competent and compassionate podiatric health professionals to improve lives in a global community.  Lecture Objectives n Recognize the history and physical findings seen in patients with crush and degloving injuries. n Demonstrate knowledge of classifications for open fractures and mangled extremities. n Demonstrate knowledge of the evaluation and management of open fractures and crush injuries.  GOALS OF OPEN FRACTURE TREATMENT n Convert contaminated wounds to clean wounds n Early soft tissue healing n Stabilize fractures  GUSTILLO AND ANDERSON CLASSIFICATION n Mechanism of injuries n Level of contamination n Configuration of fractures n Degree of soft tissue damage  TYPE I n Clean puncture < 1 cm n Simple fracture n Little soft tissue damage  TYPE II n Laceration > 1 cm n Moderate contamination n No extensive soft tissue damage n Moderate comminution  TYPE IIIA n Extensive laceration n Adequate soft tissue coverage n Severe comminution  TYPE IIIB n Massive contamination n Extensive soft tissue loss n Periosteal stripping n Bone exposure n Severe comminution  TYPE IIIC n Open fracture with arterial injury  OPEN FRACTURES TREATMENT PLAN n Surgical emergency n Golden period n Multi-system evaluation n Antibiosis/Tetanus n IRRIGATION AND DEBRIDEMENT n Stabilize fractures  OPEN FRACTURE TREATMENT PLAN n Compartment syndrome n Delayed closure n Bone grafting n Contaminated Vs. Infected n Rehabilitation  ANTIBIOTIC PROTOCOLS n Limited duration of therapy (48-72 hours) n Pen G in clostridium prone wounds  TYPE I OPEN FRACTURES ANTIBIOTIC THERAPY n Cefazolin (Ancef) 2 gm IV Q 8h TYPE II AND III OPEN FRACTURES ANTIBIOTIC THERAPY n Combined therapy n Cefazolin (Ancef) n Aminoglycoside 3-5 mg/kg/day Anderson, A., Miller, A.D., & Bookstaver, P.B. (2011). Antimicrobial prophylaxis in open lower extremity fractures. Open Access Emergency Medicine, 3: 7-11. n Level 1 – Systematic review of randomized controlled trials n Recommendations – Grade I and II open fractures treated with first generation cephalosporin within 3 hours of injury and continued for 24 hours – Grade III treated with first generation cephalosporin and aminoglycoside within 3 hours and continued for 48-72 hours  INFECTION CONSIDERATIONS n Type I: 0-2% n Type II: 2-7% n Type IIIA: 7% n Type IIIB: 10-50% n Type IIIC: 25-50% n > 50% of IIIC result in amputation  SURGICAL PRINCIPLES DEBRIDEMENT AND LAVAGE n Initial debridement and pulse lavage n Repeat debridement PRN n Repeat antibiotic protocol n Early coverage of wounds with delayed primary closure, grafts or flaps STABILIZATION OF FRACTURES n Intra-articular fractures – Complication outweighs risk of infection n Types of fixation – Internal Vs. External n Advantages for healing  INDICATIONS FOR AMPUTATION n Massive uncontrolled sepsis n Necrosis and gangrene n Primary amputation  Mangled Extremity Severity Score (MESS) n Retrospective and prospective trial revealed that a MESS value ≥ 7 predicted amputation with 100% accuracy. Johansen et al. (1990). Objective Criteria Accurately Predict Amputation following Lower Extremity Trauma. The Journal of Trauma, 30 (5), 568-573. http://www.ncbi.nlm.nih.gov/pubmed/2342140  BONE GRAFTING n Type I and II n Type III THANK YOU