Open Fractures

HPI:

18 yo male involved in a head on MVC. Patient was the unrestrained driver. The patient was initially unconscious but is now combative. Per EMS there is an obvious deformity to the right lower leg with “bone sticking out.” Patient is slightly tachycardic on arrival with a HR of 102 with a blood pressure of 132/90 and has a GCS of 15. 

EXAM:

The primary survey is unremarkable and the patient continues to maintain stable vital signs. During the secondary survey a 3 cm laceration with what appears to be protruding bone is noted 20 cm distal to the R knee. Patient has intact sensation distal to the injury with strong DP and PT pulses with good capillary refill. Steady dark bleeding is noted from the wound.  The motor exam is limited by pain and uncooperative patient. 

IMAGING:

MANAGEMENT:

1.       First priority is trauma resuscitation
2.       Thorough neurovascular examination
3.       Irrigation and debridement of the site
4.       Application of a splint to the affected limb for temporary stabilization
5.       In addition to standard trauma resuscitation tetanus prophylaxis and early administration of antibiotics is indicated

• 1st or 2nd generation cephalosporin nearly always indicated
  
• Gentamycin traditionally recommended for Gustilo III and above (larger soft tissue defect, segmental fracture and/or neurovascular compromise); however, no definitive evidence shows any benefit at this time
  
• Add fluoroquinolone when fresh or salt water is involved. 
  
• Evidence shows that if antibiotic administration is delayed > 3 hours there is an INCREASED risk of infection.
  

DISCUSSION:

-          Patients will need operative debridement and fixation of their fractures
-          Copious irrigation in the OR is key for preventing infection
-          Direct pressure, NOT blind clamping is the best way to control bleeding
-          Open fractures can often wait until the following day for operative repair. At one time it was thought every open fracture required operative repair within 6 hours to lower the risk of infection. This is NOT true.

KEY POINTS:

-          Tetanus and early antibiotic administration a MUST.
-          Thorough neurovascular examination prior to splinting
-          Remove gross debris from fracture site and cover with moist gauze.
-          Does not require immediate operative repair
-          Apply temporary splint to stabilize fracture