ystemic antibiotics are a critical part of open fracture wound management.

Their choice and duration

will depend upon several factors including severity of the wound, patient comorbidities, contamination
etc.
Antibiotics may also be applied locally to deliver high concentrations directly to the wound site itself.
Methylmethacrylate impregnated with heat-stable antibiotics is shaped into small beads to increase
their surface area and to optimize antibiotic elution. After placement onto a suture, the beads are
placed within the wound to fill the dead space. The wound is then closed primarily or covered with an
adhesive drape. Generally, beads are left in for at least 2-5 days.

Vacuum assisted closure (VAC)

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Negative pressure wound dressings (VACs) can provide helpful temporary coverage of an open
wound. They reduce external wound contamination, remove edema fluid, help to shrink wounds, and
promote growth of granulation tissue, even over exposed bone. Such dressings may allow definitive
closure by the subsequent use of split thickness skin grafts, instead of more complex flaps. In this
manner, a VAC can be used as a bridge to definitive soft-tissue coverage for type IIIA and IIIB
wounds. They should be changed every 48-72 hours.

Repeat dbridement

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Repeated dbridement may be necessary in the higher grade open fracture wounds when there is a
concern for additional necrotic tissue or when initial wounds were so badly contaminated that a second
look is necessary. This procedure should be repeated, generally every 2-3 days, until only healthy,
viable tissue remains and no further necrotic tissue is found on follow-up dbridements.

Wound closure

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The wound is closed, when the surgeon believes no further dbridements are necessary. This may be
done primarily, but is often done after a secondary procedure.
When skin grafting or soft-tissue flaps are necessary, they should be done as soon as possible. For this
reason, an expert with in these techniques should be consulted early.
Optimally, coverage should occur within the first two weeks after injury (4).

7Definitive treatment

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Definitive fixation is considered, when:

the patients clinical status is optimized

the wounds are healthy and the soft-tissue envelope will allow for chosen surgical approach

a good preoperative plan has been created.