OPEN

FRACTURE PROTOCOL PGIMER

MANAGEMENT OF OPEN FRACTURES AND GUN SHOT INJURIES


An open fracture can be defined as a broken bone that is in communication through
the skin with the environment. The amount of communication can vary from a small
puncture wound in the skin to a large avulsion of soft tissue that leaves bone
exposed. In contrast, a closed fracture is one that is contained within the extremity
without a break in the integument.

The old nomenclature of simple for closed fracture and compound for open fracture
has largely been discontinued. Open fractures are much like pregnancy: they either
are or they are not. Closed fractures, on the other hand, can contain devitalized skin
that can be easily penetrated by bacteria resulting in the same problems that occur
with open fractures. Closed fractures should, therefore, be evaluated very carefully
in regard to the intactness of the integument and its viability. Closed fractures can
usually be considered clean if the skin is not devitalized. All open fractures, on the
contrary, are considered contaminated. Deceivingly small, seemingly insignificant
puncture wounds associated with a fracture may, in fact, have severe consequences
brought about by penetration of foreign matter into the extremity combined with
neglect through nondiagnosis or improper treatment of the open fracture.

The most important factor in managing open fractures is the treatment of the soft-
tissue injury. All open fractures may be limb threatening: an infected nonunion
carries a significant risk of amputation. Correct management of the open fracture
should prevent infection, provide soft tissue cover and allow fracture union in an
acceptable position, to restore limb and joint function.

An open fracture must be recognized early in the management of the patient. Open
fractures are often due to high-energy trauma and multiple injuries are common.
The primary survey will deal with immediately life-threatening conditions. External
haemorrhage, from open fractures, should be controlled by direct pressure.
Immediate treatment of the open fracture should start with a rapid evaluation of the
wound.

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Gross contaminants should be removed but the wound should not be cleaned in the
emergency room. A photograph should be taken and the wound covered with a
moist (saline or betadine), sterile dressing. The dressing must be left undisturbed
until the patient reaches the operating room. The photograph provides a visual
record and prevents numerous clinicians disturbing the wound.

The neurovascular status of the limb must be determined and documented clearly.
The limb should then be aligned and splinted and the neurovascular status re-
assessed. Two x-rays, at right angles and including the joints above and below the
fracture, should be obtained.


GUSTILO OPEN FRACTURE CLASSIFICATION SYSTEM

Gustilo type Description Example fracture
patterns
I Open fracture, clean wound, wound <1 cm in Simple transverse or
length short oblique fractures
II Open fracture, wound > 1 cm in length without Simple transverse or
extensive soft-tissue damage, flaps, avulsions short oblique fractures
III Open fracture with extensive soft-tissue High energy fracture
laceration, damage, or loss or an open pattern with significant
segmental fracture. This type also inculdes open involvement of
fractures caused by farm injuries, fractures surrounding tissues
requiring vascular repair, or fractures that have
been open for 8 h prior to treatment
III A Type III fracture with adequate periosteal Gunshot injuries or
coverage of the fracture bone despite the segmental fractures
extensive soft-tissue laceration or damage
III B Type III fracture with extensive soft-tissue loss Above patterns but
and periosteal stripping and bone damage. usually very
Usually associated with massive contamination. contaminated
Will often need further soft-tissue coverage
procedure (i.e. free or rotational flap)
III C Type III fracture associated with an arterial Above patterns but with
injury-requiring repair, irrespective of degree of vascular injury needing
soft-tissue injury. repair

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MESS Scoring
* Score doubled for ischemia > 6 hours

Skeletal / soft-tissue injury
Low energy (stab; simple fracture; pistol gunshot wound): 1
Medium energy (open or multiple fractures, dislocation): 2
High energy (high speed MVA or rifle GSW): 3
Very high energy (high speed trauma + gross contamination): 4
Limb ischemia
Pulse reduced or absent but perfusion normal: 1*
Pulseless; paresthesias, diminished capillary refill: 2
Cool, paralyzed, insensate, numb: 3*
Shock
Systolic BP always > 90 mm Hg: 0
Hypotensive transiently: 1
Persistent hypotension: 2
Age (years)
< 30: 0
30-50: 1
> 50: 2

Recommendations for antibiotic therapy in open fracture management
(All medicine to be given intravenously)
Fracture type Antibiotic choice Antibiotic duration

I Cefazolin Every 8 h for three doses

II Pipercacillin/tazobactam† OR Continue for 24 h after wound

Cefazolin and tobramycin closure

III A Pipercacillin/tazobactam OR Three days

Cefazolin AND tobramycin‡ plus
Metronidazole
III B Pipercacillin/tazobactam OR Continue for three days after
Cefazolin AND tobramycin wound closure
Metronidazole

III C Pipercacillin/tazobactam OR Continue for three days after

Cefazolin AND Metronidazole wound closure

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*1-2 g intravenously (IV) every 8 h

†3.375 g IV every 6 h
‡5.1 mg/kg IV every 24 h (recommend pharmacy to assist with monitoring levels)
§2–4 million units IV every 4 h

Clostridium tetani prophylaxis recommendations

Tetanus immunization status Recommended dosing

Tetanus booster within last 5 years necessary No further treatment
More than 5 years since booster or has not Tetanus toxoid (if wound tetanus prone, give
completed immunization series HTIG)

More than 10 years since booster or immune Tetanus toxoid and HTIG
system compromised
HTIG: Human tetanus immune globulin.

Debridement principles in open fracture management

Tissue Principles
Excise all devitalized skin and resect edges
Skin until dermal bleeding is encountered. Extend
the open wound to evaluate underlying
structures. Longitudinal incisions are best.
Excise all devitalized tissue. Affected
Subcutaneous tissue and fat subcutaneous fat and tissue should be freely
excised. These tissues have a sparse blood
supply and on subsequent debridements,
further devitalization may become apparent
Excise all devitalized tissue. As with
subcutaneous fat, contaminated fascia
Fascia should be freely excised. It is vital to recall
that compartment syndromes can still occur
in the face of open fractures and complete
compartment releases should be undertaken
if compartment syndrome is suspected

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Excise all devitalized tissue. Muscle provides

an excellent environment for bacteria to
flourish. Thus, extensive debridement of

contaminated and devascularized tissue

Muscle should be completed. Attention to the classic
“C’s” of muscle viability can assist the
decision for excision: color, consistency,
contractility, and capacity to bleed. Caution
should be taken with excision of tendons and
ligaments. These should be meticulously
cleaned and left for later debridement if they
prove to be devitalized.
Remove all devitalized bone. The ends of the
bone should be delivered into the wound
and cleaned/debrided. Devitalized fragments
Bone
of bone should be removed. Large portions
of cancellous bone can be cleaned and used
as graft material (only if not directly involved
in the open fracture environment and not
grossly contaminated. Clinical judgment is
needed in this case).


In the OT, the open wound should be classified.
The decision to salvage the limb or undertake primary amputation will depend upon
Four important factors:
1. The age of the patient.
2. Hypovolaemic shock.
3. Warm ischaemia time.
4. Mechanism of injury (eg, crush versus penetrating).

Irrigation principles in the open fracture management*

Gustilo fracture type Irrigation volume/additives
I 3 L normal saline + betadine
II 6 L normal saline + betadine
III A-C 9 L normal saline + betadine
+ - Antibiotic solutions

*Surgeons should favor using a low to medium pressure lavage device, as higher-
pressure devices have been associated with added tissue or bone damage.

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MANAGEMENT OF GUNSHOT WOUNDS OF THE LIMBS

• The important factor is its tissue interaction: a ‘high-energy’ bullet may

sometimes produce a low-energy transfer wound
• The key is to “treat the wound, not the weapon”
• A bullet is not sterilised by firing and may carry viable bacteria into a wound.
In addition, clothing may distribute bacteria along the wound track from both
the entry and exit wounds. Bacteria may be drawn into the low pressure of
the temporary cavity and distributed along the wound track.
• Bullet or pellets when possible should be saved and packed in a plastic pouch
and labeled with Pt name and CR No and sent to CMO, ESOPD.

Algorithm for the management of gunshot fractures