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An open fracture is considered a(n) ____________.
therapeutic emergency (there are usually concomitant injuries-stabilize the patient first!)
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Open fractures are usually the result of ___________, such as...
high energy trauma; road traffic accident, gun shot wounds, kick from large animal, etc
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Describe the Gustilo-Anderson Open Fracture Classification.
- graded according to the degree of soft tissue injury and viability
- increasing grade= worse prognosis
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Describe a type I G-A open fracture.
- small skin wound <1cm
- inside-out injury (bone penetrated the skin)
- low energy fracture
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Describe a type II G-A open fracture.
- >1cm skin wound
- without extensive soft tissue damage or flaps
- high energy trauma
- outside-in wound (external trauma created wound)
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Describe a type III G-A open fracture.
- extensive soft tissue damage
- degloving, bone loss, avulsions
- a- adequate soft tissue coverage despite extensive lacerations/ flaps
- b- extensive soft tissue loss, periosteal stripping and bone exposure (requires reconstructive surgery)
- c- arterial injury associated with the open fracture(requires arterial repair)
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The most common location for open fracture in dogs is __________; in cats, it's the __________.
radius/ ulna; femur
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What are the priorities for open fractures?
- control hemorrhage
- assess neurovascular integrity
- wound treatment
- sterile dressing and bandage
- radiographs
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What are signs of vascular compromise to the distal limb?
cold foot, cyanotic, not bleeding
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What are signs of neurovascular compromise to the distal limb?
deep pain negative, absent/ depressed reflexes
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What is the single most important component of preventing infection in open fractures?
- early administration of antimicrobials (at presentation!)
- 4 quadrant coverage: gram +, gram -, aerobic, anaerobics
- general recommendation is 1st or 2nd gen cephalosporins for type I and II; type III--> add fluoroquiniolone
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How do you prevent nosocomial infection?
early soft tissue closure IF POSSIBLE
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Describe the principals of wound management with open fractures.
- some type I can be closed immediately
- if any doubt of viability of tissue/ contamination, treat as an open wound
- assess wound once daily
- debridement bandage initially (wet-to-dry)
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Describe wet-to-dry bandage debridement.
- wet gauze layer in contact with wound (saline, dextrose)
- dry gauze padding on top to dry out inner sponge
- removal of now dry gauze debride
- downside: non-selective and removes healthy tissue
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Describe hydrogel bandages.
- makes an occlusive primary layer that retains moisture within wound
- pro: not as painful on removal as wet-to-dry, does not debride healthy tissue
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Why is it important to stabilize a fracture as soon as possible, even not as a definitive fixation?
- bone will heal in the face of infection if rigidly stabilized
- helps with pain and function
- prevents ongoing tissue damage
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What are the 3 types of fracture stabilization?
- Type I- no additional special wound care, can be repaired like normal closed fracture
- Type II- requires rigid fixation, consider bone grafting, IM pin/ wires generally contraindicated
- Type III- external skeletal fixator usually best, allows for wound care
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What are the pros and cons of a bone plate?
- Pros: rigid stabilization, used successfully for types I-III fractures
- Cons: more soft tissue dissection/ spread of infection, may need to be removed later
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What are the pros of ESF?
Pros: implants away from fracture site, access for open wound management, ease of removal after healing, biologic repair
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What are surgical considerations for open fractures? (3)
- open fractures take longer to heal (loss of blood supply, risk of infection)
- type II and III open fracture- bone graft is contraindicated, MAYBE delayed graft
- do not remove bullet fragments unless in a joint or spinal canal
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What are causes of post-traumatic osteomyelitis? (3)
- iatrogenic with open fracture fixation
- puncture wounds, animal bites
- local spread (tooth abscess)
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Development of post-traumatic osteomyelitis depends on...
- integrity of soft tissues, load and virulence of organisms, host immune response
- +/- presence of metallic FB, devitalized pieces of bone
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Keep a watch out for post-traumatic osteomyelitis if...
- Hx of open fracture
- evidence of wound infection
- [remember rads lag behind clinical signs]
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What is the treatment of post-traumatic osteomyelitis? (4)
- culture- antimicrobials minimum 4 weeks
- address fracture instability
- open, lavage, debride, remove dead bone
- appropriate wound care
- remove implants after fracture heals
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