An open fracture is considered a(n) ____________.
therapeutic emergency (there are usually concomitant injuries-stabilize the patient first!)
Open fractures are usually the result of ___________, such as...
high energy trauma; road traffic accident, gun shot wounds, kick from large animal, etc
Describe the Gustilo-Anderson Open Fracture Classification.
- graded according to the degree of soft tissue injury and viability
- increasing grade= worse prognosis
Describe a type I G-A open fracture.
- small skin wound <1cm
- inside-out injury (bone penetrated the skin)
- low energy fracture
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)
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)
The most common location for open fracture in dogs is __________; in cats, it's the __________.
radius/ ulna; femur
What are the priorities for open fractures?
- control hemorrhage
- assess neurovascular integrity
- wound treatment
- sterile dressing and bandage
What are signs of vascular compromise to the distal limb?
cold foot, cyanotic, not bleeding
What are signs of neurovascular compromise to the distal limb?
deep pain negative, absent/ depressed reflexes
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
How do you prevent nosocomial infection?
early soft tissue closure IF POSSIBLE
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)
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
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
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
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
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
What are the pros of ESF?
Pros: implants away from fracture site, access for open wound management, ease of removal after healing, biologic repair
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
What are causes of post-traumatic osteomyelitis? (3)
- iatrogenic with open fracture fixation
- puncture wounds, animal bites
- local spread (tooth abscess)
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
Keep a watch out for post-traumatic osteomyelitis if...
- Hx of open fracture
- evidence of wound infection
- [remember rads lag behind clinical signs]
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