Timing of Surgical Intervention

Open fractures have traditionally been considered orthopaedic emergencies, however, there is some evidence that operative treatment within six hours of injury versus treatment after six hours has no effect on ultimate infection rates.¹¹ Definitive guidelines are not yet established for all open fractures. It is known that the location and grade of injury has a significant bearing on complication rates.¹² As the severity of the fracture increases so does the infection rate. With the tibial location of the open fracture the complication rate is highest. Current evidence with regards to delayed initial treatment is Level II.

Quality radiographs are important to determine the extent of injury and to plan both the temporary and definitive fracture management.

Type and Duration of Antibiotic Administration

Prophylactic antibiotics play a key role in the prevention of one of the most dreaded complications of open fractures; that of infection.³ It is well established that antibiotics reduce the risk of infection.⁴ Numerous studies have looked at antibiotic selection and duration. There is evidence that when infection does become established the organism is usually one that is resistant to the original antibiotic chosen.^1,5

Protocols for antibiotic selection are based upon the grade of open fracture and the degree of contamination. Although the open fracture grading system has poor interobserver reliability it still provides guidelines for treatment.⁶ There are numerous randomized control trials studying different antibiotic protocols and their conclusions are all very similar. The use of a broad spectrum antibiotic, such as cefazolin, or the use of clindamycin or cloxacillin has been proven to reduce infection rates in grade I and grade II open fractures up to seven fold.^{7,8, 9} In grade III fractures, additional coverage is needed for gram-negative organisms with an aminoglycocide or fluoroquinolone.⁸ Gross contamination or “farm injuries” necessitate the addition of clostidial coverage and this usually means adding penicillin or metronidazole. Once daily high dose gentamicin (5-6 mg/kg) has been proven to be as effective as conventional divided dosing.¹⁰ In severe open wounds the use of an antibiotic bead pouch has been shown to reduce infection rates.^20,21 Gentamicin beads are available commercially or tobramycin beads can be made by hand. Add 1.2 grams of powdered tobramycin to each package of cement. Round beads of 5 to fifteen millimeters are formed, strung on a wire, and placed in the open wound. The wound is sealed over with an adhesive, impermeable film such as Opsite or Ioban until the second debridement in 48 to 72 hours.

Irrigation Fluid during Debridement

Once the patient has been stabilized, the extremity reduced and splinted, and antibiotics and tetanus status addressed, definitive wound and possibly definitive fracture management should occur.

With the patient under anaesthetic the extremity is carefully exposed and a wound scrub is generally recommended to remove gross debris prior to preparation and draping of the fracture. Maintaining control of both sides of the fracture is imperative throughout the process. A tourniquet is applied but used only if absolutely necessary (level V). One of the most important steps in the optimization of outcomes is a meticulous layer-by-layer debridement of the open wound. An extensile exposure should be used taking care to minimize further soft tissue injury. Skin resection should be limited, knowing that questionable integument can be resected at the time of secondary debridement. Fat and fascia are generally expendable and poorly vascular. Muscle viability is evaluated along the lines of consistency, contractility, color, and capillary perfusion (4 C’s). Bone ends are delivered into the wound and cleaned and all non-viable bone is resected. Retained devascularized bone in the wound, even as a structural piece, can lead to a fifty percent increase in infection rates.¹³ Fasciotomies may be required in open fractures.

Throughout and following the surgical debridement six to twelve litres of warm isotonic irrigation should be run through the wound. The use of detergents such as castile soap as well as antibiotic solutions such as bacitracin has been studied. One large Level I prospective study concluded that neither fluid affected fracture healing or infection rates but the antibiotic solution cases had an increased rate of wound healing problems.¹⁴ Lavage fluid should be delivered by open gravity flow cystoscopy tubing or with low pressure pulsed lavage. High-pressure lavage has been shown to cause damage to bone.¹⁵