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Open Fracture Wound Care. Mitchell Goldflies. Overview. Would evaluation Initial surgical management “Why I&D should be D&I” Dressing and wound coverings Wound VAC Antibiotic Bead pouch Definitive closure. First Take a deep breath Ask about Wound Limb Timing contamination. Then
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Open Fracture Wound Care Mitchell Goldflies
Overview • Would evaluation • Initial surgical management “Why I&D should be D&I” • Dressing and wound coverings Wound VAC Antibiotic Bead pouch • Definitive closure
First Take a deep breath Ask about Wound Limb Timing contamination Then Order Antibiotics Ensure proper overall trauma “Step away from the open fracture” When the ER Calls. . .
IV Antibiotics • Tetanus prophylaxis • Antibiotics: choice and duration by grade • I/II –cephalosporin • III – ceph+ aminoglycoside • Soil, farm – add penicillin • Fresh or salt water- add penicillin
Compartment Syndrome • CAN occur with open fractures • Blick, Brumback, Polka jbjs 1986 • 198 open fractures • 9.1% compartment syndrome
Grading Open Fractures It’s not all about size! 4 contributing factors • Degree of Soft tissue damage • Comminution • Contamination • Time from injury
Low sensitivity of all scores Poor predictors of amputation Bosse JBJS 83A (1) 2001 “A Prospective Evaluation of the Clinical Utility of the Lower Extremity Injury-severity Scores”
Consensus on Scoring Systems • Not Vaild as Predictors • Useful: Emphasis factors important in decision making • Shock • Pt age • Other injuries
“The Insensate Foot Following Severe Lower Extremity Trauma: An Indication for Amputation?” • Bosse, et al; JBJS 87-a, 2005 • 55 pts with increase foot post trauma • 29 salvaged • 55% had NORMAL plantar sensation 2 years after injury
Additional Infection RiskHost-related Factors • Age • Co-mobility • Obesity • Diabetes • RA and Steroid Use • Mal-nutrition • Malignancy
Wound Size Shape Location Edges contamination Extremity Pluses Perfusion Sensation Motor Other injuries Open Fracture Evaluation
Timing • Delay thought to increase risk of infection • Recent studies indicate minor delays do not increase risk of infection 6-8 hours
Surgical Managemet Think “D&I” not “I&D”!!!
Debridement • Initial procedure is most important • Goals • Remove all foreign material • Remove nonviable host tissue • Decrease bacterial load • Create clean, living wound
Debridement Principles • Experienced surgeon • Gentile Tissue handling • Extend wound- longitudinal! Very long incision, at least 3:1
Increased Injury Trauma Requires Decreased Surgical Trauma
Debridement Principles Systematic, sharp debridment • Layer by layer • Surface to deep • Save skin in key areas • Fat and fascia are expendable • Dead muscle MUST go • Non-viable bone should usually go
Avoid the Dreaded “three “Ds” • Dead bone • Dead muscle • Dead space
Wound Irrigation • Volume… lots • Delivery Method • High or low pressure? • Pulsatile or continous? • Choice of solution • Antiseptics • Antibiotics • detergents
Surgical Treatment • Debridement • Irrigation • Stabilization! • Wound Coverage • Peri-operative anitbiotics
Role of Stability • Stabilized open fractures are less susceptible to infection
Stability • Provisional External fixation good option • Allows thorough 2nd D&I • Always a safe option • ORIF safe Grade I and II upper extremity fxs • IM nail Grade I, II +/- IIIA tibia safe
Options “Loose” Skin closure Avoids retraction Antibiotic Bead Wound VAC Avoid Wet-Dry My Choices Exposed bone or hardware… Bead pouch Exposed muscle… Wound VAC Temporary Wound Coverage
Antibiotic Bead Pouch Rationale • Deliver a high local concentration of antibiotics with low systemic levels • Reduce wound desiccation • Reduce dressing changes • Lessen contamination • Lessen patient discomfort
Antibiotic Bead Pouch Effectievnes • Animal Studies • Equally or more effective than systemic antibiotics • Human Studies • Most retrospective • Used in conjunction with systemic antibiotics