Diferencia entre revisiones de «Open fracture»
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| Línea 34: | Línea 34: | ||
*Nerve, vascular, muscular, and/or ligamentous injury | *Nerve, vascular, muscular, and/or ligamentous injury | ||
== | ==Work-Up== | ||
*ATLS | *ATLS | ||
*X-ray | *X-ray | ||
| Línea 41: | Línea 41: | ||
==Management== | ==Management== | ||
===Pain control=== | ===Pain control=== | ||
*[[Fentanyl]] | |||
*[[Morphine]] | |||
===[[Antibiotics (Main)|Prophylactic Antibiotics]]=== | ===[[Antibiotics (Main)|Prophylactic Antibiotics]]=== | ||
{{Antibiotics Open Fracture}} | {{Antibiotics Open Fracture}} | ||
===Wound Managment=== | ===Wound Managment=== | ||
*Surgical debridement and washout | |||
**Irrigation may be started in the ED for grossly contaminated wounds | |||
*[[Tetanus prophylaxis]] | |||
==Disposition== | ==Disposition== | ||
Revisión del 17:40 12 abr 2015
Background
- Fractures that have communication with the outside environment are considered open
- The fractured portion does not have to be overtly exposed
- True orthopedic emergency
Clinical Features
- Suspect open fracture with overlying wound regardless of how small
- Free air on x-ray may suggest open fracture in more equivocal cases
- Open fractures can be classified using the Gustillo-Anderson grading scale
- As the grade increase, so does the risk of infection
- Grading is based on wound size, neurovascular injury, and contamination
Grade I
- Wound <1cm
- Little soft tissue injury or crush injury
- Moderately clean puncture site
- Infection risk 0-12%
Grade II
- Laceration >1cm
- No extensive soft tissue damage, but slight or moderate crush injury
- Moderate contamination
- Infection risk 2-12%
Grade III
- Extensive damage to soft tissue, including neurovascular structures and muscle
- High degree of contamination
- Infection risk 5-50%
- Further subcategorized:
- III A: Fracture covered by soft tissue (Infection risk 5-10%)
- III B: Loss of soft tissue and evidence of bone stripping (Infection risk 10-50%)
- III C: Any fracture with an associated arterial injury that requires surgical repair (Infection risk 25-50%)
Additional Considerations
- Fracture with non-communicating overlying wound
- Additional sites of injury found in 40-80% of cases
- Nerve, vascular, muscular, and/or ligamentous injury
Work-Up
- ATLS
- X-ray
- Trauma labs
Management
Pain control
Prophylactic Antibiotics
Prophylactic Antibiotics for Open fractures
Initiate as soon as possible; increased infection rate when delayed[1]
Grade I & II Fractures Options
- Cefazolin (Ancef) 2 g IV (immediately and q8 hours x 3 total doses)[2]
- Cephalosporin allergy: clindamycin 900 mg IV (immediately and q8 hours x 3 total doses)[2]
Grade III Fracture Options
- Ceftriaxone 2 g IV (immediately x 1 total dose) PLUS vancomycin 1 g IV (immediately and q12 hours x 2 total doses)[2]
- Cephalosporin allergy: aztreonam 2 g IV (immediately and q8 hours x 3) PLUS vancomycin 1 g IV (immediately and q12 hours x 2 total doses)[2]
Special Considerations
- Concern for clostridium (soil contamination, farm injuries, possible bowel contamination): additionally add penicillin[3][2]
- Fresh water wounds: fluoroquinolones OR 3rd/4th generation cephalosporin
- Saltwater wounds (vibrio): doxycycline + ceftazidime OR fluoroquinolone
Wound Managment
- Surgical debridement and washout
- Irrigation may be started in the ED for grossly contaminated wounds
- Tetanus prophylaxis
Disposition
Admission to ortho or trauma surgery
See Also
External Links
Sources
- ↑ Gosselin RA, et al. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004; (1):CD003764.
- ↑ 2.0 2.1 2.2 2.3 2.4 Garner MR, et al. Antibiotic Prophylaxis in Open Fractures: Evidence, Evolving Issues, and Recommendations. Journal of the American Academy of Orthopaedic Surgeons. April 15, 2020. 28(8):309-315
- ↑ HoffWS, Bonadies JA, Cachecho R, Dorlac WC: East practice management guidelines work group: Update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma 2011;70:751-754.
Uptodate Gustilo, RB et al. Prevention of infection in the treatment of 1,025 open fractures of long bones: retrospective and prospectivel. JBJS. 1976;58A(4)453-458. http://www.ncbi.nlm.nih.gov/pubmed/14974035