1. Management of Open Fractures Christine Kennedy Pediatric Emergency Fellow October 22, 2009

2. Objectives 1) Review the different types of open fractures 2) Discuss the current treatment of open fractures 3) Review the literature supporting non-operative management of Type 1 open fractures

3. Introductory Case 8 yr boy with a midshaft radius & ulna # 8 yr boy with a midshaft radius & ulna # Obvious deformity on clinical exam Obvious deformity on clinical exam Small scab on volar surface of forearm Small scab on volar surface of forearm –not actively bleeding Xray…. Xray….

6. Case Question was…Does this need to go to the OR? Question was…Does this need to go to the OR? Ortho consulted…advised to attempt a closed reduction and give a dose of Ancef Ortho consulted…advised to attempt a closed reduction and give a dose of Ancef If successful, mark wound area on cast, send home on Keflex and F/U in ortho clinic If successful, mark wound area on cast, send home on Keflex and F/U in ortho clinic During the reduction…wound started to ooze on my foot… During the reduction…wound started to ooze on my foot…

7. Post-reduction X-Rays

8. Case-Follow up at day 39

9. Open Fracture Classification Gustilo and Anderson Type I Type I –Clean wound <1 cm in length –# is simple, transverse or oblique with little comminution Type II Type II –Laceration >1cm without extensive soft tissue damage, flaps or avulsions Type III Type III –Extensive soft tissue damage, crushing or a traumatic amputation  Subtypes 3A, 3B, 3C

10. Open Fracture Classification Type 3 subtypes Type 3 subtypes –3A: Adequate soft tissue coverage –3B: Inadequate soft tissue coverage –3C: Arterial injury requiring repair 3B

11. Open Fracture Classification

12. Type I Type IIIb Type IIIc

13. Open Fracture Classification Gustilo and Anderson Type I Infection rate 0-2% Type I Infection rate 0-2% –Clean wound <1 cm in length –# is simple, transverse or oblique with little comminution Type II Infection rate 2-7% Type II Infection rate 2-7% –Laceration >1cm without extensive soft tissue damage, flaps or avulsions Type III Infection rate 10-25% Type III Infection rate 10-25% –Extensive soft tissue damage, crushing or a traumatic amputation Gustilo et al. Current Concepts Review The Management of Open Fractures. Journal of Bone and Joint Surgery. 1990;72:299-304.

14. Open Fracture vs Abrasion

15. Open fracture –disruption of the dermis with communication into the subcutaneous tissue contiguous with the bone

16. Open Fracture vs Abrasion Abrasion Soft tissue injury into the dermis (not through the dermis) Soft tissue injury into the dermis (not through the dermis) usually due to friction or shearing usually due to friction or shearing An abrasion on its own over a fracture does not communicate with the fracture because the sc tissue is intact An abrasion on its own over a fracture does not communicate with the fracture because the sc tissue is intact The pattern of bleeding from an abrasion is pinpoint dermal bleeding The pattern of bleeding from an abrasion is pinpoint dermal bleeding –If you squeeze an abrasion, you may get bleeding but the pattern is different than a laceration that extends into the deeper tissue

17. How do the Orthopedic Surgeons decide? Probing the wound is not recommended Probing the wound is not recommended Pull on the skin adjacent to the wound to see if you can SEE any subcutaneous fat as evidence that the dermis is broken Pull on the skin adjacent to the wound to see if you can SEE any subcutaneous fat as evidence that the dermis is broken Contact the on call surgeon to discuss Contact the on call surgeon to discuss

18. How Common are Open Fractures? For forearm fractures (most common fracture pattern in children) For forearm fractures (most common fracture pattern in children) –0.5%-4.5% are open Luhmann et al. Complications and Outcome of Open Pediatric Forearm Fractures. J Pediatr Orthop 2004;24:1-6.

19. Management of Open Fractures Traditionally Traditionally –Considered a “true surgical emergency” –Required operative debridement and fracture stabilization –“Golden Period” was 6-12 hours from time of patient arrival

20. Management of Open Fractures Now…. Now…. Type II & III Type II & III –Require surgical debridement Wounds with high energy injuries result in devitalized tissue, local edema & ischemia Wounds with high energy injuries result in devitalized tissue, local edema & ischemia This alters the ability of local host defenses to resist infection This alters the ability of local host defenses to resist infection

21. Management of Open Fractures Type 1 Type 1 –Operative vs non-operative, why the controversy?

22. Type 1 Open Fractures Maintain a relatively intact soft tissue envelope therefore the vascular supply to the zone of injury is preserved Maintain a relatively intact soft tissue envelope therefore the vascular supply to the zone of injury is preserved This decreases the risk factors for development of infection This decreases the risk factors for development of infection –Devitalized tissue –Ischemia –Edema

23. Type 1 Open Fractures Allows adequate penetrance of the host defense mechanisms and IV antibiotics to protect further against possible infection Allows adequate penetrance of the host defense mechanisms and IV antibiotics to protect further against possible infection

24. Type 1 Open Fractures Routine operative debridement might cause increased soft tissue trauma, periosteal stripping and osseous devascularization Routine operative debridement might cause increased soft tissue trauma, periosteal stripping and osseous devascularization

25. Type 1 Open Fractures Children have better healing potential than adults Children have better healing potential than adults –Differences in the malleability & strength of the bone –Better vascular supply to the extremities –Thicker periosteum

26. In the old orthopedic literature… Cases of gas gangrene in children with open fractures managed non-operatively Cases of gas gangrene in children with open fractures managed non-operatively Before the routine use of antibiotics Before the routine use of antibiotics

27. Infection Rate with Operative Management Literature’s infection rate for type 1 open fractures treated operatively is an average of 1.9%* Literature’s infection rate for type 1 open fractures treated operatively is an average of 1.9%*

28. Infection Rate with Operative Management

30. Organisms Cultured from Open Fractures The majority of bacteria cultured are normal skin flora The majority of bacteria cultured are normal skin flora –Staphylococcus epidermidis –Proprionibacterium acnes –Corynebacterium species

31. Organisms Cultured from Open Fractures Farm related injuries increase the risk of Farm related injuries increase the risk of –Clostridium perfringens Exposure to fresh water increases the risk of Exposure to fresh water increases the risk of –Pseudomonas aeruginosa –Aeromonas hydrophilia

32. Organisms Cultured from Open Fractures The frequent growth of S. aureus & P. aeruginosa from patients who have an infection contrasts with the infrequent growth of these organisms on initial wound culture The frequent growth of S. aureus & P. aeruginosa from patients who have an infection contrasts with the infrequent growth of these organisms on initial wound culture Suggests that these infections are acquired in the hospital Suggests that these infections are acquired in the hospital

33. Importance of Antibiotics Prospective, double blind, randomized study Prospective, double blind, randomized study Infection rate was Infection rate was –13.9% in placebo group –9.7% in group treated with Penicillin & Streptomycin –2.3% in group treated with a 1 st generation cephalosporin Patzakis et al. The Role of Antibiotics in the Management of Open Fractures. The Journal of Bone and Joint Surgery 1974;56:532-541.

34. Importance of Antibiotics Meta-analysis demonstrated a significant reduction in wound infections in patients who received antibiotics for all types of open fractures Meta-analysis demonstrated a significant reduction in wound infections in patients who received antibiotics for all types of open fractures 13.4% of patients who were not treated with antibiotics developed an infection 13.4% of patients who were not treated with antibiotics developed an infection 5.5% of treated patients developed an infection 5.5% of treated patients developed an infection NNT 13 [8-25] NNT 13 [8-25]

35. Which Antibiotic? Most common pathogens causing infections after open fractures Most common pathogens causing infections after open fractures –Staphylococcus aureus –Facultative gram-negative bacilli In type I open fractures In type I open fractures –1 st generation cephalosporin sufficient In type II & III In type II & III –Combinations therapy with a cephalosporin and an aminoglycoside OR 3 rd generation cephalosporin

36. Timing of Antibiotics is Important One study with over 1000 open fractures found that starting antibiotics within 3 hours of injury lowered the infection rate* One study with over 1000 open fractures found that starting antibiotics within 3 hours of injury lowered the infection rate* –Infection rate 4.7% if antibiotics w/in 3 hours –Infection rate 7.4% if antibiotics started >3h after injury Of note, surgical debridement was performed for all open fractures in this study Of note, surgical debridement was performed for all open fractures in this study

37. Guidelines for Antibiotic Length? No standardized protocol for length of Abx following open fractures No standardized protocol for length of Abx following open fractures One report published which demonstrated no difference b/w 1 & 5 days of IV Abx One report published which demonstrated no difference b/w 1 & 5 days of IV Abx In the adult literature, anywhere from 1-3 days of antibiotics is the recommendation In the adult literature, anywhere from 1-3 days of antibiotics is the recommendation

38. Non Operative Management of Type 1 Open Fractures What does the literature say these days? What does the literature say these days?

39. Reviews the results of non operative management of type I open fractures in children Reviews the results of non operative management of type I open fractures in children Retrospective chart review (1998-2003) Retrospective chart review (1998-2003) 40 patients followed until healed 40 patients followed until healed –clinically & radiographically 1 deep infection occurred 1 deep infection occurred –overall infection rate 2.5%

40. 0% infection rate in the 32 upper extremity type I open fractures 0% infection rate in the 32 upper extremity type I open fractures 0% infection rate in the 23 patients under 12 years 0% infection rate in the 23 patients under 12 years

41. Details of Study #1 40 patients diagnosed with type 1 open fracture 40 patients diagnosed with type 1 open fracture –33 boys, 7 girls Age 10 years [range 4-15y] Age 10 years [range 4-15y] Fracture distribution Fracture distribution –8 tibia –18 diaphyseal radius & ulna –14 distal radius & ulna Mechanism Mechanism –Most low-moderate energy  Falls from bikes, skateboards, rollarblades, scooters –7 kids hit by motor vehicle

42. Details of Study #1 Treatment: Initiated in the ED 1) Initiation of IV antibiotics 2) Cleansing and/or irrigation of the open wound with Betadine & saline 3) Protecting the wound with Xeroform & sterile gauze 4) Tetanus prophylaxis if needed 5) Closed reduction & immobilization

43. Details of Study #1 Patients were admitted to hospital for 48- 72 hours for observation, continued IV antibiotics and wound management Patients were admitted to hospital for 48- 72 hours for observation, continued IV antibiotics and wound management Patients were discharged w/o abx Patients were discharged w/o abx –but 4/40 were sent home on 1 week of Keflex, at the treating surgeon’s discretion

44. Details of Study #1 Patients were followed until fracture union Patients were followed until fracture union –Clinically: no longer tender at fracture site –Radiologically: bridged by sufficient callus

45. Details of Study #1 Definitions Definitions Deep infection: proceeded to debridement Deep infection: proceeded to debridement –Increasing pain, drainage from the wound and radiologic changes within the bone Superficial infections Superficial infections –Inflammation of the skin/subcutaneous tissue w/o radiologic evidence of osteomyelitis

46. Results of Study #1 Average hospital stay: 2.5 days (1-5) Average hospital stay: 2.5 days (1-5) No documented fevers No documented fevers No patients developed malunion/nonunion No patients developed malunion/nonunion No patients developed osteomyelitis No patients developed osteomyelitis No wound complications during admission No wound complications during admission No superficial infections No superficial infections 1 deep infection of the tibia (at 3 months) 1 deep infection of the tibia (at 3 months)

47. Results of Study #1

54. How does this healing compare to fracture healing after OR irrigation?

56. Results of Study #1

60. The 1 infection The 1 infection –15 yr male, comminuted midshaft tibia # –Fall down the stairs –Small nidus of dead bone found anterior to the fracture site--->caused a draining sinus to form over the anterior tibia –Sinus tract was excised & the dead bone debrided in the OR –Patient made a full recovery

61. Conclusions Study #1 Non operative management of Pediatric type I open fractures is safe and effective Non operative management of Pediatric type I open fractures is safe and effective Non operative management does not appear to affect the healing potential Non operative management does not appear to affect the healing potential Children over age 12 with lower extremity type I open fractures are at risk for failing non-operative management Children over age 12 with lower extremity type I open fractures are at risk for failing non-operative management –Should consider traditional irrigation and debridement of the wound in the OR

62. Evaluates the results of non operative management of grade 1 open fractures treated in the ED or with a <24hour admission (for IV antibiotics) Evaluates the results of non operative management of grade 1 open fractures treated in the ED or with a <24hour admission (for IV antibiotics) Retrospective chart review (2000-2006) Retrospective chart review (2000-2006) 25 patients followed until healed (clinically and radiographically) 25 patients followed until healed (clinically and radiographically) 1 patient had persistent draining from the wound site & fever (overall infection rate 4%) 1 patient had persistent draining from the wound site & fever (overall infection rate 4%)

63. Details of study #2 25 patients diagnosed with type 1 open fracture 25 patients diagnosed with type 1 open fracture –20 boys, 5 girls Age range 2-15y Age range 2-15y Fracture distribution Fracture distribution –5 tibial shaft +/- fibula –18 radius & ulna –2 Monteggia fracture/dislocations

64. Details of study #2 14 patients were admitted (<24h) 14 patients were admitted (<24h) 11 were treated exclusively in the ED 11 were treated exclusively in the ED

65. Details of study #2 Treatment: Initiated in the ED 1) Initiation of IV antibiotics 2) Irrigation of the wound with sterile saline 3) Protecting the wound with Xeroform or Betadine soaked gauze 4) Tetanus prophylaxis if needed 5) Closed reduction & immobilization

66. Details of study #2 IV antibiotics used IV antibiotics used –20/25 patients received Ancef –Others  Ampicillin/sulbactam  Ceftriaxone  Gentamicin

67. Details of study #2 Patients who were admitted overnight remained on IV antibiotics until discharge Patients who were admitted overnight remained on IV antibiotics until discharge At discharge oral antibiotics were given to 20 of 25 patients At discharge oral antibiotics were given to 20 of 25 patients –19 received Keflex –1 received Clindamycin –Duration ranged from 1-7 days

68. Details of study #2 Follow up schedule: 7-10 days: radiograph & wound check (windowing) 7-10 days: radiograph & wound check (windowing) 14-17 days: radiograph in cast 14-17 days: radiograph in cast 6-8 weeks: radiograph out of cast 6-8 weeks: radiograph out of cast Followed until healed Followed until healed –Non-tender, full ROM at joint above & below –Bridging bone on radiograph

69. Results of study #2 1 patient diagnosed clinically with an infection (culture negative) 1 patient diagnosed clinically with an infection (culture negative) 8 yr boy 8 yr boy Tibia fracture (from football tackle) Tibia fracture (from football tackle) At F/U on day 6:erythema & serosanguineous drainage from wound At F/U on day 6:erythema & serosanguineous drainage from wound Admitted and treated with 2 days of IV Clinda* Admitted and treated with 2 days of IV Clinda* Complete resolution of drainage/erythema Complete resolution of drainage/erythema Discharged with 1 week course of oral Clinda Discharged with 1 week course of oral Clinda Fracture union at 11 weeks (no further complications) Fracture union at 11 weeks (no further complications)

70. Results of study #2 Average time to union Tibia fractures: 67 days Tibia fractures: 67 days Forearm fractures: 45 days Forearm fractures: 45 days Monteggia fracture/dislocations: 29 days Monteggia fracture/dislocations: 29 days

71. Conclusions Non-operative management of grade 1 open fractures is safe in pediatrics Non-operative management of grade 1 open fractures is safe in pediatrics Eliminates any possible general anesthetic risk Eliminates any possible general anesthetic risk Significantly decreases the cost of caring for these patients in the health care system Significantly decreases the cost of caring for these patients in the health care system –OR costs –Cost of prolonged hospital admissions –Social costs of a hospitalized child

72. Current protocol Treat low energy grade 1 open fractures Treat low energy grade 1 open fractures –sustained in a clean environment with no gross contamination In the ED as an outpatient In the ED as an outpatient Conscious sedation and reduction Conscious sedation and reduction Superficial cleansing Superficial cleansing Single dose of IV Abx Single dose of IV Abx 3-5 days of oral antibiotics 3-5 days of oral antibiotics

73. Adult Literature There is precedent for non-operative treatment of grade 1 open fractures There is precedent for non-operative treatment of grade 1 open fractures

74. 0% infection rate in 91 open grade 1 fractures 0% infection rate in 91 open grade 1 fractures

75. Details of Study #3 Retrospective review (1990-1997) Retrospective review (1990-1997) 91 patients with isolated Type I open fractures 91 patients with isolated Type I open fractures –78 adults, 13 children –60 males, 31 females Exclusion criteria: Exclusion criteria: –multiple injuries –gunshot wounds –hand injuries –compartment syndrome –Intra-articular fractures

76. Details of Study #3 All received antibiotics and were followed until fracture union All received antibiotics and were followed until fracture union Charts were reviewed for Charts were reviewed for –Type of fracture –Mechanism of injury –Type of treatment –Length of hospital stay –Complications encountered

77. Details of Study #3

81. All patients received antibiotics (within 6h) All patients received antibiotics (within 6h) –Adults 1g cefazolin –Children 1g (11), 750mg (1), 500 mg (1) All were admitted for at least 48 hours All were admitted for at least 48 hours Wounds greater than a puncture site were irrigated with several liters of saline Wounds greater than a puncture site were irrigated with several liters of saline –Majority did not receive irrigation Wounds were dressed with sterile gauze Wounds were dressed with sterile gauze

82. Details of Study #3 32 pts had surgery for definitive treatment of their fracture 32 pts had surgery for definitive treatment of their fracture –1 pt had surgery w/in 8 hours “golden period” –All others had surgery after 12 hours  Average time was 5 days [12h-15days] None of the wounds had evidence of infection None of the wounds had evidence of infection Open wound was not debrided unless it was included in the operative exposure Open wound was not debrided unless it was included in the operative exposure

83. Results of Study #3 Hospital stay Hospital stay –9 days on average –11 days for those who had surgery* –4.5 days for those without surgery Follow up Follow up –Averaged 7 months [2mo - 5y]

84. Results of Study #3 Complications Complications –Developed in 10 pts (8 in lower extremities) –6/10 pts needed surgery for definitive treatment Infection rate Infection rate –0%

85. Conclusions Study #3 Immediate operative debridement may not be necessary in isolated, low-energy Type 1 open fractures with stable fracture patterns Immediate operative debridement may not be necessary in isolated, low-energy Type 1 open fractures with stable fracture patterns

86. Results of Study #3 Current Protocol: Low energy type 1 open fracture do not need operative debridement Low energy type 1 open fracture do not need operative debridement Do not classify open fractures by the size of the soft tissue wound alone Do not classify open fractures by the size of the soft tissue wound alone –Comminuted fractures are taken to the OR and reclassified after operative debridement

87. Guidelines for antibiotic length? In the 2 pediatric studies we just reviewed In the 2 pediatric studies we just reviewed –1 dose of IV antibiotics was sufficient in 1 study (20/25 d/c’d on 1-7 days of PO Abx) –~48 hours of IV antibiotics was sufficient for the other study (only 4/40 were d/c’d on PO Abx)

88. Calgary Consensus Call on call surgeon for personal preference Call on call surgeon for personal preference 1 dose of IV Ancef, then 3-7 days PO antibiotics 1 dose of IV Ancef, then 3-7 days PO antibiotics Routine windowing of the cast is not done Routine windowing of the cast is not done –Surgeon dependent Have the patient return to the ED if there are any problems within the first 3 days for urgent evaluation (pain, fever, tachycardia, odour) Have the patient return to the ED if there are any problems within the first 3 days for urgent evaluation (pain, fever, tachycardia, odour) The size of the wound by itself is not indication for non-operative debridement The size of the wound by itself is not indication for non-operative debridement

89. Back to the Objectives 1) Review the different types of open fractures 2) Discuss the current treatment of open fractures 3) Review the literature supporting non-operative management of Type 1 open fractures

90. Summary The literature suggest that treating type 1 open fractures with IV antibiotics and closed reductions is safe The literature suggest that treating type 1 open fractures with IV antibiotics and closed reductions is safe –But no randomized controlled trials Different surgeons ---> different approaches, therefore discuss with the on call surgeon first Different surgeons ---> different approaches, therefore discuss with the on call surgeon first Use of antibiotics is not advocated as a substitute for proper clinical judgment Use of antibiotics is not advocated as a substitute for proper clinical judgment