Definition
Fracture with break in skin communicating with fracture or fracture hematoma
- contamination with micro-organisms
- leads to increased risk in infection and healing problems
Gustilo Classification
| Grade I | Grade II | Grade III A | Grade III B | Grade III C | |
|---|---|---|---|---|---|
| Definition | Wound < 1 cm | Wound 1 - 10 cm | Wound > 10 cm | Requires skin graft / flap for coverage | Vascular injury |
| Infection rate | |||||
| Antibiotics | Cephalosporin | Cephalosporin + Gentamycin |
Cephalosporin + Gentamycin +/- penicillin - farm injury +/- Ciprofloxacin - fresh or salt water |
Cephalosporin + Gentamycin +/- Penicillin - farm injury +/- Ciprofloxacin - fresh or salt water |
Cephalosporin + Gentamycin +/- Penicillin - farm injury +/- Ciprofloxacin - fresh or salt water |
Infection Rate
I: 0-2%
II: 2-7%
IIIA: 7%
IIIB: 10-50%
IIIC: 25-50% with 50% or more amputation
Management
Goals
Prevent infection
Manage the wound
Stabilise the fracture
Enable healing
Immediate
EMST / ATLS Principles
Assess Limb
- vascular
- neurology
- skin defect / contamination
- photos
Wound / fracture care
- irrigate wound
- apply betadine dressing
- stabilise with POP if possible
- appropriate antibiotics / tetanus
- early surgery for irrigation / debridement / stabilisation
Antibiotics
Guidelines
- grade 1: first generation cephalosporin
- grade 2: add gentamicin (increased rate of gram negative infections)
- farmyard / heavily contaminate add penicillin (clostridium / gas gangrene)
Patzakis JBJS Am 1974
- prospective, randomised controlled trial
- infection with preoperative cephalothin was 2.3%
- infection 13.9% without antibiotic
Swabs
- studies finding of initial swab correlating with infecting organism has been discredited
- no real correlation between road-side organisms & subsequent infection
- subsequent infection are typically hospital acquired
Gustilo
- increased rate of gram negative infection in Grade II
- hence add aminoglycoside if Grade II
- add penicillin if soil contamination
- no evidence any other combination is better
Timing
- delay > 3 hours increases infection risk
- 48 - 72 hours post injury
- 48 - 72 hours post each procedure
Wound Management
Irrigation
Gustilo JBJSA 1987
- infection higher if < 10L washout
Anglen 1984
- pulse lavage 100 x effective than bulb
Debridement
Must remove all non viable tissue
- remove cortical bone with no ST covering
Timing of wound closure
Do so when wound is clean
No evidence of increased infection with primary closure
- may prevent secondary contamination
- risk of clostridial myonecrosis
DPC (delayed primary closure)
- prevent anaerobic conditions in wound
- facilitates drainage
- allows second debridement
- can seal the wound via vacuum dressing
Fracture Stabilisation
Advantage
- prevent soft tissue from further injury
- facilitates host response to bacteria despite presence of implants
- allows mobilisation and functional rehab
Femur
- IMN best for I, II, IIIA and B
- 10% deep infection in type III B
- best to plate in type IIIC before revascularisation
Tibia
Reamed v unreamed
- no difference in infection rate
IMN v External fixator
- reduced risk of revision surgery, malunion and superficial infection with IM nail
- no difference in infection rate or union
External fixator
- heavily contaminated wound
- non amenable to nail (i.e. very distal)
- vascular injury
Soft Tissue Reconstruction
Options
Proximal tibia - local pedicle gastrocnemius flap
Middle third - soleus flap
Distal third - free muscle flap (rectus / gracilis / lat dorsi)
Timing
Gopal et al JBJS Br 2000
- early < 72 hours v late > 72 hours
- 6% v 29% deep infection
- did not use antibiotic beads