Classification and Management of Acute Wounds and Open Fractures
Classification and Management of Acute Wounds and Open Fractures
Classification and Management of Acute Wounds and Open Fractures
The aetiology of traumatic wounds is diverse and the mechanism, C Definitive management
pattern, location, energy imparted to the tissues and degree of Multidisciplinary approach
contamination all play a role in their inherent ability to heal. As Closure: when, where and how?
such, initial assessment and treatment should be systematic, and
C Rehabilitation
subsequent management is tailored to each individual wound. The
Dressings
general principles of wound management are outlined in Box 1.
Splints?
Physiotherapy/hand therapy
Types of wound
To gain a broad overview of wounds in a clinical context, the
terms simple and complex can be used. Box 1
an operative time more than the 75th centile for similar Management of traumatic wounds and open fractures
procedures.
Early administration of systemic antibiotics and timely surgical
The higher the score, the greater the probability there is wound
debridement, skeletal stabilization and delayed wound closure
infection. This is primarily a tool for audit, but it does highlight
are the mainstay principles of treatment in open fractures.
the fact that both wound characteristics as well as pre-existing
Initial guidelines for the management of open fractures were
patient factors will influence wound healing.
published in 1997. This guidance has subsequently been revised
by the British Orthopaedic Association and British Association of
Open fractures
Plastic, Reconstructive and Aesthetic Surgeons in 2009.5
The presence of a soft tissue wound communicating with an Traditional teaching has been that the timing of definitive
underlying fracture remains a true orthopaedic emergency. The debridement should be within 6 hours of the injury. Karl Reyher,
skin acts as a barrier preventing the invasion of microorganisms in 1881, reported a decrease in mortality rates with the use of
that would otherwise colonize and infect the fracture site. early debridement during the Franco-Prussian War. Later in
Infection complicating a fracture may well lead to non-union 1898, Freidrich demonstrated in a guinea pig model that the
with subsequent deformity and loss of function, and may effectiveness of debridement of a soft tissue wound was limited
culminate in chronic deep bone infection that is difficult to to about 6 hours, but this has never been reproduced. A pro-
eradicate. Current preference in terminology is to describe such spective study in Australia has shown that an average time to
fractures as ‘open fractures’ rather than compound injuries. debridement of 8 hours did not alter the outcome of their pa-
The Gustilo and Anderson3 classification (Box 2) is the most tients.6 However, it has been demonstrated that starting broad-
commonly used to describe open fractures. It takes into account a spectrum antibiotics within 3 hours of injury will reduce infec-
number of factors, not just the size of the associated wound. The tion rates by almost 40%.7
presence or absence of a neurovascular injury, the degree of The new guidelines have recognized that the best outcomes
contamination (farmyard injuries are grade III injuries), energy are achieved by timely, specialist surgery rather than emergency
transfer (degree of fragmentation and periosteal stripping) and surgery by less experienced teams. It should be noted that the
wound dimensions are used to classify the injury. It has been guidelines are specifically for high-energy lower limb fractures
shown that the grade correlates with the risk of infection.4 The where a significant soft tissue defect, vascular injury or
definitive grade should be assigned in theatre after thorough contamination exists. The guidelines also are, however, a very
debridement. useful tool in guiding treatment in all open fractures.
Use of antibiotics
The use of antibiotics in traumatic wounds that do not involve
bone or joint remains controversial. However, antibiotics should
Gustilo and Anderson open fracture classification3 be administered as soon as possible in all open fractures, and
preferably within 3 hours.7 Organisms that require coverage
Grade I: The wound is less than 1 cm long. It is usually a moderately include: Staphylococcus species, Pseudomonas species, Entero-
clean puncture, through which a spike of bone has pierced the skin. coccus, Escherichia coli, Proteus species, Enterobacter, Klebsiella
There is little soft-tissue damage and no sign of crushing injury. The and Serratia species.
fracture is usually simple, transverse or short oblique, with little The current guidelines recommend the use of co-amoxyclav
fragmentation. (1.2 g) or cefuroxime (1.5 g) 8-hourly and are continued until
wound debridement. Clindamycin 600 mg 6-hourly can be used if
Grade II: The laceration is more than 1 cm long, and there is no a penicillin allergy exists. At the time of first debridement, co-
extensive soft-tissue damage, flap or avulsion. There is slight or amoxyclav (1.2 g) or cefuroxime (1.5 g) should be given along
moderate crushing injury, moderate fragmentation of the fracture and with gentamicin (1.5 mg/kg) at induction of anaesthesia. This
moderate contamination. should be continued until soft tissue cover is achieved or for a
maximum of 72 hours, whichever is sooner.
Grade III: These are characterized by extensive damage to soft tis- Gentamicin (1.5 mg/kg) and either vancomycin (1 g) or teico-
sues, including muscles, skin and neurovascular structures, and a planin (800 mg) should be administered at induction of anaesthesia
high degree of contamination. The fracture is often caused by high- at the time of definitive skeletal stabilization and definitive soft tis-
velocity trauma, resulting in a great deal of fragmentation and sue closure. Vancomycin should ideally be given 90 minutes prior to
instability. surgery and these agents should not be continued postoperatively.5
III A e Soft tissue coverage of the fractured bone is adequate.
III B e Extensive injury to, or loss of soft tissue, with periosteal Tetanus prophylaxis
stripping and exposure of bone, massive contamination, and severe The introduction of a comprehensive infant vaccination pro-
fragmentation of the fracture. After debridement and irrigation a local grammes in the 1960s has dramatically reduced the incidence of
or free flap is needed for coverage. tetanus in the UK, although there are still approximately 10 cases
III C e Any open fracture that is associated with an arterial injury that per year.8 Tetanus contamination is more likely in wounds that
must be repaired, regardless of the degree of soft tissue injury. are contaminated with soil or manure, and deep wounds that
contain devitalized tissue, especially muscle. Current guidelines
Box 2 are illustrated in Table 1.
Clean/minor wound
Unknown or <3 doses of absorbed tetanus toxoid Yes No
>3 doses of absorbed tetanus toxoid No (unless >10 years since booster) No
All other wounds
Unknown or <3 doses of absorbed tetanus toxoid Yes Yes
>3 doses of absorbed tetanus toxoid No (unless >5 years since booster) No
Table 1
Figure 2 The wound edges have been excised and the wound debrided of
all devitalized tissues and foreign material in this open tibial fracture. A
bridging external fixator has been applied to achieve initial skeletal sta-
bility. This will be exchanged for alternative definitive fixation at a later
date. Antibiotic-loaded cement beads have been employed to assist in
dead-space management.
REFERENCES
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