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Orthopedics Nov 2015Open fractures are complex injuries associated with high morbidity and mortality. Despite advances made in fracture care and infection prevention, open fractures remain... (Review)
Review
Open fractures are complex injuries associated with high morbidity and mortality. Despite advances made in fracture care and infection prevention, open fractures remain a therapeutic challenge with varying levels of evidence to support some of the most commonly used practices. Additionally, a significant number of studies on this topic have focused on open tibial fractures. A systematic approach to evaluation and management should begin as soon as immediate life-threatening conditions have been stabilized. The Gustilo classification is arguably the most widely used method for characterizing open fractures. A first-generation cephalosporin should be administered as soon as possible. The optimal duration of antibiotics has not been well defined, but they should be continued for 24 hours. There is inconclusive evidence to support either extending the duration or broadening the antibiotic prophylaxis for type Gustilo type III wounds. Urgent surgical irrigation and debridement remains the mainstay of infection eradication, although questions persist regarding the optimal irrigation solution, volume, and delivery pressure. Wound sampling has a poor predictive value in determining subsequent infections. Early wound closure is recommended to minimize the risk of infection and cannot be substituted by negative-pressure wound therapy. Antibiotic-impregnated devices can be important adjuncts to systemic antibiotics in highly contaminated or comminuted injuries. Multiple fixation techniques are available, each having advantages and disadvantages. It is extremely important to maintain a high index of suspicion for compartment syndrome, especially in the setting of high-energy trauma.
Topics: Anti-Bacterial Agents; Antibiotic Prophylaxis; Bone Transplantation; Debridement; External Fixators; Fracture Fixation; Fractures, Open; Humans; Negative-Pressure Wound Therapy; Prostheses and Implants; Tetanus Toxoid; Therapeutic Irrigation; Wound Infection
PubMed: 26558667
DOI: 10.3928/01477447-20151020-12 -
The Orthopedic Clinics of North America Jul 2016Open fractures in children are rare and are typically associated with better prognoses compared with their adult equivalents. Regardless, open fractures pose a challenge... (Review)
Review
Open fractures in children are rare and are typically associated with better prognoses compared with their adult equivalents. Regardless, open fractures pose a challenge because of the risk of healing complications and infection, leading to significant morbidity even in the pediatric population. Therefore, the management of pediatric open fractures requires special consideration. This article comprehensively reviews the initial evaluation, classification, treatment, outcomes, and controversies of open fractures in children.
Topics: Child; Fractures, Open; Humans; Multiple Trauma; Wound Infection
PubMed: 27241379
DOI: 10.1016/j.ocl.2016.02.003 -
Surgical Infections Nov 2022Open fractures, defined as fractures communicating with the environment through a skin wound, cause substantial morbidity after traumatic injury. Current evidence...
Open fractures, defined as fractures communicating with the environment through a skin wound, cause substantial morbidity after traumatic injury. Current evidence supports administration of prophylactic systemic antibiotic agents to patients with open extremity fractures to decrease infectious complications. The Therapeutic and Guidelines Committee of The Surgical Infection Society convened to revise guidelines for antibiotic use in open fractures. PubMed was queried for pertinent studies. Evaluation of the published evidence was performed using the GRADE framework. All committee members voted to accept or reject each recommendation. In type I or II open extremity fractures, we recommend against administration of extended-spectrum antibiotic coverage compared with gram-positive coverage alone to decrease infections complications, hospital length of stay or mortality. In type III open extremity fractures, we recommend antibiotic therapy for no more than 24 hrs after injury, in the absence of clinical signs of active infection, to decrease infectious complications, hospital length of stay or mortality, and we recommend against extended antimicrobial coverage beyond gram-positive organisms to decrease infectious complications, hospital length of stay or mortality. In type III open extremity fractures with associated bone loss, we recommend antibiotic therapy in addition to systemic therapy to decrease infectious complications. Although antibiotic agents remain a standard of care for infection prevention after open extremity fractures, our findings and surveys of clinical practice patterns clearly show that additional robust clinical trials are needed to provide stronger corroborating evidence.
Topics: Humans; Fractures, Open; Anti-Bacterial Agents; Antibiotic Prophylaxis; Anti-Infective Agents; Extremities; Surgical Wound Infection; Retrospective Studies
PubMed: 36350736
DOI: 10.1089/sur.2022.206 -
Der Unfallchirurg Aug 2021Open fractures are associated with a higher rate of infections and delayed fracture healing; therefore, in addition to fracture fixation, infection prevention and soft...
Open fractures are associated with a higher rate of infections and delayed fracture healing; therefore, in addition to fracture fixation, infection prevention and soft tissue management are also important. Administration of antibiotics should be carried out as early as possible and over 24-72 h depending on the injury. The initial debridement and assessment of the severity of injury determine the treatment strategy. Fracture fixation follows the general traumatological principles. Simple injury patterns can be treated by primary fixation and wound closure. With substantial contamination, loss of bone or extensive soft tissue damage, temporary fixation and temporary wound closure are carried out. The definitive treatment with soft tissue coverage should be performed within 72 h in order to reduce the risk of fracture-related infections. For osseous segmental defects, different approaches are available to restore bone continuity, depending on the size and soft tissue situation.
Topics: Debridement; Fracture Fixation, Internal; Fractures, Open; Humans; Retrospective Studies; Surgical Wound Infection; Tibial Fractures; Treatment Outcome
PubMed: 34255105
DOI: 10.1007/s00113-021-01042-2 -
Hand Clinics Feb 2018Open fractures of the hand are a common and varied group of injuries. Although at increased risk for infection, open fractures of the hand are more resistant to... (Review)
Review
Open fractures of the hand are a common and varied group of injuries. Although at increased risk for infection, open fractures of the hand are more resistant to infection than other open fractures. Numerous unique factors in the hand may play a role in the altered risk of postinjury infection. Current systems for the classification of open fractures fail to address the unique qualities of the hand. This article proposes a novel classification system for open fractures of the hand, taking into account the factors unique to the hand that affect its risk for developing infection after an open fracture.
Topics: Anti-Bacterial Agents; Debridement; Fracture Fixation; Fractures, Open; Hand Injuries; Humans; Surgical Wound Infection
PubMed: 29169590
DOI: 10.1016/j.hcl.2017.09.013 -
Clinics in Podiatric Medicine and... Oct 2014Open fractures of the lower extremity cover a wide gamut of injuries ranging from the mangled, pulseless leg necessitating amputation to the more innocuous pinhole open... (Review)
Review
Open fractures of the lower extremity cover a wide gamut of injuries ranging from the mangled, pulseless leg necessitating amputation to the more innocuous pinhole open wounds associated with simple fracture patterns. Prompt diagnosis and appropriate care can make a dramatic difference in decreasing complication rates and improving ultimate outcomes. Principles of management of open fractures have been created with the main goal of decreasing infection rates, while providing for stabilization of the bone and soft tissue injury.
Topics: Amputation, Surgical; Ankle Injuries; Debridement; Early Diagnosis; Early Medical Intervention; Foot Injuries; Fracture Fixation; Fracture Healing; Fractures, Open; Humans; Postoperative Complications; Prognosis; Reoperation; Surgical Flaps
PubMed: 25281509
DOI: 10.1016/j.cpm.2014.06.001 -
Journal of Pediatric Orthopedics Oct 2022In the care of open fractures, time to antibiotic administration has been shown to be a critical factor in preventing infection. To help improve outcomes at our... (Review)
Review
BACKGROUND
In the care of open fractures, time to antibiotic administration has been shown to be a critical factor in preventing infection. To help improve outcomes at our institution we designed and implemented an open fracture pathway with the goal of reducing the time from emergency department (ED) arrival to antibiotic administration. Here we evaluate the success of this pathway, propose improvements in the protocol, and provide a framework for initiation at other institutions.
METHODS
We compared a retrospective prepathway cohort with a prospective postpathway cohort for 1-year pre and postpathway implementation. First, we analyzed the number of patients from outside facilities who had received antibiotics before transfer. For patients who had not received antibiotics before arriving at our institution, we reviewed pathway metrics including time from ED arrival to the ordering and administration of antibiotics, whether the correct antibiotic type was selected, and time to surgical debridement.
RESULTS
There were 50 patients in the prepathway cohort and 29 in the postpathway cohort. Prepathway 60.5% of transfers (23 of 38) received antibiotics before transfer, whereas post-pathway 90.0% of transfers (18 of 20) received antibiotics ( P =0.032). For patients who had not received antibiotics before arriving at our institution and were included in pathway metric analysis, there were no differences in demographics or fracture characteristics. Time from ED arrival to antibiotic order decreased from 115.3 to 63.5 minutes ( P =0.016). Time from antibiotic order to administration was similar between groups (48.0 vs. 35.7 min, P =0.191), but the overall time from ED arrival to antibiotic administration decreased from 163.3 to 99.2 minutes ( P =0.004). There were no significant differences in whether the correct antibiotic type was chosen ( P =0.354) or time from ED arrival to surgery ( P =0.783).
CONCLUSIONS
This study provides evidence that for pediatric patients presenting with open fractures, a care pathway can successfully decrease the time from ED arrival to antibiotic administration.
LEVEL OF EVIDENCE
Therapeutic level III-retrospective comparative study.
Topics: Anti-Bacterial Agents; Child; Emergency Service, Hospital; Fractures, Open; Humans; Orthopedics; Prospective Studies; Retrospective Studies
PubMed: 35941088
DOI: 10.1097/BPO.0000000000002217 -
JBJS Reviews Feb 2019Evidence with regard to antibiotic prophylaxis for patients with open fractures of the extremities is limited. We therefore conducted a systematic survey addressing... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Evidence with regard to antibiotic prophylaxis for patients with open fractures of the extremities is limited. We therefore conducted a systematic survey addressing current practice and recommendations.
METHODS
We included publications from January 2007 to June 2017. We searched Embase, MEDLINE, CINAHL, the Cochrane Central Registry of Controlled Trials (CENTRAL), and the Cochrane Database of Systematic Reviews for clinical studies and surveys of surgeons; WorldCat for textbooks; and web sites for guidelines and institutional protocols.
RESULTS
We identified 223 eligible publications that reported 100 clinical practice patterns and 276 recommendations with regard to systemic antibiotic administration, and 3 recommendations regarding local antibiotic administration alone. Most publications of clinical practice patterns used regimens with both gram-positive and gram-negative coverage and continued the administration for 2 to 3 days. Most publications recommended prophylactic systemic antibiotics. Most recommendations suggested gram-positive coverage for less severe injuries and administration duration of 3 days or less. For more severe injuries, most recommendations suggested broad antimicrobial coverage continued for 2 to 3 days. Most publications reported intravenous administration of antibiotics immediately.
CONCLUSIONS
Current practice and recommendations strongly support early systemic antibiotic prophylaxis for patients with open fractures of the extremities. Differences in antibiotic regimens, doses, and durations of administration remain in both practice and recommendations. Consensus with regard to optimal practice will likely require well-designed randomized controlled trials.
CLINICAL RELEVANCE
The current survey of literature systematically provides surgeons' practice and the available expert recommendations from 2007 to 2017 on the use of prophylactic antibiotics in the management of open fractures of extremities.
Topics: Administration, Intravenous; Anti-Bacterial Agents; Antibiotic Prophylaxis; Fractures, Open; Humans; Practice Guidelines as Topic; Publications; Randomized Controlled Trials as Topic; Surveys and Questionnaires
PubMed: 30724762
DOI: 10.2106/JBJS.RVW.17.00197 -
Surgical Infections Apr 2021Management of open fractures remains a major clinical challenge because of the higher energy involved in the injury, the greater local trauma, tissue necrosis, and... (Review)
Review
Management of open fractures remains a major clinical challenge because of the higher energy involved in the injury, the greater local trauma, tissue necrosis, and extensive contamination. Even though early surgical debridement was thought to be critical, limited available operative techniques have minimized surgery in favor of early antibiotic administration. No clear agreement on the surgical approach, debridement, or irrigation technique exists. Surgeons continue to argue about the use of various fluids, the appropriate pressure of irrigation, antiseptics, and other factors. The current work reviews the available data and summarizes the capabilities of modern orthopedic irrigation solutions. To delineate available research on the topic, the PubMed database was queried for the most common techniques, fluid variables, and chemical adjuvants utilized in current open fracture and wound irrigation methodologies. Modes of delivery, volume, pressure, temperature, timing, solution type, and additives are evaluated in the context of known outcomes to determine which solutions may be preferable. Various methods have been described with their own advantages as well as limitations. Particular solutions may apply to specific clinical scenarios, presence of implants, and degree of tissue contamination. Desired irrigation solutions are isotonic, non-toxic, non-hemolytic, transparent, sterilizable, efficient in removing debris and pathogens, as well as affordable; however, no current irrigant achieves all these desired characteristics. Despite being crucial for the healing of open fractures, there is no clear gold standard for irrigation. Although there are some novel irrigation solutions, there has been a paucity of research on finding new, safer, and more effective irrigation solutions that will promote wound healing and reduce infection.
Topics: Anti-Bacterial Agents; Anti-Infective Agents, Local; Fractures, Open; Humans; Surgical Wound Infection; Therapeutic Irrigation
PubMed: 32589513
DOI: 10.1089/sur.2020.075 -
The Orthopedic Clinics of North America Jan 2016Open fractures of the hand are a common and varied group of injuries. Although at increased risk for infection, open fractures of the hand are more resistant to... (Review)
Review
Open fractures of the hand are a common and varied group of injuries. Although at increased risk for infection, open fractures of the hand are more resistant to infection than other open fractures. Numerous unique factors in the hand may play a role in the altered risk of postinjury infection. Current systems for the classification of open fractures fail to address the unique qualities of the hand. This article proposes a novel classification system for open fractures of the hand, taking into account the factors unique to the hand that affect its risk for developing infection after an open fracture.
Topics: Antibiotic Prophylaxis; Debridement; Fingers; Fractures, Open; Hand Injuries; Humans; Metacarpal Bones; Thumb
PubMed: 26614938
DOI: 10.1016/j.ocl.2015.08.021