- See:
- Arterial Trauma:
- Wound Management:
- Antibiotic Prophylaxis
- Common Antiseptics:
- Gun Shot Wounds:
- Discussion of Open Femur Frx:
- rates of wound infection should be < 4 % w/ meticulous debridement of wound;
- rates of union and the functional results have been comparable with those obtained after nailing of closed fractures;
- compartment syndrome of thigh after open frx is rare;
- rate of infection based on gustilo classification:
- in the study by K. Yokoyama et al 1999, all patients with open fractures received debridement but no antibiotic beads;
- rate of infection was 2.3% for grade I and II vs 17.6% for grade III;
- Early vs. Delayed IM roding;
- work up for IM Nailing
- multiply injured patient w/ injury severity score > 18 run high risk of pulmonary complications and benifit significantly from early fracture stabilization;
- frx fixation should be within 24 hrs of injury;
- improved survival results from lower incidence of sepsis due to a decreased rate of pulmonary and cardiovascular insufficiency;
- degree of soft tissue necrosis, crush, & periosteal stripping is well detailed in the Gustilo classification;
- risk of infection vs operative timing:
- the longer wound remains open, greater chance for wound contamination;
- this is reflected in Gustilo classification by categorizing any open fracture whose debridement is delayed for more than 8 hrs as a grade III open fracture;
- Brumback et. al. JBJS 1989;
- concluded that immediate IM nailing of open femoral frx was contraindicated if debridment procedure was delayed > 8 hrs;
- timely, debridment is prerequisite to immediate IM nailing;
- in the study by K. Yokoyama MD et al 1999, there was no significant difference in the infection rate between early and delayed fixation of open femoral fractures;
- in the study by Klemm and Borner (CORR Vol 212 1986), there was a deep infection rate of 8.5% when IM nailing was delayed 7-10 days;
- references:
- Immediate Nailing of Open Fractures of the Femoral Shaft.
- Comparison of mortality of patients with multiple injuries according to type of fracture treatment--a retrospective age- and injury-matched series.
- Blunt multiple trauma (ISS 36), femur traction, and the pulmonary failure-septic state.
- Early versus Delayed Stabilization of Femoral Fractures. A Prospective Randomized Study.
- no pt w/ isolated femoral fracture (ISS < 18) developed pulmonary insufficiency, but 23% of those w/ isolated injuries treated w/ delayed ( > 72 hrs)
had abnormal blood gases as compared to 10% of pts whose frx were treated within 24 hrs;
- in the multiply injured patients, the difference was even greater;
- Lozman et. al. Arch. Surg. 1986
- Goris et. al. J. Trauma. 1982
- Johnson et al. J. Trauma 1985
- Riska et al. J. Trauma 1982
- Guidelines:
- injury, grade I & grade II open frx w/o gross medullary contamination are best treated by immediate IM nailing;
- w/ IM rodding: debridment should be separate procedure from nailing; frx site should be isolated from operative field;
- grade IIIA open femoral frx may be rx'ed w/ immediate IM nailing, if debrided w/ in 8 hrs of injury;
- if debridment is delayed, or if IIIB injury is present, then temporary external fixation is rx of choice;
- most grade I, II, and IIIA have low rates of infection, however, grade IIIB will have significant rates of infection;
- isolated open frx w/ severe contamination require external fixation;
- grade IIIC: frx associated w/ arterial lesions
- external fixation is best method of stabilization
- quickly applied and may be repositioned;
- if patient is unstable, consider amputation;
- Wound Management:
- Wound Dressings:
- Contaminated Wound Care:
- Drains and Closure of Wounds
- Antibiotic Beads:
Immediate Nailing of Open Fractures of the Femoral Shaft.
Intramedullary nailing of open fractures of the femoral shaft.
Comparison of mortality of patients with multiple injuries [m according to type of fracture treatment--a retrospective age- and injury-matched series.
Early complications in the management of open femur fractures: A retrospective study. A Green and PG Trafton. J. Orthop. Trauma. Vol 5. 1991. p 51-56.
Deep infection and fractue healing in immediate and delayed locked intramedullary nailing for open femoral fractures.
K. Yokoyama MD et al. Orthopedics. May 1999. Vol 22. No 5. p 485.
Interlocking nailing for the treatment of femoral fractures due to gunshot wounds.
Management of open fractures with sterilization of large, contaminated, extruded cortical fragments.
The role of intramedullary fixation in open fractures.
Open adult femoral shaft fracture treated by early intramedullary nailing.
Femur fractures caused by gunshots: treatment by immediate reamed intramedullary nailing.
Immediate interlocking nailing of fractures of the femur caused by low- to mid-velocity gunshots.
