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Open Fractures

 - Discussion: 
    - fracture types: open tibia fractures, open fractures of femur 
    - treat all open fractures as an emergency;
    - perform thorough initial eval to dx other life-threatening injuries: (see trauma management);
    - open joint injuries
    - gun shot wounds 
    - controversies: non operative treatment:
          - Nonoperative Management of Pediatric Grade 1 Open Fractures With Less Than a 24-Hour Admission

Sequential Management:
Current Practice in the Initial Management of Open Fractures Among Orthopaedic Trauma Surgeons
- antibiotics:
           - essential that antibiotics be given within one hour of injury;
           - therapeutic doses of ancef, clindamycin, and/or tobramycin for 48 hrs are appropriate;
           - w/ contamination consider anaerobic antibiotics (penicillins, clindamycin, flaggyl);
           - tetanus prophylaxis if appropriate;
           - references:
                  - Once daily high-dose gentamicin to prevent infection in open fractures of the tibial shaft: a preliminary investigation. 
                  - Once daily, high dose versus divided, low dose gentamicin for open fractures.
                  - Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. 
                  - Ciprofloxacin Inhibition of Experimental Fracture Healing.
                  - Clostridial myonecrosis.
                  - The use of antibiotics in open fractures.
                  - Duration of preventive antibiotic administration for open extremity fractures.  
                  - Current Practice in the Initial Management of Open Fractures Among Orthopaedic Trauma Surgeons.
                  - A comparison of more and less aggressive bone debridement protocols for the treatment of open supracondylar femur fractures.

 - debridement and irrigation: 
         - bacterial cultures:
                 - initial bacterial cultures are probably not helpful;
                 - references:
                      - Efficacy of primary wound cultures in long bone open extremity fractures: are they of any value?
                      - Epidemiology of bacterial infection during management of open leg fractures.
                      - Efficacy of cultures in the management of open fractures. 
                      - The significance of perioperative cultures in open pediatric lower-extremity fracture.
         - skin preparation 
         - topical antimicrobials 
         - pressure irrigation 
         - debridement:
                 - debridement of open tibial fractures / debridement of muscle:
                 - immediately debride wound using copious irrigation (9 lit) and, for type-II and type-III frx, repeat debridement in 24-72 hours;
                 - w/ wounds contaminated by dirt (vs grease, asphault ect) need aggressive repeated debridement in order to avoid
                          infection and subsequent osteomyeltis);
                 - references:
                          - Comparison of isotonic saline, distilled water and boiled water in irrigation of open fractures.
                          - The use of bacitracin irrigation to prevent infection in postoperative skeletal wounds. An experimental study.
                          - Efficacy of cultures in the management of open fractures.
                          - The Effect of Surgical Delay on Acute Infection Following 554 Open Fractures in Children.
Comparison of soap and antibiotic solutions for irrigation of lower-limb open fracture wounds. A prospective, randomized study
                          - Outcomes in open tibia fractures: relationship between delay in treatment and infection.
                          - A review of open tibia fractures in children.
                          - The use of detergent irrigation for musculoskeletal wounds.
                          - Treatment of isolated type I open fractures: is emergent operative debridement necessary?
                          - The effect of the timing of antibiotics and surgical treatment on infection rates in open long-bone fractures: a 9-year prospective study from a district general hospital.
                          - Infection in conflict wounded
                          - Time to initial operative treatment following open fracture does not impact development of deep infection: a prospective cohort study of 736 subjects.

 - fracture stabilization: 
         - synthes product menu
         - open tibia fractures 
         - open fractures of femur 
         - references:
                        - The role of early internal fixation in the management of open fractures.  
                        - Immediate internal fixation of open fractures of the diaphysis of the forearm.
                        - The influence of skeletal implants on incidence of infection. Experiments in a canine model.
                        - Nonoperative management of pediatric type I open fractures. 
                        - Maintenance of hardware after early postoperative infection following fracture internal fixation
- timing of wound closure:
            - wound closure of open tibial fractures
                  - in many cases, a delayed primary closure is performed for open wounds, but surgical incisions made during the case can be
                           closed primarily;
                  - issues involve complete removal of foreign debris as well as need to reassess devitalized muscle;
                  - second look debridement can be performed at 48 hours w/ wound closure; 
          - local antibiotics:

                  - antibiotic bead pouch and/or wound vac are useful methods of covering the wound;
                  - references:
                          - Wound management for severe open fractures: use of antibiotic bead pouches and vacuum-assisted closure.
                          - Local antibiotic therapy for severe open fractures. A review of 1085 consecutive cases.
          - soft tissue coverage:
                  - general wound management 
                  - contaminated wound care 
                  - drains and closure of wounds
                  - wound dressings and wound vac 

- bone grafting:
         - management of tibial defects and bone grafting for open tibia fracture
         - it is controversial as to whether bone grafting should be performed in open fractures;
                 - Chapman, et al (1997) 31% of open frx were treated w/ bone graft substitutes and 28% of open fractures were treated
                           w/ autogenous bone grafts;
                  - in this same study, infection at the fracture site occured in 5% of patients in which bone graft substitutes were used versus
                          13% of fractures in which autogenous grafts were used; 
         - references:
                 - Staged Bone Grafting Following Placement of an Antibiotic Spacers for the Management of Segmental Long Bone Defects
                 - Current Practice in the Management of Open Fractures Among Orthopaedic Trauma Surgeons. Part B: Management of Segmental Long Bone Defects. A Survey of Orthopaedic Trauma Association Members.                - Current Practice in the Management of Segmental Bone Defects Among Orthopaedic Trauma Surgeons.

- references: 
Nonoperative Management of Pediatric Type I Open Fractures
Treatment of Compound Fractures.
The early management of open joint injuries. A prospective study of one hundred and forty patients.
The use of quantitative bacterial counts in open fractures.
Risk of Infection After Open Fracture of the Arm or Leg.
Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses.  
Duration of preventive antibiotic administration for open extremity fractures 
Winner of the Frank Horan essay prize: the effect of war on the evolution of the treatment of open fractures
Lead arthropathy: arthritis caused by retained intra-articular bullets.

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