13.03.08 Open fractures

Priorities

• • Sepsis

    • Augmentin

      • Or clindamycin if allergic

    • 2nd generation cephalosporin

      • Best balance G+ve / G-ve

      • Cefuroxime

    • Gent + Vanc in theatre

  • Irrigate

    • Normal saline

    • NOT iodine (hyperosmolar => tissue damage)

  • Pain relief

    • IV morphine

  • Reduce

    • May restore downstream circulation (removes kink)

  • Photograph for later comparison

  • Dress

  • Immobilise

    • Or maybe not until after Xray

  • X ray

Gustilo-Anderson Open Fracture Classification

Tetanus

• • Tetanus toxoid booster:

    • Patient has not completed the tetanus toxoid immunization

    • Patient has not had a booster in the last 5 years

  • Human tetanus immune globulin (HTIG):

    • Wound prone to contamination with Clostridium tetani

    • Give 250–500 IU depending on risk

  • Both toxoid and HTIG:

    • More than 10 years elapsed since the last tetanus booster

    • Patient's immune system is compromised

Notes

• • Bone doesn't have to be sticking out (e.g. spike injury)

  • Look for air bubbles on Xray to suggest an open fracture

    • cf Clostridium / Surgical emphysaema

  • AMPLE

  • Six hour golden rule

    • Injury to theatre time

    • No longer considered crucial, unless gross contamination/mangled/vascular compromise

  • MESS = Mangled Extremity Severity Score

  • Don't bother swabbing - You'll only culture the wrong thing

  • Hormones in COCP/pregnancy => Irreversible worsening of otosclerosis

  • POP = Plaster of Paris