2009 10 22-kennedy-management of open fractures (1)

Management of Open Management of Open FracturesFractures

Christine KennedyChristine KennedyPediatric Emergency FellowPediatric Emergency Fellow

October 22, 2009October 22, 2009

ObjectivesObjectives1)1) Review the different types of Review the different types of

open fracturesopen fractures2)2) Discuss the current treatment Discuss the current treatment

of open fracturesof open fractures3)3) Review the literature Review the literature

supporting non-operative supporting non-operative management of Type 1 open management of Type 1 open fracturesfractures

Introductory CaseIntroductory Case 8 yr boy with a midshaft radius & 8 yr boy with a midshaft radius &

ulna #ulna # Obvious deformity on clinical examObvious deformity on clinical exam Small scab on volar surface of Small scab on volar surface of

forearmforearm– not actively bleedingnot actively bleeding

Xray….Xray….

CaseCase Question was…Does this need to go to Question was…Does this need to go to

the OR?the OR? Ortho consulted…advised to attempt a Ortho consulted…advised to attempt a

closed reduction and give a dose of closed reduction and give a dose of AncefAncef

If successful, mark wound area on cast, If successful, mark wound area on cast, send home on Keflex and F/U in ortho send home on Keflex and F/U in ortho clinic clinic

During the reduction…wound started to During the reduction…wound started to ooze on my foot…ooze on my foot…

Post-reduction X-RaysPost-reduction X-Rays

Case-Follow up at day 39Case-Follow up at day 39

Open Fracture ClassificationOpen Fracture ClassificationGustilo and AndersonGustilo and Anderson

Type IType I– Clean wound <1 cm in lengthClean wound <1 cm in length– # is simple, transverse or oblique with little # is simple, transverse or oblique with little

comminutioncomminution Type IIType II

– Laceration >1cm without extensive soft tissue Laceration >1cm without extensive soft tissue damage, flaps or avulsionsdamage, flaps or avulsions

Type IIIType III– Extensive soft tissue damage, crushing or a Extensive soft tissue damage, crushing or a

traumatic amputationtraumatic amputation Subtypes 3A, 3B, 3CSubtypes 3A, 3B, 3C

Open Fracture ClassificationOpen Fracture Classification Type 3 subtypesType 3 subtypes

– 3A: Adequate soft tissue coverage3A: Adequate soft tissue coverage– 3B: Inadequate soft tissue coverage3B: Inadequate soft tissue coverage– 3C: Arterial injury requiring repair3C: Arterial injury requiring repair

3B

Open Fracture ClassificationOpen Fracture Classification

Open Fracture ClassificationOpen Fracture Classification

Type I Type I

Type IIIb Type IIIc

Open Fracture ClassificationOpen Fracture ClassificationGustilo and AndersonGustilo and Anderson

Type I Type I Infection rate 0-2%Infection rate 0-2%– Clean wound <1 cm in lengthClean wound <1 cm in length– # is simple, transverse or oblique with little # is simple, transverse or oblique with little

comminutioncomminution Type II Type II Infection rate 2-7%Infection rate 2-7%

– Laceration >1cm without extensive soft tissue Laceration >1cm without extensive soft tissue damage, flaps or avulsionsdamage, flaps or avulsions

Type III Type III Infection rate 10-25%Infection rate 10-25%– Extensive soft tissue damage, crushing or a Extensive soft tissue damage, crushing or a

traumatic amputationtraumatic amputationGustilo et al. Current Concepts Review The Management of Open

Fractures. Journal of Bone and Joint Surgery. 1990;72:299-304.

Open Fracture vs AbrasionOpen Fracture vs Abrasion

Open Fracture vs AbrasionOpen Fracture vs AbrasionOpen fractureOpen fracture

– disruption of the dermis with disruption of the dermis with communication into the subcutaneous communication into the subcutaneous tissue contiguous with the bone tissue contiguous with the bone

Open Fracture vs AbrasionOpen Fracture vs AbrasionAbrasionAbrasion Soft tissue injury Soft tissue injury intointo the dermis (not the dermis (not

throughthrough the dermis) the dermis) usually due to friction or shearingusually due to friction or shearing An abrasion on its own over a fracture An abrasion on its own over a fracture

does not communicate with the fracture does not communicate with the fracture because the sc tissue is intactbecause the sc tissue is intact

The pattern of bleeding from an abrasion The pattern of bleeding from an abrasion is pinpoint dermal bleedingis pinpoint dermal bleeding– If you squeeze an abrasion, you may get bleeding but If you squeeze an abrasion, you may get bleeding but

the pattern is different than a laceration that extends the pattern is different than a laceration that extends into the deeper tissueinto the deeper tissue

How do the Orthopedic How do the Orthopedic Surgeons decide?Surgeons decide?

Probing the wound is not Probing the wound is not recommendedrecommended

Pull on the skin adjacent to the wound Pull on the skin adjacent to the wound to see if you can SEE any to see if you can SEE any subcutaneous fat as evidence that the subcutaneous fat as evidence that the dermis is brokendermis is broken

Contact the on call surgeon to discussContact the on call surgeon to discuss

How Common are Open How Common are Open Fractures?Fractures?

For forearm fractures (most common For forearm fractures (most common fracture pattern in children)fracture pattern in children)– 0.5%-4.5% are open0.5%-4.5% are open

Luhmann et al. Complications and Outcome of Open Pediatric Forearm Fractures. J Pediatr Orthop 2004;24:1-6.


TraditionallyTraditionally– Considered a “true surgical emergency”Considered a “true surgical emergency”– Required operative debridement and Required operative debridement and

fracture stabilizationfracture stabilization– ““Golden Period” was 6-12 hours from Golden Period” was 6-12 hours from

time of patient arrivaltime of patient arrival


Now….Now…. Type II & IIIType II & III

– Require surgical debridementRequire surgical debridement

Wounds with high energy injuries result Wounds with high energy injuries result in devitalized tissue, local edema & in devitalized tissue, local edema & ischemiaischemia

This alters the ability of local host This alters the ability of local host defenses to resist infectiondefenses to resist infection


Type 1Type 1– Operative vs non-operative, why the Operative vs non-operative, why the

controversy?controversy?

Type 1 Open FracturesType 1 Open Fractures Maintain a relatively intact soft tissue Maintain a relatively intact soft tissue

envelope therefore the vascular supply envelope therefore the vascular supply to the zone of injury is preservedto the zone of injury is preserved

This decreases the risk factors for This decreases the risk factors for development of infectiondevelopment of infection– Devitalized tissueDevitalized tissue– IschemiaIschemia– EdemaEdema

Type 1 Open FracturesType 1 Open Fractures Allows adequate penetrance of the Allows adequate penetrance of the

host defense mechanisms and IV host defense mechanisms and IV antibiotics to protect further against antibiotics to protect further against possible infectionpossible infection

Type 1 Open FracturesType 1 Open Fractures Routine operative debridement might Routine operative debridement might

cause increased soft tissue trauma, cause increased soft tissue trauma, periosteal stripping and osseous periosteal stripping and osseous devascularizationdevascularization

Type 1 Open FracturesType 1 Open Fractures Children have better healing Children have better healing

potential than adultspotential than adults– Differences in the malleability & Differences in the malleability &

strength of the bonestrength of the bone– Better vascular supply to the extremitiesBetter vascular supply to the extremities– Thicker periosteumThicker periosteum

In the old orthopedic In the old orthopedic literature…literature…

Cases of gas gangrene in children Cases of gas gangrene in children with open fractures managed non-with open fractures managed non-operativelyoperatively

Before the routine use of antibioticsBefore the routine use of antibiotics

Infection Rate with Operative Infection Rate with Operative ManagementManagement

Literature’s infection rate for type 1 Literature’s infection rate for type 1 open fractures treated operatively is open fractures treated operatively is an average of 1.9%*an average of 1.9%*

Infection Rate with Operative Infection Rate with Operative ManagementManagement

Organisms Cultured from Open Organisms Cultured from Open FracturesFractures

The majority of bacteria The majority of bacteria culturedcultured are normal skin flora are normal skin flora – Staphylococcus epidermidisStaphylococcus epidermidis– Proprionibacterium acnesProprionibacterium acnes– Corynebacterium speciesCorynebacterium species


Farm related injuries increase the Farm related injuries increase the risk ofrisk of– Clostridium perfringensClostridium perfringens

Exposure to fresh water increases Exposure to fresh water increases the risk ofthe risk of– Pseudomonas aeruginosaPseudomonas aeruginosa– Aeromonas hydrophiliaAeromonas hydrophilia


The frequent growth of The frequent growth of S. aureusS. aureus & & P. P. aeruginosaaeruginosa from patients who have from patients who have an infection contrasts with the an infection contrasts with the infrequent growth of these organisms infrequent growth of these organisms on initial wound cultureon initial wound culture

Suggests that these infections are Suggests that these infections are acquired in the hospitalacquired in the hospital

Importance of AntibioticsImportance of Antibiotics Prospective, double blind, Prospective, double blind,

randomized studyrandomized study Infection rate was Infection rate was

– 13.9% in placebo group13.9% in placebo group– 9.7% in group treated with Penicillin & 9.7% in group treated with Penicillin &

StreptomycinStreptomycin– 2.3% in group treated with a 12.3% in group treated with a 1stst

generation cephalosporingeneration cephalosporin

Patzakis et al. The Role of Antibiotics in the Management of Open Fractures. The Journal of Bone and Joint Surgery 1974;56:532-541.

Importance of AntibioticsImportance of Antibiotics Meta-analysisMeta-analysis demonstrated a demonstrated a

significant reduction in wound infections significant reduction in wound infections in patients who received antibiotics for in patients who received antibiotics for all types of open fracturesall types of open fractures

13.4% of patients who were not treated 13.4% of patients who were not treated with antibiotics developed an infectionwith antibiotics developed an infection

5.5% of treated patients developed an 5.5% of treated patients developed an infectioninfection

NNT 13 [8-25]NNT 13 [8-25]

Which Antibiotic?Which Antibiotic? Most common pathogens Most common pathogens causing causing

infectionsinfections after open fractures after open fractures– Staphylococcus aureusStaphylococcus aureus– Facultative gram-negative bacilliFacultative gram-negative bacilli

In type I open fracturesIn type I open fractures– 11stst generation cephalosporin sufficient generation cephalosporin sufficient

In type II & IIIIn type II & III– Combinations therapy with a cephalosporin Combinations therapy with a cephalosporin

and an aminoglycoside OR 3and an aminoglycoside OR 3rdrd generation generation cephalosporincephalosporin

Timing of Antibiotics is Timing of Antibiotics is ImportantImportant

One study with over 1000 open fractures One study with over 1000 open fractures found that starting antibiotics within 3 found that starting antibiotics within 3 hours of injury lowered the infection hours of injury lowered the infection rate*rate*– Infection rate 4.7% if antibiotics w/in 3 hoursInfection rate 4.7% if antibiotics w/in 3 hours– Infection rate 7.4% if antibiotics started >3h Infection rate 7.4% if antibiotics started >3h

after injuryafter injury Of note, surgical debridement was Of note, surgical debridement was

performed for all open fractures in this performed for all open fractures in this studystudy

Guidelines for Antibiotic Guidelines for Antibiotic Length?Length?

No standardized protocol for length No standardized protocol for length of Abx following open fracturesof Abx following open fractures

One report published which One report published which demonstrated no difference b/w 1 & demonstrated no difference b/w 1 & 5 days of IV Abx5 days of IV Abx

In the adult literature, anywhere In the adult literature, anywhere from 1-3 days of antibiotics is the from 1-3 days of antibiotics is the recommendationrecommendation

Non Operative Management of Non Operative Management of Type 1 Open FracturesType 1 Open Fractures

What does the literature say these What does the literature say these days?days?

Reviews the results of non operative Reviews the results of non operative management of type I open fractures in management of type I open fractures in childrenchildren

Retrospective chart review (1998-2003)Retrospective chart review (1998-2003) 40 patients followed until healed40 patients followed until healed

– clinically & radiographicallyclinically & radiographically 1 deep infection occurred1 deep infection occurred

– overall infection rate 2.5%overall infection rate 2.5%

0% infection rate in the 32 upper 0% infection rate in the 32 upper extremity type I open fracturesextremity type I open fractures

0% infection rate in the 23 patients 0% infection rate in the 23 patients under 12 yearsunder 12 years

Details of Study #1Details of Study #1 40 patients diagnosed with type 1 open 40 patients diagnosed with type 1 open

fracturefracture– 33 boys, 7 girls33 boys, 7 girls

Age 10 years [range 4-15y]Age 10 years [range 4-15y] Fracture distributionFracture distribution

– 8 tibia 8 tibia – 18 diaphyseal radius & ulna18 diaphyseal radius & ulna– 14 distal radius & ulna14 distal radius & ulna

MechanismMechanism– Most low-moderate energyMost low-moderate energy

Falls from bikes, skateboards, rollarblades, scootersFalls from bikes, skateboards, rollarblades, scooters– 7 kids hit by motor vehicle7 kids hit by motor vehicle

Details of Study #1Details of Study #1Treatment: Initiated in the EDTreatment: Initiated in the ED1)1) Initiation of IV antibioticsInitiation of IV antibiotics2)2) Cleansing and/or irrigation of the Cleansing and/or irrigation of the

open wound with Betadine & salineopen wound with Betadine & saline3)3) Protecting the wound with Xeroform Protecting the wound with Xeroform

& sterile gauze& sterile gauze4)4) Tetanus prophylaxis if neededTetanus prophylaxis if needed5)5) Closed reduction & immobilizationClosed reduction & immobilization

Details of Study #1Details of Study #1 Patients were admitted to hospital Patients were admitted to hospital

for 48-72 hours for observation, for 48-72 hours for observation, continued IV antibiotics and wound continued IV antibiotics and wound managementmanagement

Patients were discharged w/o abx Patients were discharged w/o abx – but 4/40 were sent home on 1 week of but 4/40 were sent home on 1 week of

Keflex, at the treating surgeon’s Keflex, at the treating surgeon’s discretiondiscretion

Details of Study #1Details of Study #1 Patients were followed until fracture Patients were followed until fracture

unionunion– Clinically: no longer tender at fracture Clinically: no longer tender at fracture

sitesite– Radiologically: bridged by sufficient Radiologically: bridged by sufficient

calluscallus

Details of Study #1Details of Study #1 DefinitionsDefinitions Deep infection: proceeded to Deep infection: proceeded to

debridementdebridement– Increasing pain, drainage from the wound Increasing pain, drainage from the wound

and radiologic changes within the boneand radiologic changes within the bone Superficial infectionsSuperficial infections

– Inflammation of the skin/subcutaneous Inflammation of the skin/subcutaneous tissue w/o radiologic evidence of tissue w/o radiologic evidence of osteomyelitisosteomyelitis

Results of Study #1Results of Study #1 Average hospital stay: 2.5 days (1-5)Average hospital stay: 2.5 days (1-5) No documented feversNo documented fevers No patients developed malunion/nonunionNo patients developed malunion/nonunion No patients developed osteomyelitisNo patients developed osteomyelitis No wound complications during admissionNo wound complications during admission No superficial infectionsNo superficial infections 1 deep infection of the tibia (at 3 months)1 deep infection of the tibia (at 3 months)

Results of Study #1Results of Study #1

How does this healing compare How does this healing compare to fracture healing after OR to fracture healing after OR

irrigation?irrigation?

Results of Study #1Results of Study #1

Results of Study #1Results of Study #1 The 1 infectionThe 1 infection

– 15 yr male, comminuted midshaft tibia #15 yr male, comminuted midshaft tibia #– Fall down the stairsFall down the stairs– Small nidus of dead bone found anterior Small nidus of dead bone found anterior

to the fracture site--->caused a draining to the fracture site--->caused a draining sinus to form over the anterior tibiasinus to form over the anterior tibia

– Sinus tract was excised & the dead bone Sinus tract was excised & the dead bone debrided in the ORdebrided in the OR

– Patient made a full recoveryPatient made a full recovery

Conclusions Study #1Conclusions Study #1 Non operative management of Pediatric Non operative management of Pediatric

type I open fractures is safe and effectivetype I open fractures is safe and effective Non operative management does not Non operative management does not

appear to affect the healing potentialappear to affect the healing potential Children over age 12 with lower Children over age 12 with lower

extremity type I open fractures are at risk extremity type I open fractures are at risk for failing non-operative managementfor failing non-operative management– Should consider traditional irrigation and Should consider traditional irrigation and

debridement of the wound in the ORdebridement of the wound in the OR

Evaluates the results of non operative Evaluates the results of non operative management of grade 1 open fractures management of grade 1 open fractures treated in the ED or with a <24hour treated in the ED or with a <24hour admission (for IV antibiotics)admission (for IV antibiotics)

Retrospective chart review (2000-2006)Retrospective chart review (2000-2006) 25 patients followed until healed (clinically 25 patients followed until healed (clinically

and radiographically)and radiographically) 1 patient had persistent draining from the 1 patient had persistent draining from the

wound site & fever (overall infection rate wound site & fever (overall infection rate 4%)4%)

Details of study #2Details of study #2 25 patients diagnosed with type 1 25 patients diagnosed with type 1

open fractureopen fracture– 20 boys, 5 girls20 boys, 5 girls

Age range 2-15yAge range 2-15y Fracture distributionFracture distribution

– 5 tibial shaft +/- fibula5 tibial shaft +/- fibula– 18 radius & ulna18 radius & ulna– 2 Monteggia fracture/dislocations2 Monteggia fracture/dislocations

Details of study #2Details of study #2 14 patients were admitted (<24h)14 patients were admitted (<24h) 11 were treated exclusively in the ED11 were treated exclusively in the ED

Details of study #2Details of study #2Treatment: Initiated in the EDTreatment: Initiated in the ED1)1) Initiation of IV antibioticsInitiation of IV antibiotics2)2) Irrigation of the wound with sterile Irrigation of the wound with sterile

salinesaline3)3) Protecting the wound with Xeroform Protecting the wound with Xeroform

or Betadine soaked gauzeor Betadine soaked gauze4)4) Tetanus prophylaxis if neededTetanus prophylaxis if needed5)5) Closed reduction & immobilizationClosed reduction & immobilization

Details of study #2Details of study #2 IV antibiotics usedIV antibiotics used

– 20/25 patients received Ancef20/25 patients received Ancef– OthersOthers

Ampicillin/sulbactamAmpicillin/sulbactam CeftriaxoneCeftriaxone GentamicinGentamicin

Details of study #2Details of study #2 Patients who were admitted Patients who were admitted

overnight remained on IV antibiotics overnight remained on IV antibiotics until dischargeuntil discharge

At discharge oral antibiotics were At discharge oral antibiotics were given to 20 of 25 patientsgiven to 20 of 25 patients– 19 received Keflex19 received Keflex– 1 received Clindamycin1 received Clindamycin– Duration ranged from 1-7 daysDuration ranged from 1-7 days

Details of study #2Details of study #2Follow up schedule:Follow up schedule: 7-10 days: radiograph & wound check 7-10 days: radiograph & wound check

(windowing)(windowing) 14-17 days: radiograph in cast14-17 days: radiograph in cast 6-8 weeks: radiograph out of cast6-8 weeks: radiograph out of cast

Followed until healedFollowed until healed– Non-tender, full ROM at joint above & belowNon-tender, full ROM at joint above & below– Bridging bone on radiographBridging bone on radiograph

Results of study #2Results of study #2 1 patient diagnosed clinically with an infection 1 patient diagnosed clinically with an infection

(culture negative)(culture negative) 8 yr boy8 yr boy Tibia fracture (from football tackle)Tibia fracture (from football tackle) At F/U on day 6:erythema & serosanguineous At F/U on day 6:erythema & serosanguineous

drainage from wounddrainage from wound Admitted and treated with 2 days of IV Clinda* Admitted and treated with 2 days of IV Clinda* Complete resolution of drainage/erythemaComplete resolution of drainage/erythema Discharged with 1 week course of oral Clinda Discharged with 1 week course of oral Clinda Fracture union at 11 weeks (no further Fracture union at 11 weeks (no further

complications)complications)

Results of study #2Results of study #2Average time to unionAverage time to union Tibia fractures: 67 daysTibia fractures: 67 days Forearm fractures: 45 daysForearm fractures: 45 days Monteggia fracture/dislocations: 29 Monteggia fracture/dislocations: 29

daysdays

ConclusionsConclusions Non-operative management of grade 1 open Non-operative management of grade 1 open

fractures is safe in pediatricsfractures is safe in pediatrics Eliminates any possible general anesthetic Eliminates any possible general anesthetic

riskrisk Significantly decreases the cost of caring for Significantly decreases the cost of caring for

these patients in the health care systemthese patients in the health care system– OR costsOR costs– Cost of prolonged hospital admissionsCost of prolonged hospital admissions– Social costs of a hospitalized childSocial costs of a hospitalized child

Current protocolCurrent protocol Treat low energy grade 1 open fracturesTreat low energy grade 1 open fractures

– sustained in a clean environment with no gross sustained in a clean environment with no gross contaminationcontamination

In the ED as an outpatient In the ED as an outpatient Conscious sedation and reductionConscious sedation and reduction Superficial cleansing Superficial cleansing Single dose of IV AbxSingle dose of IV Abx 3-5 days of oral antibiotics3-5 days of oral antibiotics

Adult LiteratureAdult Literature There is precedent for non-operative There is precedent for non-operative

treatment of grade 1 open fracturestreatment of grade 1 open fractures

0% infection rate in 91 open grade 1 0% infection rate in 91 open grade 1 fracturesfractures

Details of Study #3Details of Study #3 Retrospective review (1990-1997)Retrospective review (1990-1997) 91 patients with isolated Type I open 91 patients with isolated Type I open

fracturesfractures– 78 adults, 13 children78 adults, 13 children– 60 males, 31 females60 males, 31 females

Exclusion criteria:Exclusion criteria:– multiple injuriesmultiple injuries– gunshot wounds gunshot wounds – hand injurieshand injuries– compartment syndrome compartment syndrome – Intra-articular fracturesIntra-articular fractures

Details of Study #3Details of Study #3 All received antibiotics and were All received antibiotics and were

followed until fracture unionfollowed until fracture union Charts were reviewed forCharts were reviewed for

– Type of fractureType of fracture– Mechanism of injuryMechanism of injury– Type of treatmentType of treatment– Length of hospital stayLength of hospital stay– Complications encounteredComplications encountered

Details of Study #3Details of Study #3

Details of Study #3Details of Study #3 All patients received antibiotics (within All patients received antibiotics (within

6h)6h)– Adults 1g cefazolinAdults 1g cefazolin– Children 1g (11), 750mg (1), 500 mg (1)Children 1g (11), 750mg (1), 500 mg (1)

All were admitted for at least 48 hoursAll were admitted for at least 48 hours

Wounds greater than a puncture site were Wounds greater than a puncture site were irrigated with several liters of salineirrigated with several liters of saline– Majority did not receive irrigationMajority did not receive irrigation

Wounds were dressed with sterile gauzeWounds were dressed with sterile gauze

Details of Study #3Details of Study #3 32 pts had surgery for definitive 32 pts had surgery for definitive

treatment of their fracturetreatment of their fracture– 1 pt had surgery w/in 8 hours “golden 1 pt had surgery w/in 8 hours “golden

period”period”– All others had surgery after 12 hoursAll others had surgery after 12 hours

Average time was 5 days [12h-15days]Average time was 5 days [12h-15days] None of the wounds had evidence of None of the wounds had evidence of

infectioninfection Open wound was not debrided unless it Open wound was not debrided unless it

was included in the operative exposurewas included in the operative exposure

Results of Study #3Results of Study #3 Hospital stayHospital stay

– 9 days on average9 days on average– 11 days for those who had surgery*11 days for those who had surgery*– 4.5 days for those without surgery4.5 days for those without surgery

Follow upFollow up– Averaged 7 months [2mo - 5y]Averaged 7 months [2mo - 5y]

Results of Study #3Results of Study #3 ComplicationsComplications

– Developed in 10 pts (8 in lower Developed in 10 pts (8 in lower extremities)extremities)

– 6/10 pts needed surgery for definitive 6/10 pts needed surgery for definitive treatmenttreatment

Infection rateInfection rate– 0%0%

Conclusions Study #3Conclusions Study #3 Immediate operative debridement Immediate operative debridement

may not be necessary in isolated, may not be necessary in isolated, low-energy Type 1 open fractures low-energy Type 1 open fractures with stable fracture patternswith stable fracture patterns

Results of Study #3Results of Study #3Current Protocol:Current Protocol: Low energy type 1 open fracture do Low energy type 1 open fracture do

not need operative debridementnot need operative debridement Do not classify open fractures by the Do not classify open fractures by the

size of the soft tissue wound alonesize of the soft tissue wound alone– Comminuted fractures are taken to the Comminuted fractures are taken to the

OR and reclassified after operative OR and reclassified after operative debridementdebridement

Guidelines for antibiotic Guidelines for antibiotic length?length?

In the 2 pediatric studies we just In the 2 pediatric studies we just reviewedreviewed– 1 dose of IV antibiotics was sufficient in 1 dose of IV antibiotics was sufficient in

1 study (20/25 d/c’d on 1-7 days of PO 1 study (20/25 d/c’d on 1-7 days of PO Abx)Abx)

– ~48 hours of IV antibiotics was sufficient ~48 hours of IV antibiotics was sufficient for the other study (only 4/40 were d/c’d for the other study (only 4/40 were d/c’d on PO Abx)on PO Abx)

Calgary Consensus Calgary Consensus Call on call surgeon for personal preferenceCall on call surgeon for personal preference 1 dose of IV Ancef, then 3-7 days PO antibiotics1 dose of IV Ancef, then 3-7 days PO antibiotics Routine windowing of the cast is not doneRoutine windowing of the cast is not done

– Surgeon dependentSurgeon dependent Have the patient return to the ED if there are Have the patient return to the ED if there are

anyany problems within the first 3 days for urgent problems within the first 3 days for urgent evaluation (pain, fever, tachycardia, odour)evaluation (pain, fever, tachycardia, odour)

The size of the wound by itself is not indication The size of the wound by itself is not indication for non-operative debridement for non-operative debridement

Back to the ObjectivesBack to the Objectives1)1) Review the different types of Review the different types of

open fracturesopen fractures2)2) Discuss the current treatment Discuss the current treatment

of open fracturesof open fractures3)3) Review the literature Review the literature

supporting non-operative supporting non-operative management of Type 1 open management of Type 1 open fracturesfractures

SummarySummary The literature suggest that treating type The literature suggest that treating type

1 open fractures with IV antibiotics and 1 open fractures with IV antibiotics and closed reductions is safeclosed reductions is safe– But no randomized controlled trialsBut no randomized controlled trials

Different surgeons ---> different Different surgeons ---> different approaches, therefore discuss with the approaches, therefore discuss with the on call surgeon firston call surgeon first

Use of antibiotics is not advocated as a Use of antibiotics is not advocated as a substitute for proper clinical judgment substitute for proper clinical judgment

2009 10 22-kennedy-management of open fractures (1)

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