Gustilo type IIIA open femur fracture.
A 48-year-old man presents to the emergency department by way of ambulance after a motorcycle accident. He was thrown off his bike after hitting another vehicle and sustained a left open femur fracture. He was wearing a helmet and denies loss of consciousness. On examination, you note a Gustilo type IIIA open femur fracture, shown in Figure 1. Anteroposterior and lateral trauma X-rays are shown in Figures 2 and 3. After orthopedic consultation, the patient is scheduled for an urgent irrigation and debridement (I&D).
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The treatment goal of any open fracture is to make sure that the wound is cleaned early, the fracture is stabilized, and all measures are taken to prevent a deep infection postoperatively. Complications of an open fracture may include superficial wound infection, nonunion of the fracture, deep soft tissue infection, and osteomyelitis. Factors such as early irrigation and debridement, early antibiotic administration, fracture severity, neurovascular injury, obesity, and diabetes have all been shown to influence the rate of a postoperative deep infection. Time to surgery, however, may be the least important of these factors. Emergent debridement within 6 hours has long been used as a general guideline for all open fractures. However, time to operative debridement can be influenced by a variety of factors including time to emergency room arrival, the patient’s medical status in regards to operating room clearance, and availability of the operating room team. Orthopedic surgeons are often unable to bring patients with open fractures to the operating room within 6 hours due to these factors.
The general belief that I&D must occur within 6 hours of injury to reduce the risk of postoperative infection has been proven untrue in numerous studies. Weber et al published a large prospective cohort study of almost 800 open long bone fractures and concluded that the development of deep infection was not associated with time to initial surgery. Weber et al and other studies have shown that factors such as injury severity (increasing Gustilo type fracture), late antibiotic administration, neurovascular injury, obesity, and diabetes do increase the rate of deep infection postoperatively. These studies have changed the way many open fractures are treated. Often times, patients with these fractures were taken to the OR in the middle of the night under suboptimal conditions for the surgeon and surgical team to meet the 6-hour window. These studies confirm that emergent I&D within 24 hours is as safe and effective as urgent I&D within 6 hours. I&D done within 24 hours, and during daytime hours when all operative resources are readily available to the surgeon, is appropriate and preferable. High-energy open long bone fractures with evidence of wound contamination generally require multiple I&Ds prior to wound closure. Common protocols call for I&D, obtaining surgical site cultures, and fracture stabilization within 24 hours of injury. Patients are usually taken back for repeat I&D at 48 hours, and cultures are repeated if the initial cultures were positive. Definitive fixation and wound closure can be performed if operative cultures come back negative, there is adequate soft tissue coverage for closure, and if the surgeon deems appropriate.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Werner CM, Pierpont Y, Pollak AN. The urgency of surgical debridement in the management of open fractures. J Am Acad Orthop Surg. 2008;16:369-375.
- Weber D, Dulai SK, Bergman J, Buckley R, Beaupre LA. Time to initial operative treatment following open fracture does not impact development of deep infection: a prospective cohort study of 736 subjects. J Orthop Trauma. 2014;28:613-619.