1. Antibiotics should be administered intravenously as soon as an open fracture is identified, ideally within 1 hour of the injury without delaying transfer to hospital.
2. Splinting is a highly effective form of analgesia and should be performed prehospital.
3. Clinical examination of the neurological and vascular status must be thorough, performed repeatedly, and documented, particularly after an intervention has taken place.
4. Transport people with suspected open fractures directly to a major trauma centre or specialist centre that can provide orthoplastic care if a long bone, hindfoot, or midfoot are involved, or to the nearest trauma unit or emergency department if the suspected fracture is in the hand, wrist, or toes, unless there are prehospital triage indications for direct transport to a major trauma centre.
5. For isolated open fractures, orthogonal views on radiographs should be obtained. In patients where an initial ‘trauma CT’ (computed tomography) is indicated there should be protocols to maximise the useful information and minimise delay; the initial sequence should include a head to toes scanogram. This should be used with clinical correlation to direct further specific limb sequences during that initial CT examination.
6. There should be a local policy on the inclusion of angiography in any extremity CT related to open fractures.
7. Irrigation of the wound should not be performed prehospital or in the emergency department. It should be reserved until after surgical excision of the wound in the operating theatre.
An open long bone fracture is a serious injury not only because of the associated significant soft tissue damage but because the exposed bone is contaminated and the risk of infection increased greatly. Urgent assessment and appropriate treatment can reduce disability and improve quality of life for patients with open fractures.
Patients with open fractures should be treated in centres that can offer the full spectrum of orthoplastic services, including soft tissue and bone reconstruction. Such teams are found in major trauma centres and in some specialist orthoplastic centres. These are the preferred primary destinations for such patients (1). Although much of the evidence described here is based upon open fracture of the tibia, the principles described also apply to open fractures of other long bones, including those of the upper limb (excluding the hand and wrist), even though complex soft tissue reconstruction is required less commonly.
Not all open fractures occur in the context of high-energy trauma, but many do and a systematic approach to assess, identify, and treat the most serious injuries first is imperative. The management of the open fracture is considered concurrently with other patient co-morbidities and associated injuries. In the UK, the Major Trauma Networks have guidance based upon the international Advanced Trauma Life Support (ATLS)® system; this includes prehospital assessment, transport of patients, rapid whole-body cross-sectional imaging, and major transfusion protocols (2, 3).
After scene safety, the CABCDE (Circulation (exsanguinating haemorrhage), Airway, Breathing, Circulation, Disability, Exposure) principles should be followed. Although angulated fractures may draw the prehospital clinician’s attention, life-threatening conditions should take priority (1, 2, 3). Exsanguinating external haemorrhage should be controlled prior to the management of airway or breathing.
Assessment of the limb
Limb assessment in the prehospital environment is dictated by the setting, other injuries, and obvious flags such as patient signs and symptoms. Once the patient’s primary survey findings have been addressed, a secondary assessment of the limb can be undertaken. The paradigm of ‘look, feel, and move’ on limbs should identify important injuries at this stage (1), but this is omitted in the presence of obvious fractures to avoid more pain. Wounds are of relevance and raise the possibility of an open fracture. If there is doubt about an open fracture, it is safer to proceed as though open until proven otherwise; a photograph of the wound in the prehospital setting may aid decisions in treatment.
A key initial assessment is for vascular injury by the presence or absence of each of the distal pulses. Vascular deficit mandates immediate realignment. The capillary refill time can be misleading and hard signs (palpable pulses, expanding haematoma, continued bleeding) should be relied upon. Neurological assessment of motor function should test for active movements and of sensation by response to touch.
Management of limb
Adequate analgesia is important in all patients suspected of a fracture; additionally, reduction of deformity and splintage reduce bleeding and pain. If the bone ends of an open fracture retract into the wound during splinting, this information must be documented. A traction device is used if the injury is above the knee. All other long bone injuries should be splinted with a vacuum splint (1, 2). When an intervention is performed, e.g. application of a splint, the vascular and neurological assessments should be repeated and documented.
Irrigation of open fractures at the prehospital stage is not recommended but gross contamination should be removed. Clean saline-soaked gauze held with an occlusive layer should be applied to the wound. Information about potential contamination by agricultural, marine, or sewage matter needs to be relayed to the admitting team as this has direct implications for the urgency of surgical wound excision.
Antibiotics are given as soon as possible and preferably within an hour of injury. The administration of prophylactic antibiotics for patients with open fractures is supported by a Cochrane Systematic review (4), which reported an absolute risk reduction of 0.08 based on data from 913 participants in seven published studies (see the section on ‘Antibiotics’ for choice of antibiotics). Timing of administration of the antibiotics was found to be an independent risk factor in a retrospective study, with delay beyond 1 hour after injury associated with an increased risk of infection (odds ratio 3.78, CI 1.16–12.31) (5). The National Institute for Health and Care Excellence (NICE) recommends the administration of antibiotics within 1 hour of the injury but this should not delay transfer to hospital (4).
◆ direct pressure onto the wound;
◆ wound packing;
◆ prehospital tourniquet (windlass type);
◆ hospital tourniquet (pneumatic type).
The use of tourniquets or haemostatic agents should be considered only when all other methods have failed and the patient is still exsanguinating. If a tourniquet is applied, this is an urgent indication for surgical exploration in the operating theatre.
In crush injury to the limbs, intravenous fluid replacement should be considered early. Muscle damage leads to rhabdomyolysis, myoglobinaemia, and hyperkalaemia (6).
Clinical examination of limb
After the primary survey, a repeat assessment of the limb should be performed. A photograph of the fracture wound should be added to the medical record if not already done. All hospitals are required to provide systems to enable upload of such photographs to the medical record in accordance with data protection regulations (4). Contaminants such as large foreign bodies are removed but irrigation is not performed. Antiseptics or antibiotics are not to be used in the wound dressing. Clean dressings should be reapplied if removed.
Compartment syndrome can occur in open fractures and clinicians should be aware of this possibility in the emergency department. A repeat assessment of the limb is independent of previous documented findings so that changes of arterial and neurological status can be identified promptly.
Following reassessment of the limb, temporary splints may be removed but, in many cases, a traction splint or vacuum splint may be the best way to support the limb pending definitive surgery.
Although prompt administration of antibiotics after injury is essential, there is insufficient evidence to support prolonged administration (7). Antibiotics for 1 day appear as effective as 3–5 days (8, 9, 10, 11).
A retrospective review of patients with Gustilo grade IIIB fractures showed that the majority of deep infections were caused by nosocomial organisms, most being resistant to the initial antibiotic prophylaxis aimed at environmental flora (11). This has led to our recommendation of a two-phase antibiotic protocol with a second wave of prophylaxis against nosocomial organisms at the time of definitive wound closure.
We recommend that trauma surgeons refer to local antibiotic guidelines, which should be written in conjunction with the microbiology department and pharmacy and take into account local epidemiology and formularies. Guidelines should include paediatric recommendations written with additional paediatric input. Doses for children are available in the paediatric British National Formulary (https://bnfc.nice.org.uk/).
We recommend local guidelines should be based on the following phased antibiotic regimen (only normal adult doses stated).
Within 1 hour of injury and continue until wound excision.
◆ First line:
(a) co-amoxiclav (1.2 g) 8-hourly intravenously (iv) or
(b) an intravenous cephalosporin, e.g. ceftriaxone 2 g daily.
◆ Patients with a history of non-severe penicillin allergy (e.g. rash) should receive a cephalosporin not co-amoxiclav.
◆ Those with a history of anaphylaxis or other severe reaction to penicillin should receive clindamycin 900 mg iv 8-hourly (+ gentamicin 3 mg/kg single dose for presumed Gustilo grade III fractures (12)).
◆ For patients at high risk of methicillin-resistant Staphylococcus aureus (MRSA) or those known to be positive for MRSA, a glycopeptide should be added, e.g. teicoplanin 800 mg iv daily (with extra loading dose after first 12 hours).
◆ Unusual environmental exposures should prompt early discussion with microbiology.
At the first excision of the wound, on induction of anaesthesia, a single dose of gentamicin 3 mg/kg1 § should be added to the above (unless they have already received gentamicin in the past 16 hours).
Further intra-operative doses of co-amoxiclav should be given if there is major blood loss (>10% blood volume) or if the procedure lasts more than 3 hours. Do not give additional doses of once-daily antibiotics, e.g. gentamicin, ceftriaxone, or teicoplanin, unless it has been more than 16 hours since the last dose).
Treatment with antibiotics after wound excision (phase 1) should continue for 24 hours.
◆ At the time of definitive skeletal stabilisation and definitive soft tissue coverage the patient should receive a single intravenous dose at induction of a glycopeptide, e.g. teicoplanin 800 mg (if it has been more than 12 hours since the last dose) plus gentamicin 3 mg/kg (if it has been more than 16 hours since the last dose). This is to provide cover for organisms selected out from initial prophylaxis and for nosocomial pathogens (13).
No further postoperative antibiotics are required.
Some authorities recommend 5 mg/kg gentamicin for prophylaxis (14). However, there is evidence that there may be an increased risk of nephrotoxicity when prophylactic gentamicin is introduced to protocols (15, 16, 17). A retrospective study of 167 open fractures showed that prophylactic gentamicin was not associated with acute kidney injury (AKI). AKI was associated with hypotension on admission and a higher Injury Severity Score (18). Potential nephrotoxicity should be balanced against the benefit of increasing the breadth and effectiveness of antimicrobial cover. Common practice in prophylaxis is to use a lower single dose of 3 mg/kg as suggested in this guideline.
Venous thromboembolism (VTE) is a risk for any patient with major trauma or a lower limb injury. Surveillance studies indicate 58% of patients with major trauma are affected; advanced age and obesity add further to this risk (19). All patients must be considered for thromboprophylaxis. Pharmacological VTE prophylaxis is the most widely used method for trauma patients and is supported by national guidance, although caution is needed where patients are coagulopathic or there may be bleeding from associated vascular, intracranial, or visceral injuries (20). Low molecular weight heparins such as enoxaparin have been shown to be superior to low-dose heparin and are used for this purpose (21). New oral anticoagulants (NOACs) should be used with caution as the timing of definitive surgery may not be clear in the early stages of assessment and treatment. Mechanical devices such as intermittent calf pumps may not be appropriate on the injured limb as they may affect the damaged soft tissue envelope and are not applicable if external fixation is present. Similarly, foot impulse devices may not be appropriate if there is risk of increased bleeding from the wound. The most invasive mechanical prophylaxis against embolism is the inferior vena caval (IVC) filter, which is a device implanted in the inferior vena cava that prevents thrombi reaching the pulmonary vasculature. The clinical indications and period of retention for such devices are evolving and use is reserved currently for the high-risk patients who are not suitable for pharmacological methods of prophylaxis. In all cases, clinicians should refer to their local hospital guidelines and the NICE guidance on VTE (20).
Imaging of limb
Necessary imaging should be obtained without unnecessary delay. For isolated open fractures, orthogonal radiographs should include visualisation of the joint above and below the injured segment. Further cross-sectional imaging is valuable particularly in peri-articular injuries, e.g. tibial plateau fractures. In patients where an initial ‘trauma CT’ is indicated there should be protocols to maximise the useful information and minimise delay; the initial sequence should include a head to toes scanogram. This should be used with clinical correlation to direct further specific limb sequences during that initial CT examination.
CT angiography may be helpful if it can be performed while the patient is having the ‘major trauma series’ scan (4). Formal angiography may be useful in assessing vascular injury in preparation for free-flap reconstruction. However, angiography should not delay emergency revascularisation of an ischaemic limb; immediate surgical exploration and shunting is indicated if hard signs of vascular injury persist after any necessary restoration of limb alignment and joint reduction.
Transfer from the emergency department
The trauma team leader, in conjunction with relevant specialists, will determine the most appropriate destination for the patient. This will be either directly to the operating theatres, to the intensive care unit, or to the major trauma ward. This important decision must be made jointly between senior orthopaedic and senior plastic surgeons. However, in cases of multiple injuries, the presence of an open fracture should not preclude transfer to a specialist area of the hospital, e.g. the neurosciences unit, if other injuries take priority.
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1 Gentamicin dosing is based on the patient’s actual body weight. If the patient’s actual weight is more than 20% above ideal body weight (IBW), the dosing weight (DW) can be determined as follows: DW = IBW + 0.4 × (actual weight − IBW). If underweight by more than 20% of IBW then DW = 0.4 × (IBW − actual weight).
IBW (kg) = (males 50 kg, females 45 kg) + 2.3 kg per inch over 5ft.