Antibiotic prophylaxis for open fractures: Difference between revisions

Revision as of 15:57, 15 November 2019

Gustilo Classification

Type I: open fracture with skin wound <1cm in length and clean
Type II: open fracture with a wound >1cm in length without extensive soft tissue damage, flaps, or avulsions
Type III: open segmental fracture with a wound >10cm in length with extensive soft tissue injury or a traumatic amputation
- IIIA: adequate soft tissue coverage
  - All farm injuries and gunshots are automatically at least IIIA
- IIIB: significant soft tissue loss with exposed bone that requires soft tissue transfer to achieve coverage
- IIIC: associated vascular injury that requires repair for limb preservation
- Special categories:
  - gunshot injuries
  - any open fracture caused by a farm injury
  - any open fracture with accompanying vascular injury requiring repair

Risk of Infection

Type I: 0%
Type II: 2%
Type III: 6-44%
- Type IIIA: 2%
- Type IIIB: 11%
- Type IIIC: 20%

Management

Don't forget tetanus!
Antibiotic choice
- Cover Gram-positives as soon as possible after injury, e.g. with cefazolin
- Add Gram-negative coverage for type III fractures, e.g. with tobramycin
- Consider adding anaerobic coverage
- For example, one Ontario trauma center uses cefazolin, tobramycin, and metronidazole
- Add high-dose penicillin to cover Clostridium species, in the presence of fecal contamination or farm-related injuries
- Fluoroquinolones should be avoided, if possible, due to slowing bone healing
Duration
- Continue for 24 hours after wound closure
- If type III, continue for at least 72 hours post-injury if Type III

@@ Line 1: / Line 1: @@
 == Gustilo Classification ==
+* '''Type I''': open fracture with skin '''wound &lt;1cm''' in length and clean
-* Type I: open fracture with skin wound &lt;1cm in length and clean
+* '''Type II''': open fracture with a '''wound &gt;1cm''' in length without extensive soft tissue damage, flaps, or avulsions
-* Type II: open fracture with a laceration &gt;1cm in length without extensive soft tissue damage, flaps, or avulsions
+* '''Type III''': open segmental fracture with a '''wound &gt;10cm''' in length with '''extensive soft tissue injury''' or a traumatic amputation
+** '''IIIA''': adequate soft tissue coverage
-* Type III: open segmental fracture with &gt;10cm wound with extensive soft tissue injury or a traumatic amputation
+*** All '''farm injuries and gunshots''' are automatically at least IIIA
-** IIIA: adequate soft tissue coverage
+** '''IIIB''': significant soft tissue loss with '''exposed bone''' that requires soft tissue transfer to achieve coverage
-*** All farm injuries and gunshots are automatically at least IIIA
+** '''IIIC''': associated '''vascular injury''' that requires repair for limb preservation
-** IIIB: significant soft tissue loss with exposed bone that requires soft tissue transfer to achieve coverage
-** IIIC: associated vascular injury that requires repair for limb preservation
 ** Special categories:
-*** gunshot injuries
+*** '''gunshot injuries'''
-*** any open fracture caused by a farm injury
+*** any open fracture caused by a '''farm injury'''
-*** any open fracture with accompanying vascular injury requiring repair
+*** any open fracture with accompanying '''vascular injury requiring repair'''
 == Risk of Infection ==
 * Type I: 0%
 * Type II: 2%
@@ Line 23: / Line 21: @@
 == Management ==
+* Don't forget '''tetanus'''!
+* '''Antibiotic choice'''
-* Don't forget tetanus!
+** Cover Gram-positives as soon as possible after injury, e.g. with cefazolin
-* Antibiotic choice
+** Add Gram-negative coverage for type III fractures, e.g. with tobramycin
-** Cover gram-positives as soon as possible after injury
-** Add gram-negative coverage for type III fractures
+** Consider adding anaerobic coverage
-** At HGH: cefazolin, tobramycin, and metronidazole
+** For example, one Ontario trauma center uses '''[[Is treated by::cefazolin]], [[Is treated by::tobramycin]], and [[Is treated by::metronidazole]]'''
-** Add high-dose penicillin to cover clostridium, in the presence of fecal contamination or farm-related injuries
+** Add high-dose penicillin to cover [[Clostridium species]], in the presence of fecal contamination or farm-related injuries
-** Fluoroquinolones should be avoided, if possible, due to slowing bone healing
+** [[Fluoroquinolones]] should be avoided, if possible, due to slowing bone healing
-* Duration
+* '''Duration'''
 ** Continue for 24 hours after wound closure
 ** If type III, continue for at least 72 hours post-injury if Type III
 == Further Reading ==
 * Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. *J Bone Joint Surg Am*. 1976 Jun;58(4):453-8.