Ortho Hors D'oeuvres (Answer):
To review, this is a 39 year-old male presenting with wrist pain after motorcycle collision.
Questions and Answers:
1) What is the injury?
As you can see in the below radiographs, this patient has an obvious transverse, communicated, severely translated fracture of the distal radius as demonstrated by the double arrow. The patient also has an associated dislocation of the distal ulna (single arrow). This configuration of orthopedic insults is also known as a Galeazzi fracture.
More importantly, however, in the associated image of the patient's skin, small punctate lacerations are visible on the ulnar aspect of the dorsal wrist.
These lacerations are likely a result of the forceful impact of the ulnar head against the skin and soft tissues of the skin, causing a type I open fracture.
Open fractures are classified by Gustilo class. Type I open fractures are fractures associated with a laceration less than one centimeter and can often appear as small punctate abrasions on the skin. Type II open fractures are generally clean lacerations that are larger than one centimeter without significant soft tissue injury. Type III open fractures are characterized by significant soft tissue injury and contamination. Crush injuries are always type III open fractures.
This patient, with a Type I open fracture, has a 0-2% chance of infection. Patients with Type II or III open fractures run a 2-12% and 10-50% chance of infection respectively.
2) What are the next relevant steps in medication administration?
In the emergency department, the patient should have their tetanus vaccine updated, if necessary. Antibiotic coverage should be initiated as soon as possible. In a Cochrane review from 2004, the number needed to treat with antibiotics in order to prevent infection was 14. Although timing of antibiotic is less studied, antibiotic administration over 3 hours from injury was found to be associated with adverse outcome.
Appropriate antibiotic choice is also relevant. Based on culture studies, lower type injuries (I and II) should be sufficiently treated with 1-2 grams of cefazolin as these injuries are more often associated with staphylococcal infections.
Type III injuries have been found to have significant gram negative bacterial presence and should be covered appropriately. These injuries have traditionally been treated with cefazolin in order to cover the normal staph species with the addition of gentamycin for the strong additional gram negative coverage that this antibiotic offers. However, recent studies have shown that more moderate gram negative coverage might be appropriate. A recent study from University of Michigan showed that ceftriaxone for type III injuries was noninferior to clindamycin/aztreonam in terms of rates of antibiotic resistance and ongoing infection.
Wounds that are significantly infected by dirt and/or plant matter should also be given anaerobic coverage, so a penicillin or metronidazole should be included.
Antibiotic choices should be made in conjunction with your orthopedic consultant.
3) What are the next relevant procedures?
Discuss the case with your orthopedic consultant. Many current orthopedic and trauma guidelines dictate operative management and washout within 6 hours. However, several studies have demonstrated no increase in infection for patients who have waited up to 24 hours for definitive wound management. More relevant appears to be arrival time to treating trauma center, as patients with an arrival time to a treating trauma center of greater than 2 hours are associated with a 5.4-fold increased risk of developing an infection.
Open fractures should be discussed with the orthopedic consultant on call, and if the consultant on call is unable to manage the discussed injury, the patient should be transferred as soon as possible to the appropriate facility. In patients who will have delayed operative management, it is appropriate to perform a first-pass irrigation in the emergency department.
Copious volumes of irrigation fluid should be used. Formal recommendations call for no less than 5 liters of normal saline for type I and II fractures, with up to 8 liters for type III fractures, although these recommendations are for definitive, interoperative irrigation and first-pass irrigation could likely be less. Normal saline should be used. Multiple studies regarding uncomplicated wounds have shown no difference between tap water and sterile saline or water as the irrigation substrate, but this has not yet been studied in open fractures. Although recent data has shown that "very low pressure irrigation" is noninferior to high pressure irrigation, "very low pressure" is 1-2 PSI and roughly equivalent to systolic blood pressure, or the pressure of irrigating through a cap with a 18g needle opening in the cap. Irrigation devices should be used in order to assure appropriate pressure of irrigation.
After antibiotic administration and irrigation, the arm should be splinted in a position of comfort.
References:
Many thanks to Josephine Valenzuela and Robert Goodnough, who provided the case and the literature review for this discussion.
Bhandari, M., et al. "A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds." The New England journal of medicine 373.27 (2015): 2629
Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012 Feb 15;(2).
Gosselin, Richard A., Ian Roberts, and William J. Gillespie. "Antibiotics for preventing infection in open limb fractures." Cochrane Database Syst Rev 1.1 (2004)
Menkes, Jeffrey. Initial Evaluation and Management of Orthopedic Injuries. In: Tintinalli JE et al. Tintinalli Emergency Medicine 7th ed. New York: McGraw-Hill; 2011:1783-1796.
Morse JW, Babson T, Camasso C, Bush AC, Blythe PA. Wound infection rate and the irrigation pressure of two potential new wound irrigation devices: the port and the cap. Am J Emerg Med. 1998 Jan;16(1):37-42.
O’Brien, C. L., M. Menon, and N. M. Jomha. "Controversies in the Management of Open Fractures." Open Orthopaedics Journal 8.1 (2014): 178-184.
Rodriguez, Lauren, et al. "Evidence-based protocol for prophylactic antibiotics in open fractures: Improved antibiotic stewardship with no increase in infection rates." Journal of Trauma and Acute Care Surgery 77.3 (2014): 400-408.
