Initial Management of Open Fractures

Open fractures, which may be complicated by subsequent osteomyelitis, warrant prompt and meticulous attention. The most important elements in the treatment of open fractures, aside from tetanus prophylaxis that applies generally to any wound, are irrigation, debridement, and antibiotics provided as soon as is practical. Although irrigation and debridement are commonly performed in the operating room, antibiotics may be administered in the emergency department.

Early administration of antibiotics can help reduce the incidence of infection in open fractures. 45 The longer the interval between the time of injury and the initiation of antibiotic therapy, the less likely that such therapy will be of benefit. Exactly what constitutes the ideal antibiotic is controversial. An accepted combination is a first-generation cephalosporin plus an aminoglycoside, but this is by no means the only regimen in use. Aerobic and anaerobic wound cultures can be obtained before antibiotics are administered.

Antibiotics by themselves are no substitute for irrigation and debridement, both of which have been well demonstrated to be crucial to reducing the incidence of osteomyelitis in open fractures by reducing bacterial contamination and the potential for bacterial colonization. 67 Irrigation should be extensive to (1) make the area more visible for inspection for foreign material, (2) float out nonviable tissue or at least float it into the field of vision so it can be removed, and (3) float out contaminated blood clots and bits of tissue. Pulsatile pumps may increase the effectiveness of irrigation, provided the stream is not too forceful. Excessive force will simply pack debris farther into the recesses of the wound.

Debridement of minor wounds that overlie a fracture may sometimes be performed in the emergency department. When tissue damage is moderate or severe, formal debridement and irrigation are commonly performed in the operating room.

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