Pain assessment in the dog: the Glasgow Pain Scale
Pain is an unpleasant personal emotional experience. It has 3 dimensions: Sensory – discriminative (location, intensity, quality, duration)...
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Issue number 25.3 Other Scientific
Published 16/04/2021
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An open fracture is any fractured bone that is exposed to environmental contamination due to disruption of soft tissues surrounding the bone. By extension, if there is a skin wound in a limb or body segment that has a fracture...
Any fracture with a skin wound anywhere in that body segment should be considered an open fracture and to be at increased risk for later infection.
Open fracture wounds should be treated on an emergency basis, but immediate rigid stabilization of the fracture itself is not an emergency.
Every patient with vehicular trauma should receive a minimum of chest and abdominal radiographs, CBC, serum chemistry, ECG, pulse oximetry and blood pressure measurements to assess potential co-morbidities.
Initial sterile wound dressings should be applied while the patient is assessed and stabilized to protect against infections from nosocomial organisms, and systemic broad-spectrum antimicrobials should be given as soon as possible.
External skeletal fixators allow open wound access while providing rigid fixation, preserving bone blood supply and minimizing soft tissue disruption.
An open fracture is any fractured bone that is exposed to environmental contamination due to disruption of soft tissues surrounding the bone. By extension, if there is a skin wound in a limb or body segment that has a fracture, this should be considered as an open fracture, regardless of whether or not the fracture is assumed to communicate with the wound. One study reported that open fractures occurred in 16.7% of all traumatic fractures in dogs and cats, and vehicular trauma, younger age, larger body weight, and fracture comminution were associated with a greater likelihood of open fracture 1.
Proper treatment of open fractures requires recognition of two central facts:
Open fractures are often the results of vehicular trauma or other high-energy events, and such trauma can result in significant co-morbidity that must be addressed. In addition to limiting future morbidity, initial management of patients with open fractures is critically important to minimizing cost and healing time, and to the functional outcome of the patient. Especially when treating open fractures, veterinarians are best advised to strictly adhere to established principles and not attempt to cut corners to save time, cost or effort. Post-operative osteomyelitis or non-union nearly always results from compromises made in initial wound and fracture care. Figure 1 provides a useful algorithm for management of patients with open fractures.
Two factors are considered paramount in proper initial management of the fracture itself. The first is the “grade” of the fracture. Open fractures in veterinary patients are commonly classified from Grades I through III (Table 1) in an effort to better predict any potential for increased morbidity or post-operative infection, but evidence for the efficacy of grading open fractures in veterinary medicine is scant. Grade I open fractures in the past have been erroneously described in the veterinary literature as fractures where the bone “penetrated from within”, a distinction that implies a pattern of displacement during trauma that cannot be determined simply by viewing the fracture and wound after injury. This assumption of the sequence of trauma should be avoided by veterinarians and in future veterinary literature. Some authors subdivide Grade III open fractures into three subtypes 3, but subclassification for management purposes is not supported by improved fracture outcomes in the available literature.
Grade I | An open fracture with an associated wound < 1 cm in diameter. Grade I fractures are often simple, two-piece fractures and are associated with minimal soft tissue trauma. |
Grade II | An open fracture with a skin wound > 1 cm diameter but without extensive soft tissue trauma or comminution. |
Grade III | An extensively comminuted open fracture with severe soft tissue trauma and a skin wound of > 1 cm diameter. All fractures caused by projectiles are considered Grade III. |
The second and more important factor in open fracture management is consideration of the nature and duration of the microbial contamination, with a “golden period” for wound closure often described as being a period of 6 to as long as 12 hours from the initial wound trauma. In reality, the “golden period” is not strictly limited to duration, but is more appropriately viewed as the perceived degree of wound contamination or infection that has occurred up to the time of debridement and closure. Within the first 6-12 hours, contaminated wounds, including wounds that communicate with fractures, may be converted to clean wounds by effective surgical debridement and lavage, and then closed in primary fashion, decreasing the time to complete wound healing and wound care costs. After 12 hours, most wounds, regardless of any assumption concerning the degree of contamination, should be similarly debrided and lavaged, but should be closed over surgical drains or left open for delayed closure techniques. Decisions regarding wound closure or non-closure should be ideally based on peri-operative examination of a Gram-stained smear of the wound taken before debridement or lavage. The presence of visible bacteria in the smear indicates likely infection of > 1X105 bacteria/mm2 in the wound and therefore a recommendation that the wound should be managed as an open wound until uncomplicated healing with delayed closure techniques is likely to be achieved.
For all patients, a temporary sterile bandage or dressing should be placed over the wound as soon as possible during initial assessment of the patient. Ideally, samples for aerobic and anaerobic culture are collected at the level of the fractured bone at the time of presentation, although a prospective, randomized study found that only 18% of open fracture infections were caused by organisms found on initial culture 4. In a study of bacterial contamination in 110 canine fractures, 72.7% of dogs with open fractures had a positive culture for aerobic and/or anaerobic micro-organisms 5. Appropriate doses of broad-spectrum antimicrobials (see below) should be given systemically immediately after wound culture. During wound care, the animal should be placed in an aseptic environment such as a surgical suite, and all personnel should follow aseptic protocols to minimize iatrogenic contamination. Regardless of the assessed open fracture grade, and as soon as the patient is otherwise determined to be systemically stable, the open wound should be clipped free of hair to a wide margin, cleaned of gross debris by surgical antiseptic soaps, and all damaged or necrotic soft tissue debrided (Figure 2). To decrease iatrogenic contamination of the wound, the wound can be filled with sterile, water-soluble lubricant prior to clipping. Isolated bone fragments without soft tissue attachments should be removed. After debridement an initial cleansing with diluted chlorhexidine gluconate solution is recommended 3.
Debrided and cleansed wounds should then be copiously lavaged with sterile lactated Ringer’s solution or similar sterile isotonic solution; lavage volumes of 3-5 liters of isotonic solution in a 1 cm diameter wound are not excessive. It is important that lavage is achieved by a pressure of 7-8 psi (pounds per square inch) to assure adequate disruption of bacterial adherence from the tissue while causing minimal damage to healthy tissues adjacent to the wound; this is achievable with either a commercial surgical lavage device or by using a 19 G needle placed on a 60 cc syringe and vigorously sprayed over the wound. These methods assure a fluid pressure of approximately 8 psi, which is the strength of bacterial adherence to the wound surfaces. Higher pressure lavage is detrimental to healthy tissue and is not recommended. The use of antibiotics or antiseptic compounds in the lavage solution is not necessary and may be detrimental to the normal cellular elements of the tissue, but a solution of 0.05% chlorhexidine has been determined to provide antibacterial activity without causing tissue reaction 6.
Cleansing, debridement, and lavage should include the entire depth of the wound down to the fracture. Following copious lavage, the wound should again be aerobically and anaerobically cultured to assess and properly treat the microbial population left in the wound at the time of closure. At this stage the clinician should assess the tissue viability and degree of contamination and choose one of three options; repair the wound by primary means; repair the wound using a closed, sterilely maintained surgical drain; or manage the open wound with sterile dressing materials until closure can be performed at a later date, or until secondary intention healing occurs.
Open fractures do not require definitive stabilization immediately if proper emergency wound care has occurred. Definitive rigid fracture stabilization should only occur when the patient is appropriately stabilized, an experienced surgeon is to hand, and with all anticipated fixation devices and equipment immediately available.
Temporary stabilization of open fractures is performed to increase patient comfort and to minimize local soft tissue swelling and further soft tissue injury. Fractures of the lower extremities have less soft tissue coverage, and closed fractures may become open fractures or undergo additional comminution if unsupported. Analgesics (preferably opioid agonists such as morphine) should be administered to the patient to improve comfort.
Fractures proximal to the elbow or stifle are difficult to stabilize with external coaptation alone, and the patient should be cage-confined without splinting and treated with analgesics until definitive repair. Fractures distal to the elbow or stifle should be stabilized with external coaptation until definitive fixation or while awaiting transport to a referral center. External coaptation should consist of either a Robert-Jones bandage, or a modified Robert-Jones incorporating a molded lateral fiberglass splint. For fractures with wounds left open after debridement, all bandage materials should be sterile and applied in aseptic fashion. External coaptation should always immobilize the joint immediately proximal to the fracture and extend distally to the toes.
Millard RP, Towle HA. Open fractures. In: Tobias KM, Johnston SA, eds. Veterinary Surgery: Small Animal (1st ed) St Louis: Elsevier, 2012:572-575.
James Roush
James K. Roush, College of Veterinary Medicine, Kansas State University, USA Read more
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