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Open Fracture

synonyms:

Open Fx ICD-9 / CPT

  • ICD-9: Depends on associated fracture
  • CPT 11010: debridement includinge removal of foreign material; open fracture/dislocation; skin and subcutaneous tissue
  • CPT 11011: debridement includinge removal of foreign material; open fracture/dislocation; skin, subcutaneous tissue, muscle fascia and muscle
  • CPT 11012: debridement includinge removal of foreign material; open fracture/dislocation; skin, subcutaneous tissue, muscle fascia, muscle and bone.

Open Fx Etiology / Epidemiology / Natural History

  • Greater risk of infection and take longer to heal than comparable closed fractures.

Open Fx Anatomy

Open Fx Clinical Evaluation

  • Photograph the injury.

Open Fx Xray / Diagnositc Tests

  • Consider intrarticular sterile normal saline injection to distinguish superficial lacerations / abrasions from open wounds associated with joints. Injection must be done outside zone of injury and with large fluid bolus (50ml for knee).
  • Evaluate for compartment syndrome.

Open Fx Classification / Treatment

  • Gustilo-Anderson Classification
    -Grade I: <1cm
    -Grade II: >1cm
    -Grade IIIa: >10cm
    -Grade IIB: requiring local or free flap coverage of the exposed bone
    Grade IIIC:vascular injury requiring repair .
  • Classifaction has poor interobserver agreement (Brumback RJ, JBJS 1994;76A:1162).
  • IV antibiotics should be given as soon as possible. Generally Cefazolin 2 g IV Q8hrs +/- Levaquin 500mg IV QD depending on wound contamination. Historical recommendation is cefazolin +/- gentamycin. Gentamycin increases renal failure risk. Add penicillin for any wound heavily contaminated with soil.
  • Antibiotic duration is 3 days for grade I and II open fx; 5 days for grade III.(Wilkins J, Orthop Clin North Am 1991;22:433).
  • Tetnus vaccinationshould be given if last vaccination was > 10yrs prior or unknown. If wound is severely contaminated give vaccination in vaccination was >5yrs prior.
  • Photograph the injury.
  • Operative debridement should be done in a timely fashion. Exact timeline is unknown. Most important factor is when IV antibiotics where given. Associated lacerations should be extended to inspect entire zone of injury. Irrigate with low-pressure lavage (high-pressure may drive contamination into soft tissues).
  • Consider wound VAC and/or antibiotic beads. Antibiotic beads made with polymethyl methacrylate impregnated with vancomycin or tobramycin.
  • Exteral fixation vs internal fixation vs traction depending on fracture type and severity of soft tissue injury.
  • Initial wound closure remains controversial. Recent OTA study on 415 patients with open tibial shaft fractures noted no difference in infection/union between delayed or initial closure with adequate debridement.
  • Consider 4th generation cephalosporin for open fractures with pond or stream water contamination. Prophylaxis against Aeromonas.
  • Open fracture Debridement CPT codes: 11010(skin, subq), 11011(skin, subq, muscle, fascia), (skin subq, muscle, fascia, bone)

Open Fx Associated Injuries / Differential Diagnosis

Open Fx Complications

Open Fx Follow-up Care

  • Early soft tissue coverage indicated when soft tissues permit. May require repeated I&D's before wound is completely free of debrie and non-vialbe tissue.
  • See Flaps for coverage options.

Open Fx Review References

Rockwood and Green's Fractures in Adults 6th ed, 2006

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