Page 422 - WSAVA2018
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 25-28 September, 2018 | Singapore
M. Glyde1
1BVSc MACVSc MVS HDipUTL Diplomate ECVS, College of Veterinary Medicine. Murdoch University
At the end of this session you will be able to:
· Use the grading system for open fractures to decide treatment options
· Recognise the significance of a full thickness skin wound over a fracture
· Decide on appropriate antibiotic use for open frac- tures based on an understanding of the difference between contamination and infection
Open fractures are a common presentation in small animal practice. The long- standing approach to managing open fractures has been open wound management and the use of external skeletal fixators (ESFs). This “traditional” approach has been associated with a relatively high occurrence of non-union resulting in the need for revision surgery and, in some cases,
limb amputation. Prolonged open wound management leading to “treatment fatigue” of both owners and veterinary staff, significant on-going patient morbidity and often the development of multi-resistant bacteria are also associated with this older-style approach.
Type I
Type I open fractures are low energy fractures where an open wound typically less than 1cm is created by the internal force of a bone fragment protruding through the skin. These have a small external skin wound that in many cases is not apparent until the hair is clipped for surgery.
Any full thickness skin wound near a fracture should be classed as open. Probing the wound to determine whether it connects with the fracture is contraindicated, as this will carry bacteria and debris into the soft tissues and fracture site.
Type II
Type II open fractures involve higher energy trauma in which the soft tissue wound is created by a combination of internal and external force. There is more damage to the soft tissues than with a type I. The skin laceration is larger than a type I but sufficient tissue exists to close the wound without needing to use a skin flap or other advancement technique.
Type III
Type III open fractures are the most severe type and result from high-energy external trauma such as
· Classifying the type of open fracture helps determine both the prognosis and the recommended treatment options.
· Primary or delayed-primary wound closure following appropriate debridement improves blood supply to the healing fracture, reduces morbidity, reduces the likelihood of producing resistant bacteria, saves time and in most cases is ultimately cheaper than on-go- ing open wound management.
· ESFs in many severe open fractures (Type III) will not last the distance until the bone is healed and will fail or need revision before the fracture has healed.
· Bone plates and interlocking nails are not contrain- dicated in open fractures. Early re-establishment of healthy well-vascularised soft tissue over a healing fracture speeds fracture healing and reduces the occurrence of infection.
· Should implants be removed after fracture healing? Implants placed in open fractures may be contami- nated and so there is some degree of risk of future cryptic infection developing. How likely this is to occur in canine and feline open fractures is not clear. Currently owners should be advised that bone plates probably should be removed on completion of frac- ture healing.
Open Fracture Classification
Identifying the type or severity of open fracture is useful in determining the prognosis and in deciding on the treatment options available in that case.
Open fractures may be divided into three types based on the severity of the injury.
    More recently, through a better understanding of managing traumatic wounds and a better understanding of fracture biology, newer approaches to managing open fractures have been developed that limit or avoid many of the negative issues associated with “traditional” treatment of open fractures. These newer approaches concentrate on early primary closure or early delayed primary closure of open wounds through a variety of strategies in combination with fracture stabilisation with bone plates.
This session will focus on the following key points:
  · The treatment of an open fracture on initial presenta- tion affects the outcome. Open fractures are con- taminated initially rather than being infected. Infec- tion will only develop if wound management is not appropriate. Infection is more likely with prolonged open wound management and in the presence of poor soft tissue blood supply.
· The majority of infections in open fractures are acquired in hospital. The long- term prophylactic use of antibiotics in open fractures is not justified and encourages the establishment of resistant bacteria within your practice.
· Longer courses of antibiotics if infection does de- velop is justified but should be based on cultures of deep tissue samples from the fracture site.

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