Page 424 - WSAVA2018
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 25-28 September, 2018 | Singapore
Type I open fractures rarely require any debridement prior to definitive fracture stabilisation however the same approach to lavage should be undertaken at the time of fracture repair as with the more severe types.
·Definitive fracture repair
Rigid stability is essential in the repair of open fractures. For this reason intramedullary pins, orthopaedic wire and external coaptation are contraindicated in open fractures.
External skeletal fixators (ESFs) have been reported to be the fixation method of choice in type II and III open fractures (provided a sufficiently rigid frame can be placed). This dogmatic advice should be carefully considered as in many type II and
nearly all type III open fractures definitive fracture repair with an ESF is usually not achieved. This is because the poor biology of type II and III open fractures means that healing will be prolonged and, in most cases, the ESF will fail before the fracture has healed.
ESFs have several theoretical benefits in open fractures:
· ESFs provide rigid stability remote from the fracture site. This minimises soft tissue damage and reduc- es the likelihood of infection localised around the implant.
· ESFs allow easy access for open wound manage- ment.
· ESFs are useful in radial and tibial open fractures (which are the most common sites of open fracture)
The reality however is that the majority of ESFs placed will fail to a greater or lesser degree prior to completion of fracture healing in more severe open fractures necessitating ESF revision or transfer to some form of internal fixation. In some cases revision surgery of the ESF with removal of loose pins and replacement with other pins may be effective. In most cases however removal of the ESF completely and replacement with
a bone plate and bone graft to manage the delayed or non- union that has developed is necessary.
It is advisable to inform owners prior to surgical management of type II and type III fractures with an ESF that initial treatment with an ESF to facilitate open wound management followed by definitive treatment with internal fixation once the open wounds are resolved will be necessary.
Bone plates, interlocking nails or ESFs are suitable for type I open fractures as they all can provide sufficiently rigid stability. Bone plates are the implant most commonly used in managing type I open fractures.
Bone plates and interlocking nails can be used for type II and III open fractures. In our practice bone plates are used in preference to ESFs in type II and III fractures provided that the open wound can be closed either primarily or through delayed-primary closure. To
achieve this in severe fractures usually requires closure of the wounds with axial pattern flaps or other soft tissue transfer methods. This has the dual advantage of closing the open wound and replacing traumatised tissue with robust well-vascularised tissue that is much more resistant to soft-tissue infection.
The advantage of bone plates and interlocking nails over ESFs is that they have greater longevity, which is often necessary in more severe open fractures.
Owners should be advised prior to surgery that
removal of the bone plate after fracture healing is advised to reduce the risk of future cryptic infection
that can potentially occur when implants are placed
in contaminated sites. ESFs also require subsequent surgery to remove although removal is relatively simpler than bone plate removal.
Cancellous bone grafting is recommended in open fractures managed with open reduction. Direct placement of a graft is usually possible in type I and II open
fractures and in all type III fractures where primary closure or delayed primary closure is performed. Where prolonged open wound management is elected in type III fractures bone grafting cannot be performed until healthy granulation tissue has covered the fracture site. The graft is usually placed at a second surgery through a separate incision to the open wound through an area of good soft tissue coverage.
Where ever possible closure of open wounds in
type III open fractures using an axial pattern flap or pouching or other methods of closing the wound with well- vascularised robust soft tissue is preferable to on-going open wound management. This improves outcome, minimises morbidity, minimises treatment time and is ultimately cheaper than prolonged open wound management.
Dos of open fractures
· Do place a quick sterile dressing to cover the open wound while treating the animal for shock. This will reduce the likelihood of the traumatised soft tissue wound picking up a hospital- derivedinfection.
· Do provide temporary splint support with the initial sterile dressing in fractures that are distal to the elbow or stifle joint. This will greatly reduce the animal’s pain and limit ongoing damage of the soft tissue envelope of the fracture from the fractured boneends.
· Do give prophylactic intravenous broad- spectrum antibiotics on initial presentation and for the first few days only until the results of the bacterial deep tissue culture obtained at surgery (the “exit” culture) are obtained. If the exit culture at the time of surgery grows bacteria then this suggests an established or an establishing

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