Page 423 - WSAVA2018
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gunshot injuries and motor vehicle trauma producing shearing injuries. Extensive skin and soft tissue injuries exist. There is insufficient soft tissue to cover the wound.
Complications including infection are significantly higher in type III fractures reflecting the greater degree of
soft tissue compromise. Type III open fractures can be repaired with very good outcomes however this requires considerable financial and time commitment on the owner’s part to achieve a good outcome.
Open wound management of type III open fractures
is prolonged and expensive and is nearly always complicated by the development of significant infection including the establishment of multi-resistant bacteria.
Early primary closure or delayed- primary closure of type III fractures usually “short- circuits” prolonged open wound management, reduces morbidity and the occurrence of infection, speeds fracture healing and is ultimately cheaper and less time- consuming than open wound management.
In most type III open fractures, treatment with an ESF will facilitate open wound management but the ESF will rarely last long enough without revision for the fracture to heal. In most cases where an ESF is used revision surgery or replacement with a bone plate is necessary.
It is not contraindicated to use bone plates or interlocking nails in severe open fractures.
Management of Open Fractures
· protect the wound from nosocomial contamination
Open fractures should be covered with a quick sterile dressing to prevent further contamination while patient assessment and stabilisation is underway. In a study
of open fractures in people it was found that 80%
of infections were hospital-derived with only 20% of subsequent infections developing from bacteria present on initial presentation.
It is important when applying temporary support to open fractures at this stage to not reduce protruding bone fragments, as this will further contaminate the soft tissues at the fracture site. Reduction of any protruding bones should not be performed until after debridement.
·administer intravenous antibiotics
Early administration of broad-spectrum intravenous antibiotics as soon as possible on presentation has been shown to reduce subsequent infection rates. The degree of soft tissue compromise in type III open fractures means that these are more susceptible to infection than both type I and type II fractures.
The most common bacteria present in open fractures are gram-positive bacteria such as Staphylococcus spp. and Streptococcus spp. and gram-negatives such as E.coli,
Pseudomonas Klebsiella. First or second-generation cephalosporins or intravenous forms of potentiated amoxicillin / clavulanic acid are appropriate.
Addition of a fluoroquinolone has been shown to be beneficial in reducing infection rates in type III open fractures in humans.
It is important to differentiate both the concepts of pro- phylactic and therapeutic antibiotic usage and contam- ination and infection.
Antibiotics should be administered prophylactically for three-five days initially then subsequent administration either prophylactically or therapeutically based on exit cultures or deep tissue cultures in response to clinical signs of infection if indicated. The long-term usage of antibiotics is only indicated in established osteomyelitis and is not routinely necessary in open fractures.
·wound debridement
Type II and Type III open fractures should be debrided
prior to fracture stabilisation ideally as soon as the animal is physiologically stable for anesthesia for debridement. Type I fractures rarely need debridement preoperatively.
Debridement should be performed in a sterile surgical manner. The wound should be covered in clean single use K-Y jelly, which is water miscible and protects the wound from the hair and debris of clipping. After clipping the K-Y jelly is cleaned away as part of the surgical preparation. A full surgical preparation should be performed. Do not use open or multi-use K-Y jelly.
The wound should be explored in a sterile manner.
It is important to remember that open fractures are biologically compromised areas and as such are more susceptible to infection than normal sites.
Copious lavage with warm sterile isotonic saline should be undertaken. Use of a sterile giving set, three way stopcock, 35ml syringe and 18-gauge needle will facilitate this. Given the large amount of fluid used the use of waterproof drapes and/or suction is advisable to minimise the risk of nosocomial contamination, as cloth drapes will be rendered non-sterile once wet.
Sharp debridement of necrotic tissue and any particulate matter should be performed. Bone fragments that have soft tissue attachments should be minimally disrupted. Small bone fragments with no soft tissue attachments should be discarded. In severe injuries where there
is some doubt over the viability of soft tissue serial debridement over several days will enable subsequent identification of devitalised tissue.
Controversy exists over the value of entrance or exit cultures. An exit culture at the time of major debridement and, if definitive fracture repair surgery is delayed, then again at the time of fracture repair.
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