Subject: Delayed treatment of open femur fracture
Date: Thu, 10 Apr 2003 08:53:11 -0700
From: John Ruth
Living near the US/Mexico border we frequently receive patients with unaddressed injuries. Today we received an 18 year old with splenic injury, poorly resuscitated and an open femur shaft fracture (1 cm wound no gross contamination) which occurred at least 48 hours prior to patient arriving here. The patient has not been in skeletal traction, has not been washed out and it is uncertain whether he has received any IV antibiotics. MY plan is to wash out femur and administer 24 hours of IV antibiotics (cephalosporin plus aminoglycoside) and then do a repeat washout and rod the femur. I will then keep him on IV antibiotics for another 48-72 hours post IM rodding. Any other recommendations? Reaming a concern?
Date: Thu, 10 Apr 2003 12:10:31 EDT
Regarding case of open femur shaft fracture with initial treatment 48 hours post injury. Your plan appears sound. The theoretical concern is that the bacteria in the contaminated wound have had enough time to multiply and cause an infection if you do a nail at 48 hours. Unfortunately there is not much data to know the exact infection rate as a function of number of days of delay. Presumably doing a wash out and debridement, traction (vs XF) (+/- antibiotic beads) followed in a few days by a staged nailing would minimize infection rate; but again not much data. Unreamed vs reamed nails- I doubt much difference. Solid vs cannulated nail- I doubt much difference.
I WOULD beware of fat embolism syndrome or ARDS. There is a "second hit" phenomena associated with FES/ARDS where the pneumatocytes are supposedly "triggered" into a state of readiness by the first exposure to lipids and have time to gear up. A second exposure to fat then triggers their inflammatory response with resultant sequellae. So you could have 3 hits here (two chances for second hits") with the first shower of intravascular medullary content being from the fracture, the second shower of intravascular medullary content being from the I & D 2 days later, the third being from the IM nail 4 days later. Watch the pO2 closely preop and postop.
Date: Thu, 10 Apr 2003 12:44:13 -0400
From: Clifford Jones, M.D.
Sounds good. I do not know if reaming with a vent hole distally initially would help reduce bacterial titer, any nonviable tissue, and improve irrigation? Sounds like I am pretty lucky getting "hot" trauma at 6-8 hours out from injury.
Date: Thu, 10 Apr 2003 13:36:39 -0400
From: Peter Trafton
reply to John Ruth:
I'd debride, culture, ex fix and dress open with tobramycin bead pouch. If cultures negative, would proceed with (reamed) IM nail in 3-5 days. If positive cultures, would ensure adequate antibiotic coverage and clean-appearing wound before nailing. If wound infection became manifest before nailing, I'd leave ex-fix til infection controlled - then fix with plate.
What's happened to her spleen? (see J Trauma 1995 Apr;38(4):639-41 Open tibia fractures in the splenectomized trauma patient: results of treatment with locking, intramedullary fixation. Sterett WI, Ertl JP, Chapman MW, Moehring HD.)
Date: Thu, 10 Apr 2003 11:57:33 -0700
From: Johh Ruth
Spleen is still in patient. No plans now for removal.
Date: Fri, 11 Apr 2003 07:17:15 +0530
I have no access to JOT but reading the abstract it seems that since it is a retrospective study with no possible randomisation,there is a risk that they were comparing very badly traumatised spleens (ie, needing removal) with less badly damaged spleens (not needing removal). Would this not make a difference as to the general condition of the patient and likelihood of infections as well ?
Consultant Orthopaedic Surgeon,
Lords Hospital & Cosmopolitan Hospital,
Date: Thu, 10 Apr 2003 23:34:32 EDT
I have thought about but have not had the courage to use antibiotic impregnanted bioabsorbable calcium sulfate beads. I have use three times in established osteomyelitis. Just a thought.
Sincerely and respectively,
M. Bryan Neal, MD
Arlington Orthopedics and Hand Surgery Specialists, Ltd.
Arlington Heights, Illinois 60005
Date: Fri, 11 Apr 2003 00:23 EST
From: Bill Burman
>Spleen is still in patient. No plans now for removal.
I have been trying to follow a recent discussion on the AAST list re splenic injury. Even if you have conservative care or embolization or splenorrhapy or a partial splenectomy for a splenic injury (i.e. no total splenectomy), the injury may still knock out splenic immune function. Some said they were looking for Howell Jolly bodies (RBC's with nuclear remnants that the spleen would ordinarily filter) in the peripheral smear as an indicator of splenic immune dysfunction.
Also note a good OTA BFC discussion of open femur fracture management between Mike Chapman and Bob Winquist.
Date: Sat, 12 Apr 2003 13:47:02 +0600
From: Alexander Chelnokov
JR> no gross contamination) which occurred at least 48 hours prior to
patient arriving here. The patient has not been in skeletal traction,
another 48-72 hours post IM rodding. Any other recommendations?
Reaming a concern?
We often receive delayed patients (e.g. case). In our settings (without ER and OR available 24h/7d) the patient would be put on traction (or most primitive monolateral ex-fix applied - depending on what time he is admitting at and whether OR is empty) for 3-4 days, with antibiotics and IV fluid. When we ensured that the wound is healing without signs of infection closed locked nailing would be performed with UFN-like solid nail and minimal (to fit) reaming.
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia