Section: CME Category: Surgery

Open Fractures - How to Address Soft Tissue and Bone

Michael Troiano, DPM

Michael Troiano, DPM discusses the basics of open fractures in the lower extremity, proper management, as well as assessing the soft tissue envelope and its effects on surgery.

CPME (Credits: 0.75)

  • CME Progress
  • Pre-Test

  • View Lecture ( CPME Credits: )

    Lecture Transcript

  • Post-Test

    Requires: Pre-Test, View Lecture
  • Survey

    Requires: Pre-Test, View Lecture, PostTest
  • Certificate

    Requires: All Content Above
Method of Participation

Complete the 4 steps to earn your CE/CME credit:

  1. Complete the Pre-Test
  2. View the Lecture
  3. Complete the Quiz (Min. 70% Passing Score)
  4. Complete the program Survey
Goals and Objectives
  1. Review the basics of open fractures of the lower extremity
  2. Review management of open fractures
  3. Describe the effects of an open fracture on the soft tissue envelope and its implications on surgical planning
  • Accreditation and Designation of Credits
  • CPME (Credits: 0.75)

    PRESENT e-Learning Systems is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine. PRESENT e-Learning Systems has approved this activity for a maximum of 0.75 continuing education contact hours

    Release Date: 12/26/2018 Expiration Date: 12/31/2020

  • Author
  • Michael Troiano, DPM

    Center for Foot and Ankle Disorders
    University of Pennsylvania - Penn Wound Care
    Adjunct Clinical Professor, TUSPM
    Philadelphia, PA

  • System Requirements
  • To view Lectures online, the following specs are required:

    • PC Pentium-III class or better processor
    • 256MB minimum of RAM
    • Cable or DSL broadband Internet
    • Browsers must have javascript enabled. Most browsers have this feature enabled by default.
    • Adobe Acrobat Reader (Free) to print certificates
    • Supported Browsers:
      • Chrome
      • Firefox
      • IE 10+
      • Safari
      Supported Mobile OS:
      • Apple iOS 4.3+
      • Android 2.3+
      • Honeycomb 3.1+
      • Blackberry Playbook
  • Disclosure Information
  • It is the policy of PRESENT e-Learning Systems and it's accreditors to insure balance, independence, objectivity and scientific rigor in all its individually sponsored or jointly sponsored educational programs. All faculty participating in any PRESENT e-Learning Systems sponsored programs are expected to disclose to the program audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation. It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts.

    ---

    Michael Troiano has disclosed that he is a consultant for Stryker and Smith and Nephew.

  • Lecture Transcript
  • TAPE STARTS – [00:00]


    Speaker: Our next speaker comes from Philadelphia, Pennsylvania, happens to my partner, happens to be a young man that did his residency with me, fellowship with me and has really taken the bull by the horns and have become a major force in the Philadelphia area as a foot and ankle reconstructive surgeon. He is board certified by the American Board of Podiatric surgery in foot, ankle and reconstructive surgery. So on the staff at Penn Presby Medical Center, he is really in charge of the wound center at Penn Presby, on staff at Temple University Hospital and he is really making a mark into what he is doing. And I couldn’t be more proud just to be able to say that I have watched him develop mature and go beyond what my expectations ever could have been and probably my skills ever could have been. At this point, Dr. Troiano is going to talk about fixation of ankle fractures. Please welcome Dr. Troiano.

    Dr. Troiano: Okay. Good afternoon. So I am actually going to talk about open fractures and how to address soft tissue and bone. I think ankle fractures will be tomorrow, but outstanding conference, classy place as usual, cogent faculty, learning new products. We are going to talk about something old though, open fractures. Now, people think of open fractures, they think of these dislocated pile-on fractures, they think of trimalleolar fractures, tibial plateau fractures, what have you but we see open fractures every day in our practice and unfortunately lot of us including myself can miss them when we don't think about the mechanism of injury associated with even the laceration.

    [02:08]

    So in beginning -- maybe we aren't going to begin. Okay, sorry about that. So definition of open fracture. The way we commonly think of it is soft tissue disruption that results in communication of the fracture site with the external environment. So fracture occurs, bone pushes through the skin, bone is exposed the outside elements, but it's also the external environment communicating with the bone while it remains in the body. That is also an open fracture. Someone hits their foot against the bed post, creates a proximal phalanx fracture, the fifth metatarsal, bed post pokes in, hits the bone, bone breaks. How many times we are seeing something like that. So we really need to do a good thorough examination with the patient and also historical examination as well. So speaking of history, prior to World War I, mortality rate for an open fracture was 80% to 90% secondary to sepsis. So you can imagine how drastic of an injury this is. World War II, we start to see the advent of antibiotics and open fractures are treated with topical sulfa.

    [04:06]

    Sulfa obviously still used in this capacity. Silver sulfa kill just about everything. MRSA can show a little bit of resistance to overly used silver products but by and large they kill everything including VRE. And there is a high success rate with delayed closure. Someone on the battle field, start the antibiotics, get them back, stabilize the fracture, suture the wound. In 1969, Gustilo and Anderson came out with their protocol identifying an ongoing 11% of mortality rate or infection down to 4 with their protocol. So Gustilo and Anderson changed the game even more. Problem is 1969, half the room probably wasn't even born yet, right? So we have new bacteria that we were discussing. We have new treatment algorithm that we are discussing and things that we really need to consider going forward. However, the pathognomonic characteristic property of Gustilo-Anderson was aggressive antibiotic use in the open fracture setting. Stanley Boyd in 1895 said the most important divisions of fractures simple, compound and complicated are based on the condition of the soft parts, meaning the fracture is bad, but really, the soft tissue envelope is paramount to long-term success. How bad is the soft tissue envelope? I can remember I have had 18-year-old kid with an open medial mal fractures, probably the most simple medial mal fracture ever, one or two K-wires I think because I didn't want to put in internal hardware in literally about the size of my thumb open area where there was devoid of soft tissue and this kid took months to heal ultimately requiring free flap because I just couldn't get that soft tissue over the bone. So soft tissue if you think of blood supply, 75% of blood is endosteal, 25% to 35% from the soft tissues and then if you think of soft tissue coverage and bacterial contamination in the form of stopping contamination is absolutely paramount.

    [06:18]

    So soft tissue much more important than bone in an open fracture. When someone comes in with their open fracture, we obviously have to go through a good trauma evaluation, primary and secondary survey, you are going to do your ABCDEs of trauma, is there a poly-trauma, compartment syndrome, lower back injury, infection control. Irrigant at the bedside is fine. There is nothing wrong with numbing someone up in an emergency room, in washing them out before you can get to the operating room. The cultures are questioned. We are going to get into that. Anatomic stability, reduction at bedsides. In other words, if someone is dislocated and you need to get them back under, that's going to increase the blood [00:06:57] [indecipherable] to that area and allow the antibiotics to penetrate. And then there becomes this question of the golden hour, six hours surgical emergency, we are going to discuss that a little more. So this is what I refer to when I say this is something we see on a daily basis. This is that bedpost injury, alright. Gregory Boyd from Oregon identified this injury in 1996 looking at 50 consecutive patients and a very common treatment for open fractures of the knee, hip, elbow. It's what called the saline load test. Basically, it's just that. Simple stupid. You look at these x-rays and you say base of the fourth metatarsal is broken -- excuse me, base of the proximal phalanx fourth toe is broken, fifth toe base is broken. Alright, no big deal. Tape the two toes together, buddy splint, surgical shoe, no problem except for if you look this little laceration is there. So what you do is you numb the patient up back here at the metatarsal level and you take about 5 mL of saline with an 18 gauze needle and you inject away from the fracture site.

    [08:06]

    If you being to see some of that saline -- extra of the saline throughout the laceration, then in actuality, that's an open fracture. The second time that we describe not the first. Not the first where the bone pushes through the skin but where the skin makes its way so that there is contiguous communication with the actual bone. That is a saline load test. I know that I probably did not start doing them except for the past maybe three or four years and overwhelming amount of my simple digital fractures, metatarsal fractures, otherwise innocuous, no big deal fractures have proved to be open fractures. So in his study, Boyd identified 35% were false positives, 43% false negatives. This is the one that we need to look at here is they were deemed closed but actually open fractures in 43% of the 50 patients. So treatment needed to be adjusted 40% of the time and I guarantee you if you implement this into your own practice, you are certainly going to find similar results. So when you see this, you have to ask yourself, should I be putting this person on antibiotics? Should I be documenting an open fracture? Is this something that is going to turn out later to develop osteomyelitis or similar problem to the Gustilo-Anderson prior classification treatment? So now Gustilo-Anderson, this I put for historical reference if you are going to look at the slides later. The open fracture protocol, Gustilo and Anderson invented in 1955. That's when the paper was written and that's when -- that's based on obvious study prior. Infection rates ranged from 5% to 12%. Antibiotic choice, Ancef can be primarily close in type 1. The pathognomonic finding is less than 1% in length.

    [10:01]

    Type 2 is 1 cm to 5 cm in length of the laceration adding Ancef and then augmenting with clindamycin also can be primarily closed according to this classification system. Everything else 5 cm in length and greater which is not a big laceration is a type 3. 3A with adequate soft tissue coverage, 3B with extensive soft tissue coverage and then 3C with arterial damage. I have yet to see 3C in the better part of 15 years of practice. Most of them fall into this B or A category. However, once you see any of these three, you are going to recommend aminoglycocide. So here is your typical picture associated with a grade 2. It's 1 to 5 cm. There is adequate soft tissue coverage. Contamination is present. So this person is going to be on Ancef and Clinda according to this classification system and then of course they are going to need local wound care. Once you fix contamination, you can go ahead and suture the lac. However, I would call your attention down here. Prognosis is definitive grade after proper debridement, meaning that you won't necessarily know what Gustilo-Anderson classification exist until you are doing the debridement. This is an after debridement classification. So how many 1 cm you are going to see after debridement? Not a whole heck of a lot. The vast majority are going to be in that Gustilo-Anderson two to three. So as much as I don't see 3C, I also don't really see 1 except for that bedpost type injury that we talked about. This is your typical 3B, again high energy great deal of comminution, instability soft tissue becomes an issue but no repairable or identifiable laceration to the artery.

    [12:04]

    And there of course is your 3C, provided only that there is repairable artery. These are lacerations that we will see in any day of practice. Here is your classic Rosenthal open fracture or Malay open fracture of the nail bed, again associated with your typical bedpost injury. Somebody in the middle of the night can of soup drops, kid playing soccer gets a cleat. The nail comes off. There is a laceration in the bed and you are looking at Gustilo-Anderson one or two. Is it an open fracture? Perform the load test and then you will know. Type 2, this obviously is a little bit more severe. Big toe needs emergent surgery to put the toe back in the position and then this is actually an open ankle fracture that I recently treated, type 2 level, no need for artery repair. So if we are to -- now look at Gustilo-Anderson classification for open fractures and we delineate each one of them based on infection rate and amputation rate. We can see that grade 1 through 3 has an amputation rate of 0 overall. But once we introduce the A, B and C, our rates can rise dramatically. Thankfully with antibiotics, we are looking at 5% for most of our fractures of amputation and this is really our concern. But now if we take the next level here, infection can range as high as 50% in grade 3B, which brings up a whole host of questions like, do you culture the patient? How long does the patient go on antibiotics? Is it safe to close the patient? And that's what the next few slides we are going to discuss. For anyone who is recertifying for boards or certifying for boards in the room, I put this as a historical representation as well because this is a slide which I have been asked on various examination and asked my students several times what are the most common bacteriology associated with each type of mechanism?

    [14:00]

    So starting with the bottom, war wounds, high energy, gunshot wounds, you have to cover for gram negative. That's not to say that there is dissociation of gram positive but certainly be concerned with the gram negative. Seawater, vibrios is a concern. I can attest to this myself. I recently was on vacation and stepped on a sea urchin and got a nice vibrio infection from that. Fresh water, pseudomonas is of concern and then of course, farm wound, clostridium, make sure everybody has their tetanus shot when they come into your office. Farm wound doesn't necessarily farm. It can be kid playing on a softball field. Just a dirt infection. So also make sure these people who have otherwise innocuous presentations in your office have updated clostridium or tetanus shots. And then of course, you have your blunt trauma, low energy, gunshot wounds, staph and strep. So accepted standard with grade 1, 2, 3, farm and war injury or first generation cephalosporin, add gentamicin plus or minus for the two depending on the size and then three plus or minus gentamicin penicillin. Infection control, the first and greatest concern for the open fractures that high risk of infection as we said up to 50% with type 3. So infection can result in chronic osteomyelitis, non-union and high reoperation rates as well as loss of function, limb loss or death. So infection, antibiotics are something that are paramount to success in the open fracture. Antibiotic should be administered as soon as possible. Study show that delay of greater than three hours increases the infection rate from 4.3% to 7.4%. So the resident calls you that person comes in, hey, I broke my toe, I need to see you right away. First thing you should do before you even see them is calling antibiotic or start that bag of antibiotics before you even schedule the operating room. That's a knee jerk reflex.

    [16:00]

    Other fractures leading to infection; vascular compromise, compartment syndrome Gustilo-Anderson grade 3. Vascular compromise is a huge one. So you take someone who maybe is seeing you for the routine diabetes or peripheral vascular disease or something, we need to be cognizant that even a vascular compromise makes them super, super likely to develop an infection because antibiotic [indecipherable] [00:16:21] is not as good as it would be in an uncompromised host. So antibiotics even more so need to be started quickly. Significance of culture, so do you culture the patient that comes in? The answer is, I don't know. I always do but if you look through here historically literature advocates for cultures taken upon presentation of open fractures. A short duration of antibiotic prophylaxis in open fracture did not enhance the risk of subsequent infection. So if you talk to the infectious disease people in the hospital, they will tell you that you should not routinely start someone on antibiotics and you should not routinely culture someone. But even if I continue that antibiotics just for a few hours or a day or two, I know that it's not really based on the study going to enhance the risk of subsequent infection. In other words, the infectious disease people will tell you that by putting someone on a short course of antibiotics, you are making opportunistic infection occur. So you put somebody on Ancef, you are allowing the MRSA to develop. In theory, now they are going to get a MRSA infection. But I will kindly point them to the study in 2013 by Duncan, which is obviously argumentative towards that fact. The congruence of pre-infection, samples collected with infectious pathogen found in absence of relationship is what they will you. In other words, what you culture out isn't necessarily what infects later, but boy, do I feel a whole heck of lot of better, I would rather have a culture that I am not going to use than no cultural data whatsoever. There is nothing saying that once person gets an infection, you don't get another opportunity to culture them again. So I culture, I look, I carry antibiotics for about 10 to 24 hours, then go from there.

    [18:03]

    Either continue them, stop them or reculture if an infection is going -- is developing. In a journal of trauma and acute care surgery 2014, there is an evidence-based protocol for prophylactic antibiotics in open fracture, improved antibiotic stewardship with no increase in infection rates. So prophylactic antibiotics again 2014 identifies that there is no increase in infection rate and that says, well do you start, do you not start? The answer is start, absolutely. Problem is we have to reconsider antibiotics. One out of two people in Philadelphia comes into the emergency room and I am sure similar in any big city across the United States have MRSA. And unfortunately there is a big push years ago to do surveillance cultures on everyone that came into the emergency room just to know if he or she was colonized with MRSA. However, that's kind of fallen off the grid. With that said, if someone comes into the emergency room, you have to keep in the back of your mind that they have MRSA. So the Ancef that you are using may be causing over population of the MRSA but at the least is not helping their current open wound. So with that said what is the role of Bactrim, doxycycline, clindamycin, vancomycin in open fractures? Is there a reason to rethink the Gustilo-Anderson classification? The people in Nebraska thought yes, there is. So new Nebraska Medical Center protocol has kind of taken over the Gustilo-Anderson classification, it's level two. So it's Gustilo-Anderson version 2. So without going through all of this, recognize that it does still use Gustilo-Anderson classification for 1, 2, 3 and separates it into soil or fecal and standing water contamination. And then from then, we still have our Ancef but once we have a known MRSA colonization, we are going to start to add vanco in each one of these sections.

    [20:05]

    And then it actually gives a regimen for when to consult ID. So if it gets to your type 3, ID should be consulted is what they identify. So these are the highlights that I have boxed out for you, the changes that you should be aware of in Gustilo-Anderson type 2 before it was 600 mg of Clindamycin that we are talking about, 900 mg in each of the situations here and of course type 3 standing water vancomycin becomes 15 mg/kg q.12h. is the big change here in all of these but especially in the standing water. So surgical emergency, when I was in school -- so that covers the antibiotics and when you should start or not start antibiotics and whether or not you should culture or not culture. Now, we are going to address the bone and soft tissue surgically. It has always been taught to me that there is a 6 to 8 hour surgical emergency golden window. That is to say that within 6 to 8 hours, that person has to be in operating room, otherwise they are going to have an untoward event or poor result. But the literature shows better results when antibiotics and surgery are done within this time. And now this has become controversial because the question is if you just start antibiotics, is the outcome going to be any worse than if you take this person to the operating room? So Robson, 1973, showed that one time tenth to the fifth organism threshold for infection. That's what we learned in school. Any colonization, any tissue sample greater than one times ten to fifth of parts shows colonization to infection. At two and half hours with an open fracture, you see one times ten to the second. At three hours, one times ten to second goes to the fifth and then five hours ten to the fifth and more, hence the golden hour.

    [22:01]

    This is how this came about. So bacteriology was tracked from beginning to end hour period, hour period, hour period and greater than six hours, you are looking at contamination goes to infection. Cooney [phonetic] in 1982, the reason why this is important is because he identified that after one times ten to the five, the immune defense becomes overwhelmed. So infection not only is occurring but the immune system can't catch up with it. So these are the reasons why historically we have learned one -times ten to the five and the six-hour golden hour. However, critical timing with adequate reduction stabilization rethinks the golden window. Time to starting antibiotics is paramount. Not necessarily fixation but time to starting antibiotics and washing this out. That can be done in the emergency room. So do you need to take this person to the operating room? There is a study across the pond identifying 48 open fractures and we are talking about the New Zealand area, where there was no ability in Australia, no ability to get these patients to a hospital because they were so far removed or rural. Study encompass 48 open fractures, 12 going to the OR within six hours, 33 after the six hours, mean time 12 hours. So double the golden window and the conclusion of the study is open tibial fracture should be managed on emergency basis as early as possible. Where there is delay in treatment inevitable, you have to consider minimal preoperative handling of the wound, meticulous debridement, stabilization of the fracture, provision of soft tissue coverage and appropriate antibiotic consideration. And they go as far as to say in the study that there is no second excuse for a well-rested, well-trained surgeon. In other words, 3:00 o'clock in the morning surgeon if he or she has had a horrible day, those three extra hours of sleep are going to help the outcome with antibiotics being started, the results are not going to be far off from they would be if he or she will first thing you know waking up from bed or what have you.

    [24:13]

    So something to consider. It's the time to antibiotics is what we are learning not necessarily the time to operate. Now, there are some studies that go against this and they say sooner is better and they identify and advocate treatment within five hours and there is some that are kind of middle and not so fast. I challenge you to read these studies and make up your own decisions but as it stands in my practice, I would like to get someone to the operating room within six hours if I can, antibiotics start immediately. That 6 to 12 hour, I am fine with so as long as they are on appropriate antibiotics. A lot of people with open fractures do some crazy stuff to get the open fracture. So sometimes they are non-consentable. You have the person who is jumping off the building to commit suicide that needs to be 302ed. You have the person that's in gun fight. You have the person that's drunk on a motorcycle at 2:00 o'clock in the morning. All of these things need to considered and I know in my practice so long as those antibiotics are started, we are okay. So this brings up the question time to change our mind. General orthopedic trauma 2002, the effective time to definitive treatment on rate of non-union infection, open fractures also advocates risk of developing adverse outcome was not increased by address of debridement, lavage and definitive fixation up to 13 hours from the time of injury when early prophylactic antibiotics and open fracture care was initiated. And open fracture can just be stabilization of fracture. So besides the risk algorithms, we need to start to think of our exit plan. Patient stabilization, then limb stabilization especially in the polytrauma patient, stage procedure preventing of infections, minimizing soft tissue complications, and then finally to promote that fracture from healing.

    [26:02]

    So this is where we need to take the extra minute, do we have our external fixation? Do we have our proper wash for this wound? Do we have what we need to do to close this? I want to spend the couple of minutes on irrigation because how many of us used this gun? This pulse lavage, love it. Take the batteries out for your remote at home, kids' toys, no problem. However, irrigation is double-edged sword because there is such a thing as too high of a power of irrigation. Proper pressure is 7 psi. So the question is what creates 7 psi. Higher than 7 psi, you are going to start to see death of the osteoblast. You will see pulse lavage also will shoot the bacteria up the leg and also if antibiotics are in their early in contact with the bacteria long enough to kill it, because we have many studies that show it needs to be 5 minutes of imparted antibiotic coverage touching the actual bacteria in order for the antibiotic to kill, five minutes and that obvious quick jet is not going to stay in contact for five minutes. So are you then shoving or pushing the antibiotic up the leg? Now, people will say bulb syringe. Bulb syringe is what I used to use. First thing when someone comes in with bad pus foot, you put your gentamicin or vancomycin or whatever in the bulb syringe and you wash it out and you just squeeze it and you feel better. However, the pressure here is way lower than the 7 psi. So this is not a very good option either. So this cysto tubing with this hung bag here that you see in the first picture is the way that I now do this and this is the accepted way. This is kind of the way ortho trauma does it in hospital, plastic surgery does it in the hospital. You basically hang the bag. My rule of thumb is above eye level of the highest person in the room, tallest person in the room and then antibiotics in the bag and you just run through 3 or 5 L, at the low side 1 L or the high side 5 L of irrigation depending on how badly infected or contaminated the wound is.

    [28:13]

    And there is actually data behind this. Flow study done shows 111 open fractures, high versus low pressure lavage and low pressure may decrease the reoperation for infection, wound problems and nonunion. Really what you are concerned about is nonunion. The high pressure will kill the endosteal and periosteal blood supply so that you are asking for a nonunion in the future. Antibiotic beads, actually one more than about this. My residents and I always have a little joke about this because a lot surgeons, he or she, will not advocate putting antibiotics in their irrigation. They say, oh studies don't prove, you know, antibiotics you don't need them, saline is just the washing away. My answer to this is, do you take a shower without soap? Of course not, right? You feel a whole heck of a lot cleaner when you get out of a shower and you use that bar dial or ivory. It's a same thing. What are the antibiotics going to do? They aren't going to cause resistance. Take the extra minute to put some antibiotics in and you know I think that's my personal belief. Now, antibiotic beads to dove tail off of that. Some people believe in them, some don't. The problems with antibiotic beads are if you use anything beside the cement, you need to cover over the soft tissue. If you don't cover over, then they turn into what looks like a pussy white chalk you know just kind of just drains out, it's nasty and you can't tell if the person is infected or not. So with open wounds, with osteomyelitis with everything, I have now kind of migrated towards unfortunately the cements. And I say unfortunately because there is a period of time where I used tons of ortho-biologics with antibiotics mixed in, your Pro-Dense from Wright Medical.

    [30:01]

    Stryker has a product that I have used, name escapes me right now, but I stopped using them in something that I can't close over because they would just dissipate and go away. Now, I make bead pouches, I pack them into dead space, I put them over a wire and even now cement has antibiotics in it. You can get a tobramycin infused cement where you don't have to mix or be a cook. Come it out, mix it up, put it on the beads and that's it. Before, you used to have to do a mathematical equation. How much in way of beads I am using? How much in a way of gent or vanco I am using? What happens when I mix the two? Does it cure too quickly or not fast enough? Now, simple stupid, nice and easy. Delayed versus primary closure, moving on. Do you delay your closure or do you primarily close? Well, the answer is people do very fine with primary closure. In 44 injuries treated with debridement, secondary closure, the infection rate is 20%. 495 with primary closure, infection rate is 6%. So obviously we are looking at 10 fold the people with three-fold of the infection rate. So when you have the ability to primarily close, go ahead. With that said, look at that incision the next day of course. Look at it every single day. Don't suture it and say alright see you in a week. You want to make sure that if you start to see the infection developing, popping stitches, culturing whatever you need to do going forward, absolutely essential. Other closure options primary closure, biological skin graft substitute and VAC is where amniotic membranes or Integra or graft jacket whatever we are using, prolayer comes into play, split-thickness skin grafting, free or local muscle flaps. If you have a microvascular plastic surgeon in your hospital terrific. However, literature on antibiotic use supports early primary closure to decrease the risk of nosocomial pathogens, meaning you wouldn't want to walk around in a hospital with an open wound, right?

    [32:04]

    Close it if you can, then likelihood of developing the subsequent infection is much less and you have cultured it so you know what bacteria is likely laying there. Orthoplastics, I put this in. This is a typical ALT flap. This is anterolateral thigh, plastic surgeons taking this flap here from the thigh, tapped it into the tibialis anterior -- I mean to the anterior tibial artery and Ex-Fix to promote fractures stability. Negative pressure wound therapy. My only take-home about negative pressure is it is indicated over bone or periosteum provided you are using the right sponge. If you are not using the right sponge, you will drive the bone out and it's actually contraindicated. So the white sponge if you are using the KCI is the big one over bone or periosteum. It will also buy sometime for you and will decrease the need for flap. My personal settings what I use over bone, you try to keep low pressure 7500 mmHg at high side. If you are trying to actually increase soft tissue coverage and you have a decent vascular base, I am usually in the 175 on the intermittent setting on 10 gains with 8 minutes on and 1 minute off and study show that that will actually increase the rate of soft tissue coverage. Fracture stability you can do with K-wires. You can do it with cast. You can do with external fixator whatever the fracture demands. So I put this in there because this is -- I am sure you guys have these trampoline parks. This is a guy who took his son out to trampoline park. It was his son's 20th birthday and his 40th birthday. They share the same birthday and he came down in an inverted foot. This is actually his talus sticking out here, started antibiotics right away, relocated him, pinned him, nothing sexy, nothing crazy. Just to put the subtalar joint back in alignment.

    [34:02]

    And went on to heal. This is a 93-year-old woman with open fracture that I showed your earlier. She had a trimalleolar fracture, sutured or started antibiotics as we discussed, external fixator in place and here she is primarily closed. On a couple of days, this is what you started to see, pop some sutures, cultured her in a couple of more days. This is what you start to see. No good. Well, at this point the only way I am going to fix this fracture is to go through medial or lateral and obviously we don't have great soft tissue coverage. So I made the decision on 93 years old, I was going to put an IM nail up her leg, which was what we ultimately did. We integrated the surface here at the same time, started low pressure VAC and she went on to heal unremarkably. Once the Ex-Fix was removed then I could control her edema with Profore or multi-layer compression system and she went on to heal unremarkably. So final thing, I say this just because it's important to me. Open fractures are not free from compartment syndrome. Certainly, certainly, certainly has to be in the back of your mind still. There was a thinking that because an open fracture is occurring, someone could not get compartment syndrome. You can get compartment syndrome with an open fracture. Amputation is not a failure. If someone comes in and their toe is looking like this, you can say look we can try to salvage it or amputation, whatever you prefer, but in actuality it's a lot faster to get over it sometimes. The patient if they lose the tip of their toe, they don't have to go back and forth. There is a cost to constant antibiotics, I don't mean financial and cost and trips to the operating room and constant nonweightbearing for a long period of time where as in amputation two, three weeks the person is walking again. So in summary, to recap what we discussed rapid and intermediate antibiotics that cover gram positive bacteria is universally accepted protocol. Duration of time differs in the literature up to 72 hours, 48 to 72 is universally accepted.

    [36:07]

    When the patient is in the ER, they should have an immediate irrigation with debridement as well as reduction stabilization of the fracture as soon as possible; however, ER immediate irrigation, start your antibiotics. You should minimize the removal of the dressing due to positive nosocomial infection but at the same time be comfortable looking at the incision, peaking through document there is no signs of infection. Surgery within the golden window, six to eight hour is recommended but not absolute. Up to 13 hours, as long as those antibiotics have been started, you are in good shape. Primary closure recommended when clinically appropriate. Fixation depends on the fracture pattern and open lesions whether or not they are present. Thank you very much.

    [Applause]


    TAPE ENDS - [36:47]