Austere Open Fracture Care Scenario

[Reasonable Rascal]

Here's a problem for the resident experts to chew on a bit. What is the optimal manner in which to address the following fracture under austere conditions?

Scenario: open fracture Tibia caused by a crushing/striking blow such as a door closing too soon while the leg was in the way.

Medical necessities available: advanced first aid - less than physician level - may include IV's, oral antibiotics, plaster casting, etc but the tools to perform an open reduction, pinning, etc are not available even if a qualified doc should happen by.

Access to primary health facilities is not an option due to weather/civil unrest/lack of gas for the jeep/nuclear strike/residence in the nether regions of Hudson's Bay/name your favorite. Access will be delayed for a minimum of two weeks, possibly months. Outside communication with the Hospital on the Airwaves is likewise not likely.

Your patient is a male in his early/mid-teens, otherwise healthy.

Available practitioners have no *formal* medical training aside from the usual first aid course. Assume they can toss a few stitches, administer IM's competetantly, know the difference between grams and milligrams and can check vitals with reasonable accuracy (don't expect them to know the difference between S1 and S3 sounds though).

What are your recommendations? How would you suggest they handle this?

RR

[oswald1]

Open fractures can be difficult because they must be cleaned out. Under these conditions that may be a problem. My suggestion would be to use the IV to administer fluids initially. The wound must then be cleaned out with generous amounts of clean water or sterile saline if you have enough IV bags.

Go ahead and give the oral antibiotics. Depending on the grade of the open fracture your antibiotic choice would differ. Minimal soft tissue destruction would require a first generation cephalosporin while more extensive soft tissue damage would benefit from addition of an aminoglycoside. Farm injuries also require penicillin. A tetanus shot would be nice if available.

Examine the wound for large particles of debris and remove them but do not remove any bone fragments. This should be done under as sterile a technique as possible. It is very likely that this type of fracture will result in a soft tissue infection or an osteomyelitis. The hardest call for me to make is whether to close the wound immediately or not. These injuries require surgical irrigation and debridement for good results but that's not possible right now. I would probably be inclined to close the wound only because of the bleeding. Bone bleeds like crazy and is very difficult to stop.

Since we have plaster available I would suggest reducing the fracture and making a long leg cast or splint. If you make a cast it would be wise to leave the wound accessible for regular care. The cast or splint would have to immobilize the ankle joint as well as the knee joint.

I am interested to hear the opinions of others on how to approach this. I know how to treat this under ideal conditions but this scenario makes it difficult to make the right decision. I am not concerned about fracture healing at the moment because in the scenario we eventually expect to see a physician and the fracture can be fixed. Infection is our greatest enemy here.

[themadmedic]

IV fluids will likely not be needed,

Irrigate with tap water if local water supply hasn't been contaminated-boiling first isn't a bad idea but prepackaged sterile fluids aren't required necessarily for irrigation purposes. Lots of irrigation-solution to pollution is dilution...

I am assuming we are subacute and that bleeding has been controlled. If not, direct pressure may be used.

Pain control measures should be initiated as availible. Of course, we would withhold any NSAIDs for this patient, including (and especially) Toradol.

Attempt could be made at closed reduction. Would then splint using plaster. Depending on amount of tissue damage, pack with gauze and let heal by secondary intent. I wouldn't close this wound. CLOSE observation due to mechanism of injury for compartment syndrome...

If availible-IV antibiotics, 1st gen cephalosporin such as Kefzol or Ancef for 48hrs, then observe for S/Sx infection. If IV ATB not availible, would use appropriate oral agent(s) as alternative.

No smoking for this patient, ensure adequate nutrition.

[oswald1]

Good point on compartment syndrome. I was wondering how likely compartment syndrone would be considering that the fracture was open to begin with. I would not think that the patient would be likely to get compartment syndrome after the initial bleeding subsided.

Also, I do not have any literature on medicine in austere conditions. If anyone does, what does it suggest for open fractures? Close immediately or leave open and heal on its own.

[RESQDOC]

1. Bleeding control. Bone ends can be sealed with sterilized wax to stop the pesky oozing. Vessel bleeding control by direct pressure, tourniquets, repair.

2. Pain control, best available.

3. Extensive debridment, larger bone fragments are cleaned and retained for replacement. Cleanest fluid possible. A single Povidone Iodine pad in a 1-liter bottle of clean water works very well. Will need 5-10 liters at a minimum.

4. Close this wound and you will at best condemn the patient to amputation for osteomyelitis, at worst kill them from sepsis. Replace all bone fragments possible as near to anatomic position as possible and pack wound with, ideally, very dilute iodine impregnated or antibiotic impregnated packing. Honey +/- iodine is a reasonable alternative. Note you coat the gauze, not saturate the wound. Change twice daily at a minimum.

5. Place leg in traction, 10-15 pounds, or as needed to reduce the leg to the same length as the other leg. Orient to anatomic position, attention to distal pulses, rotation, angulation. Attention to pressure ulceration issues with the traction stirrup. Use plaster material to make a gutter splint/partial cast to protect leg and hold in line, traction site, etc. Leave wound sites open.

6. Antibiotic wash plus parenteral antibiotics, whatever is available but first gen cephalosporins or fluoroquinolones or amp+gent or similar best choices.

7. Tetanus if available.

8. Do not allow wounds to close until there is NO evidence of infection and good granulation tissue formation, then allow to close by secondary intent bottom up and inside to outside – don’t let skin close over open areas underneath.

9. Optimum nutrition, especially calcium + Vit. D, zinc, trace minerals, protein.

10. Quadriceps isometrics immediately, with flexion of knee joint as pain allows.

11. D/C traction at 4 weeks.

12. Cautious weight bearing with crutches at 8 weeks, especially if tuning fork test indicates callus formation and bony fusion. Extensive physical tx.

[themadmedic]

:kool:

[Profit of Doom]

Honey +/- iodine is a reasonable alternative. Note you coat the gauze, not saturate the wound. Change twice daily at a minimum.


Do you really mean honey? I've heard it has antibacterial properties, does this mean just coat the gauze with honey instead the other choices?
Just keep me away from the ants!!!!

[pa4ortho]

heres my version for not just entry level of providers though
1. abc Iv titrated to maintain radial pulse and/or LOC, stat tourniquet
2. pain meds / sedation with ketamine if available / ABO (see below)
3. irrigate heavily 10+ liters
3a. sterile iv solution under 15psi pressure, scrub bone with brushes (the kind we use to scrub hands prior to surg) curette for any exposed hollow marrow. (had to clean out the femur of a manure truck driver)
3b. 2-3 gtts per liter of mild dish soap like dawn. surficant sticks to bacteria and aids in removal better than caustic agents like bleach or betadine. ABO in solution of questionable benefit.
3c. Filtered water with a backpack filter is also an option with the tube ported to an 18ga cath to get 15 PSI reliably. This improv is well studied and shown to be effective. as bacterial contaminants are filtered out.
3d. boiled and cooled water, fuel and time consuming, sooner you irrigate the better.
3e. bottled watter. I have successfully treated a pre tibial abscess gone on to osteo with street corner surg digging out the tibia and irrigating with bottled water (put a pin hole in the bottle and squeeze the fluid out.) placed on oral abo (gatifloxacin x 4 weeks) packed wound open. no follow up until 2 weeks later. doing great at 6 month f/u.
4. aggressive wound debreidment on a daily or every other day basis with further irrigation is required. and old (pre abo) technique of continuous irrigation of the wound under dressings for 3 or so days may be worth considering. (messy) just to further dilute bacteria counts. Devitalized tissue just grows bugs. this fx will not heal in the face of infection. Repeated debridement is essential to maximize opportunity to heal and to assess for failure to control infection resulting in amputation vs sepsis.
5. All efforts should be made to cover the bone with viable tissue and minimize trauma to the periostium should be made to maximize blood supply to the bone. Small pieces of free bone will die but if they are clean they can be placed in the fx to provide a scaffolding for new bone growth. If they dont fit crush them up and pack them into the fx.
6. bone wax can be used to stop bleeding in a sterile surgery but acts as a foreign body in and infected wound. As it can be a nidus of infection, it is contraindicated. tie off major vessel bleeders, pack all others, the bone may bleed but will stop if left alone so it can clot.
7. ok so heres where it gets tough. this bone needs imobilisation for pain control and to minimize bleeding and definitively to allow this bone to heal (we hope)
7a. ex fix applied in the OR later plate fixation or rod when no infection.
7b. stainless self drilling (like a sheet metal screw tip) lag bolt. think small diameter and long shaft with the head removed and lightly pointed. sterilized and placed 2 above and 2 below the fx with a drill. Use a reference manual for pin placement. Cut the skin and blunt dissect to the bone. dont alow any skin tension on the pin after placement. Remember you get resistance with each cortex. stop when you pass the 2nd cortex. If you are not centered you will not get this double resistance sensation. Estimate bone diameter prior to starting drilling of bone and stop when you have progressed the desired depth. Palpate the oposite side for the tip of the screw to assess for over penetration. Reduce the fx and have an assistant maintain alignment, and rotation. if the bone is short consider not distracting the fx to length. Instead leave the ends together as malunion beats non union. take a large dowel and press it into the pins leaving a mark in the wood where the pins touch it. drill the dowel aproximating the alignment of the pins with a drill slightly smaller than the shaft of the lag portion of the screws. apply a light layer of epoxy adhesive and press dowel into place. if possible place a second dowel also
7c. Ok so if the above is not an option due to materials or skill. Plaster splint with no plaster over the wound so you can do wound care. extensive bulky padding. do not circumferentially cast due to risk of compartment syndrome in any compartments that are not open. place 4 3" kerlex rolls loosly around the leg as padding. splint with a length of 4" plaster from fibular head - under foot and up the other side . repeat starting from the medial proximal tibia going the oposite way overlapping. wrap with elastic wrap or long cloth strips rolled into place. NO DENTS When set apply a removable knee splints to control rotation.
7d. Ok so you dont have plaster use thick soft padding then flour paste and cloth strips to make a splint like paper mache but with cloth. reinforce with integrated small dowels or tent poles. remember even micro motion can lead to non union. it must be ridgid as there are layers of padding and soft tissue that are already going to unfortunately alow motion.
8. I would not advocate prolonged bucks traction due to skin breakdown. also bone heals under compresion not distraction.
9. pt must be turned frequently and be on a soft surface. elevate the injury, ice for swelling and pain
10. DVT is a significant risk so frequent movement/massage of the other leg and compartments that cant be accessed without moving the fx is important.
11. Deep breathing every hour while awake to prevent pnumonia/ards. Blow up a balloon every hour.
12. Consider donor to recipient transfusion if indicated and/or possible ( a whole other discussion)
13. 6 weeks ABO if available. (see sanfords guide) use what you have. I use a broad spectrum quinolone initialy like gatifloxacin moxifloxacin cipro. then ancef IV. doxcycline and rifampin po are a good bone penetrators.
14. If you can give a femoral and sciatic nerve block this patient will love you.
otherwise its IV po narcotics with stool softener, nsaids based on whose study you belive, tylenol,
15. no tobacco of any kind or smoked MJ due to decreased blood flow to already compromised tissue.
16. This patient can take from 8 weeks to 6 or more months to heal make sure your group has the resources to treat for the long haul or don't start.
17. this patient may require illiac crest bone graft to the fx at 3 month's if no healing.

Dont hesitate to amputate if infection cant be controlled. life over limb.
hope you never need this info but if you do I hope this helps.

pa4ortho

[pa4ortho]

case study: 2004 outside usa

11y/o moderately nourished male gsw anterior mid tibia from 7.62 x 51. NVI distal.

tx with irrigation in makeshift "OR" I had zosyn iv to give for 3 days then ancef for 2 weeks. (traded for beer) (got beer trading for info on water sanitation) initial stabilization by blind placement of off the shelf ex fix absconded from lets just say somone who wouldent miss it too much....
local wound care done by family of pt. NWB crutches. soft tissues mostly healed at 5 weeks with wet to dry dressings. ex fix removed at 8 weeks with decreased tenderness @ fx site. (ex fix given to local "hospital" for reuse) casted with plaster. TTWB in plaster. cast d/c at 12 weeks. able to get 2 view x ray finally. callus x 4 cortex. transition to FWBAT over 2 weeks. working rom, strength etc... no s/s infection
lost to further follow up untill phone call from a local medic last week. kids playing soccer well.

you can do a lot with a little
hope this helps.

pa4ortho

[Craig]

Well done pa4ortho

Your dead right. The basics done well even in the most most austere environment can and do have great outcomes more often than we imagine.

cheers
Craig

[pa4ortho]

PO Antibiotics in the event of open Fracture in remote settings.

so after literature review, 2 orthopedists, and an infectious dissease doc, heres what I got so far.

Irrigation with whatever clean solution is paramount. Time is not so important as previously thought, after review of the military trauma registry data. I spite of the data I will irrigate as soon as feasible based on the situation. I will not put the team or patient at risk to irrigate faster.

For relatively small clean wounds with minor or questionable penetration. A cephlosporin like keflex which is cheap and readily available is a first choice. Discussion on MRSA and awareness of resistance my guide other choices. doxycyline is also a good choice as most "community acquired" MRSA is still sensitive to this great old drug that should be in everyones kit. Septra is a 3rd option in a pinch.

For dirty small wounds a quinolone like moxifloxacin, levoquin, or cipro (in order of preference) are good broad spectrum choices.

If extensive periosteal stripping is present or severe compound fx with disruption of blood supply to the bone the above quinolone plus rifampin

If a contamination includes fecal mater "barnyard" irrigation canal, area with open sewers or flooding etc... add an aditional drug from the penicillin class.

I hope this is helpful, and easier to read, as I am actually typing on a keyboard instead of my phone like I usually do.

I look forward to feedback from the community

pa4ortho

[Efraim]

PA,

Nice work up. My apologies though I am something of a noob at this and have a couple questions:

PO ABO, say doxy (cause that seems to be the most common), how much?
Would you cast or use traction?

[pa4ortho]

Good questions well thought out. dont ever apologise, none of us know everthing. Your team thanks you for your interest im sure. Besides Thanks for writing and stimulating discussion on this forum. Thats how this works. (hope others take a hint and dont just read)

Doxycycline 100mg po twice a day for at least 6 weeks (12 weeks would be beter) for an open fracture
minocycline and tetracycline are in the same class. I like some of the other options like quinolones better.
PS tetra stores great if manufactured in the last 20 years. old manufacturing method had the storage toxicity problem

I advocate splinting ie molded hard strips that alow for expansion with swelling. Many fx can be managed start to finish with this if the patient can be carefull with it even after it stops hurting. alternitively as cast can be applied when the swelling is gone. 2 weeks in the splint and 4 in a cast is a typical distal radius protocol for example. There are thousands of varients to this. Hopenfeilds book on fracture management is clear concise and easy to read.
traction can be used initialy in long bone (femur) fx to minimize painfull spazm as needed. the muscles fatigue with 5-7 lbs over time and relax. Prolonged traction used to be used in fractures prior to modern surgical techniques. A pin was placed in the bone as a boot will break down skin over time. The patient cant move well (poop) in this type of set up and backside skin breakdown was common due to shear. The goal was to restore length in cominuted fractures. non union was common. with limited resources I prefer mal union (short) to non union. A shoe lift is easy to devise later. just make sure the big toe is aligned with the patella. rotation can't be fixed.
Bones require gravity (stress) to maintain their strength. Astronauts come back after extended stays osteoporotic. Compression on a fracture stimmulates bone growth. compression can only be applied surgically with hardware. dont try to push something together with a cast as it will only lead to skin breakdown.
without compression most bones will heal just fine if simply imobilized without traction.
In the above example of a tibia fracture (a difficult bone to heal) I would assess for calluss using pain and sound transmission in the absence of xray. As soon as possible initiate wt bearing to 20 lbs and very slowly progress as tolerated to stimulate further healing. Any bone type pain at the fracture means back off on the activity. Later as the wound is healed start water walking as a great way to get muscle exercise and control weight bearing by adjusting the depth of the water. Start with slow treading water in a life jacket.
Imobilization has its own risks however. skin breakdown, difficult hygene, and post casting stiffness. rehab is essential to restore mobility. Gentle prolonged stretching works best. In the above example a soft 10 inch ball can be used to gently stretch the ankle in all directions by rolling with the foot on top while seated. Scar massage, heat prior to therapy and cold after to stop inflamation in general.

the abreviations
fx fracture
nwb non weight bearing
s/s signs and symptoms

Bad grammer etc due to writing this on my phone. it puts in the word it wants to if im not looking to closely

You need to spend some time in an ortho fracture clinic to get casting/splinting skills

----pa4ortho