From the Guidelines
The treatment for open fractures of the great toe requires immediate medical attention and typically involves surgical intervention within 24 hours of injury, as suggested by the American Academy of Orthopaedic Surgeons 1. The goal of treatment is to prevent infection, promote healing, and restore function. Initial management includes:
- Thorough wound irrigation and debridement to remove contaminants and devitalized tissue
- Appropriate antibiotic therapy, such as a first-generation cephalosporin (cefazolin 1-2g IV every 8 hours) plus an aminoglycoside (gentamicin 5-7mg/kg IV daily) for broad-spectrum coverage against potential pathogens including Pseudomonas, as recommended by the American Academy of Orthopaedic Surgeons 1
- Tetanus prophylaxis should be administered if the patient's immunization status is outdated Surgical stabilization of the fracture is usually necessary, which may involve:
- Kirschner wires
- Screws
- Plates depending on the fracture pattern and severity. Following surgery, the toe is immobilized with a post-operative shoe or cast for 4-6 weeks. Weight-bearing restrictions are typically implemented for the first few weeks, with gradual progression as healing occurs. Physical therapy is often recommended after immobilization to restore range of motion and strength. The use of negative pressure wound therapy (NPWT) is not recommended for open fractures, as it does not mitigate the risk of developing a surgical site infection (SSI) 1. Early delivery of antibiotics is suggested to lower the risk of deep infection in the setting of open fracture in major extremity trauma 1. It is essential to note that open fractures require aggressive treatment because they carry significant risks of infection, delayed union, and long-term complications due to direct communication between the fracture site and external environment, which allows bacterial contamination of bone and surrounding soft tissues.
From the Research
Treatment Overview
The treatment for open fractures of the great toe involves several key steps, including:
- Adequate debridement and copious irrigation to prevent infection 2
- Parenteral administration of antibiotics, which should be started immediately and continued for a certain period depending on the wound closure method 2
- Fracture fixation, which may involve immediate internal fixation in certain cases, such as polytraumatized patients or type III open fractures 2
- Soft tissue management, which is crucial in preventing infections and promoting healing 3, 4
Timing of Treatment
The timing of treatment is critical in open fractures. While traditional practice recommends irrigation and debridement within 6 hours of injury, recent studies suggest that this may not be as crucial as previously thought, as long as it is performed within 24 hours 5. Early debridement by an experienced team within 24 hours seems adequate, but immediate surgical intervention may be required in cases of gross contamination, devascularized limb, multi-injured patient, or compartment syndrome 4.
Wound Closure and Antibiotics
Wound closure during the first surgery has been shown to result in reduced rates of infections and nonunion 4. If soft-tissue reconstruction is needed, it should be performed within the first 7 days. Broad-spectrum antibiotic therapy is reasonable for Gustilo-Anderson type I and II fractures, while additional aminoglycosides may be recommended for type III fractures 4. Local antibiotics, such as antibiotic beads, may also be beneficial in preventing infections 4.
Fracture Fixation and Soft Tissue Management
Fracture fixation should follow general traumatological principles, with simple injury patterns treated by primary fixation and wound closure, and more complex cases requiring temporary fixation and wound closure 3. Soft tissue management is critical in preventing infections and promoting healing, and may involve the use of vacuum-assisted closure (VAC) or recombinant human bone morphogenetic proteins (rhBMP)-2 in certain cases 4.