From the Guidelines
The initial management of an open radial fracture requires immediate wound irrigation, intravenous antibiotics, tetanus prophylaxis, and temporary stabilization before definitive surgical treatment, with the goal of bringing the patient to the operating room for débridement and irrigation as soon as reasonable and ideally before 24 hours post injury. Begin by controlling bleeding with direct pressure and elevating the extremity. Irrigate the wound with sterile saline to remove visible contaminants, as suggested by the guidelines 1. Start broad-spectrum antibiotics promptly, typically a first-generation cephalosporin such as cefazolin 1-2g IV every 8 hours, with addition of gentamicin 5mg/kg IV daily for heavily contaminated wounds, as recommended by the guidelines 1. Add penicillin G 4 million units IV every 4-6 hours if farm-related injury or soil contamination is present. Administer tetanus prophylaxis according to immunization status: tetanus toxoid if vaccination is current but >5 years old, or tetanus immunoglobulin plus toxoid if vaccination status is unknown or >10 years. Apply a sterile dressing to the wound and temporarily immobilize the fracture with a splint while maintaining proper alignment. Do not attempt to reduce the fracture or close the wound in the emergency setting. Pain management with appropriate analgesics is essential. The patient should remain NPO (nothing by mouth) in preparation for urgent surgical debridement, irrigation, and fracture fixation, which should ideally occur within 24 hours of injury, as suggested by the guidelines 1. This comprehensive approach addresses both the soft tissue injury and bone trauma while preventing complications like infection and compartment syndrome. Key considerations include:
- Early delivery of antibiotics to lower the risk of deep infection in the setting of open fracture in major extremity trauma 1
- Use of sterile saline solution for initial wound management, without additives, as recommended by the guidelines 1
- Temporary stabilization and preparation for urgent surgical intervention, with the goal of minimizing infection risk and promoting optimal outcomes.
From the Research
Initial Management of Open Radial Fracture
The initial management of an open radial fracture involves several key steps to prevent infection and promote healing.
- Antibiotic Prophylaxis: The use of antibiotic prophylaxis is recommended to decrease infectious complications 2, 3, 4, 5, 6.
- Timing and Duration of Antibiotics: For Grade I and II open fractures, antibiotics should be administered within 3 hours of initial injury and continued for 24 hours after initial injury 2.
- Choice of Antibiotics: A first-generation cephalosporin (e.g., cefazolin) is recommended for Grade I and II open fractures, while Grade III open fractures require coverage with an aminoglycoside in addition to a first-generation cephalosporin 2, 5.
- Surgical Débridement: Time to surgical débridement within 12 hours of injury has not been reported to affect the rate of infection, given that a patient is being treated with antibiotics 4.
- Soft-Tissue Management: The management of the bone and the soft tissues in a patient with an open fracture is the major determinant of fracture healing and functional restoration of the injured extremity 4.
- Fracture Fixation: Selection of fracture fixation depends on the fractured bone, the location of the fracture, the extent of soft-tissue injury and contamination, and the physiologic status of the patient 4.
Considerations for Specific Types of Open Fractures
- Type I or II Open Fractures: In type I or II open extremity fractures, extended-spectrum antibiotic coverage is not recommended compared with gram-positive coverage alone to decrease infections complications 6.
- Type III Open Fractures: In type III open extremity fractures, antibiotic therapy for no more than 24 hours after injury is recommended, in the absence of clinical signs of active infection, to decrease infectious complications 6.
- Type III Open Fractures with Associated Bone Loss: In type III open extremity fractures with associated bone loss, antibiotic therapy in addition to systemic therapy is recommended to decrease infectious complications 6.