Management of Gustillo Type 3 Open Fracture with Delayed OR
Do not close the wound with staples—leave it open and irrigate with saline, then cover with a sterile dressing until definitive debridement and stabilization in the OR. 1
Wound Management
Leave the wound open until OR. The AAOS guidelines support definitive stabilization and primary closure at the time of initial débridement in selected open fractures, but this is a moderate strength recommendation with significant variability in outcomes 1. For a Gustillo Type 3 fracture awaiting OR in 6 hours, premature closure with staples would trap contamination and increase infection risk.
Initial Wound Care Steps:
- Irrigate immediately with simple saline solution (without additives) - this is a strong AAOS recommendation, as soap or antiseptics provide no additional benefit 1
- Apply a sterile dressing after irrigation 2
- Avoid high-pressure irrigation, as it has not been demonstrated to be beneficial 2
Antibiotic Regimen for 80kg Patient
Start antibiotics immediately—do not wait for OR. Delaying beyond 3 hours significantly increases infection risk 3, 4.
Specific Dosing for Type III Open Fracture:
Primary regimen (preferred by AAOS):
- Piperacillin-tazobactam 3.375g IV every 6 hours (or 4.5g every 8 hours for 80kg patient) 1
- This provides both gram-positive and gram-negative coverage in a single agent
- AAOS specifically states piperacillin-tazobactam is preferred for Type III fractures 1
Alternative regimen if piperacillin-tazobactam unavailable:
- Cefazolin 2g IV every 8 hours (for 80kg patient, use 2g dosing) 1, 3
- PLUS
- Gentamicin 5-7 mg/kg IV once daily (400-560mg for 80kg patient, adjust for renal function) 1, 3
- OR Amikacin 15 mg/kg IV once daily (1200mg for 80kg patient) 5
If penicillin allergy:
Important Antibiotic Considerations:
- Do NOT add vancomycin or gentamicin to piperacillin-tazobactam—AAOS guidelines state this does not appear to be helpful 1
- Administer the first dose within 60 minutes before incision if going to OR, but given the 6-hour delay, start immediately now 3
- Continue antibiotics for 24-72 hours post-injury or until wound closure, but no more than 3-5 days without evidence of infection 3
Timing to OR
The 6-hour delay is acceptable. The AAOS guidelines debunk the traditional "six-hour rule" with moderate strength evidence showing that surgery can safely occur within 24 hours for most open fractures 1. The current evidence is insufficient to define an optimal time less than 24 hours, allowing for better resource allocation with a properly staffed OR 1.
Exceptions requiring immediate OR:
- Vascular injury requiring repair 1
- Compartment syndrome 2
- Gross contamination with devitalized tissue 2
- Multi-trauma patient requiring damage control 2
Additional Considerations for OR
Consider local antibiotic strategies during definitive surgery:
- Vancomycin powder, tobramycin-impregnated beads, or gentamicin-covered implants may all be beneficial as adjuncts (moderate AAOS recommendation) 1, 3
- These are particularly useful in Type III fractures with bone loss 3, 2
Wound closure strategy in OR:
- Definitive stabilization and primary closure at initial débridement is supported for selected open fractures, though outcomes vary 1
- If soft tissue reconstruction is needed, perform within 7 days 2
- Consider negative pressure wound therapy (NPWT) for temporary coverage if primary closure not feasible, though cost-benefit for open fractures is not fully established 1
Common Pitfalls to Avoid
- Do not close the wound before OR—this traps bacteria and increases infection risk
- Do not delay antibiotics—every hour beyond 3 hours increases infection risk 3, 4
- Do not use antiseptic irrigation solutions—saline alone is equally effective and less toxic 1
- Do not continue antibiotics beyond 72 hours without evidence of infection—this increases resistance and C. difficile risk 1, 3
- Do not add vancomycin routinely—it does not improve outcomes in Type III fractures 1, 3