What are the treatment options for an open fracture of the elbow?

From the Guidelines

An open fracture of the elbow requires immediate medical attention, and treatment should begin with wound irrigation using saline solution without additives, as recommended by the American Academy of Orthopaedic Surgeons 1. This injury involves a break in the bones of the elbow with an associated wound that exposes the fracture to the external environment.

Initial Management

Treatment should also include intravenous antibiotics, such as a first-generation cephalosporin like cefazolin 1-2g IV every 8 hours, plus gentamicin 5mg/kg IV daily for heavily contaminated wounds, as suggested by recent guidelines 1. Tetanus prophylaxis should be administered if needed. Some key points to consider in the management of open elbow fractures include:

• Early delivery of antibiotics to lower the risk of deep infection 1
• Surgical debridement within 6-8 hours of injury
• Fracture stabilization through external fixation or internal fixation depending on contamination severity
• Post-operative antibiotics continued for 24-72 hours based on wound classification

Surgical Intervention

Surgical timing has been debated, but the current evidence is insufficient to define an optimal time to initial surgical intervention of less than 24 hours 1. However, some fractures may require more urgent attention.

Pain Management and Rehabilitation

Pain management includes scheduled acetaminophen (1000mg every 6 hours), NSAIDs if not contraindicated, and opioids as needed. Physical therapy should begin as soon as stability allows, usually within days of surgery, to prevent stiffness and restore function. Open elbow fractures are serious injuries with risks of infection, nonunion, and post-traumatic arthritis, making prompt treatment crucial for preserving elbow function and preventing complications. The use of local antibiotic strategies as an adjunct, such as vancomycin powder, tobramycin-impregnated beads, and gentamicin-covered nails, may be beneficial 1. The role of negative pressure wound therapy (NPWT) should be considered independently, but it does not appear to be beneficial after open fractures 1.

From the Research

Overview of Open Fracture Elbow

• Open fractures about the elbow are an infrequent but complex injury with limited existing literature 2.
• The commonest grade of open injury was grade 3 (43%) in a study of 21 patients with open elbow fractures 2.
• Associated orthopedic injuries were present in 62% and associated system injuries in 57% of patients with open elbow fractures 2.

Treatment and Outcomes

• Complete bony union was noted in 85% of patients with open elbow fractures, and 48% of patients required removal of metalwork 2.
• The average Oxford Elbow Score, EQ-5D, and EQ-VAS scores for the whole cohort at final follow-up were 37.4,0.54, and 62.18, respectively 2.
• Subgroup analysis indicates open distal humerus fractures carry the highest risk for further procedures, most commonly in the form of removal of metalwork and fibrinolysis 2.

Antibiotic Prophylaxis

• Ceftriaxone is a safe and effective alternative for open fracture extremity management that offers the advantage of 24-hour dosing and single antibiotic coverage for grade 3 open fractures 3.
• A review of the literature strongly supports the use of antibiotic prophylaxis in open fracture management, with cephalosporins being the drugs of choice in cases of orthopaedic trauma 4.
• Antibiotic prophylaxis should be given as soon as possible to all patients with open fractures and Type 3 fractures, and prophylaxis should continue until 48 hours after adequate soft tissue coverage is achieved 4.

Best Practices

• Open fracture management is a common challenge to orthopaedic trauma surgeons and a burdensome condition to the patient, health care, and entire society 5.
• Fracture-related infection (FRI) is the leading morbid complication to avoid during open fracture management, and key strategies to prevent FRI include optimizing host factors, antimicrobial prophylaxis, surgical site management, provision of skeletal stability, and soft-tissue coverage 5.
• Elbow fractures are challenging to treat because the articular surfaces must be restored perfectly and associated soft tissue injuries must be recognized and appropriately managed 6.