Acute Management of Open Long Bone Fractures: A Scoping Review

Abstract

Objective The best practices in the acute management of open long bone fractures continues to change. We now have better data regarding interventions such as antibiotic management, irrigation solutions, appropriate timing of surgical debridement, and management of ballistic injuries. We aim to review the acute management of open long bone fractures and provide a management pathway. Method A computerized literature search of articles regarding treatment of open long bone fractures (including ballistic fractures) in adults was performed. Sixty-nine articles were included in this review. We assessed the duration of prophylactic antibiotic administration, time to debridement, irrigation practices, methods of local antibiotic delivery, and other management strategies, focusing on fractures from ballistic trauma. Result Twenty-four hours of cefazolin is the antibiotic of choice for open fractures. Adding gram-negative coverage is recommended for type III open fractures, mainly if soft tissue coverage is unlikely to be achieved within five days. Irrigation and debridement within 24 hours with low-velocity normal saline without local antibiotic delivery is acceptable. Ballistic fractures receive a course of prophylactic oral cephalosporin for low-velocity ballistic fractures and 48-72 hours of broad-spectrum coverage for communicating bowel injury. Conclusion Given the findings, our suggested management pathway is as follows: Type I open fractures receive 24 hours of intravenous (IV) cefazolin or, if discharged, one dose of IV cefazolin and Keflex for 48 hours. Vancomycin, cefepime, or aztreonam are used for type III fractures until 24 hours after wound closure. Metronidazole (Flagyl) is added for 72 hours for associated bowel injury. Additionally, vancomycin and cefepime are used when soft tissue coverage is delayed more than five days. Formal irrigation and debridement with low-velocity normal saline in the operating room is to occur within 24 hours for type II and III fractures. Level of Evidence V, Therapeutic