Managing Open Fractures: Risks, Treatments, and Infection Prevention

Q: Managing Open Fractures: Risks, Treatments, and Infection Prevention

Hello： In response to your question, your sister's condition indeed requires an experienced orthopedic surgeon with expertise in osteomyelitis treatment and soft tissue reconstruction. <br>Generally, orthopedic surgery has various subspecialties, and each attending physician has

Open fracture

Hello Dr.
Lee,
My sister was in a car accident on April 18, resulting in a severe open (comminuted) fracture of her left lower leg.
She is currently receiving treatment at Kaohsiung Chang Gung Memorial Hospital.
Due to the loss of both skin and bone tissue in her lower leg, she has only undergone soft tissue treatment so far, which involved skin grafting and muscle repair.
She is now at home recovering, waiting for the soft tissue to heal before proceeding with bone treatment.
However, during her follow-up visit to the hospital yesterday, the doctor informed her that she could prepare for surgery to address the bone issue.
The doctor also mentioned that there is a 50% chance of surgical failure, primarily due to the risk of bacterial infection, with the potential outcome being amputation.
Currently, her leg is being temporarily stabilized with an external fixator.
The doctor explained that when my sister was first admitted to another hospital (the National Defense Medical Center 802 Hospital), she underwent internal fixation, which was later removed and replaced with external fixation at Chang Gung.
Now, there are cavities in the bone, increasing the likelihood of developing osteomyelitis in the future, hence the 50% risk of surgical failure.
I would like to ask Dr.
Lee, aside from administering antibiotics and maintaining cleanliness, what other measures can be taken to completely prevent bacterial infection in my sister's leg after surgery? Is it inevitable that this type of surgery will lead to a bacterial infection? Are we really gambling with her leg? What if we lose that gamble? However, if my sister does not undergo surgery, she will be unable to walk.
What steps can we take to avoid this issue? Should we consider transferring to another hospital? The doctor has already asked us to obtain X-rays, which clearly indicates that he lacks confidence in my sister's leg.
If we decide to transfer, do you have any recommendations, Dr.
Lee?
Thank you very much for your help!

Xiao Yu, 20~29 year old female. Ask Date: 2005/06/29

Dr. Li Wenlin reply Orthopedics

Hello: In response to your question, your sister's condition indeed requires an experienced orthopedic surgeon with expertise in osteomyelitis treatment and soft tissue reconstruction.
Generally, orthopedic surgery has various subspecialties, and each attending physician has different areas of focus; your sister specifically needs an expert in osteomyelitis.
Online consultations can be challenging to address all aspects of care.
If your sister is near Kaohsiung, I personally recommend that she visit Dr.
Du Yuankun at E-Da Hospital (Yanchao, Kaohsiung), who is an authority in this field.
I believe he will provide the best advice.
Wishing her a speedy recovery.

Reply Date: 2005/06/29

More Info

Managing open fractures, particularly those that are complex and involve significant soft tissue damage, presents a unique set of challenges for both patients and healthcare providers. Your sister's situation, involving a severe open (and potentially comminuted) fracture of the left lower leg, is indeed serious and requires careful management to minimize risks, particularly the risk of infection.

Understanding Open Fractures
An open fracture is characterized by a break in the bone that communicates with the external environment through a wound in the skin. This type of fracture is particularly concerning because it provides a direct pathway for bacteria to enter the body, significantly increasing the risk of infection. In your sister's case, the presence of soft tissue loss and contamination from the accident (e.g., exposure to dirt and oil) further complicates the healing process.

Risks and Infection Prevention
The primary risks associated with open fractures include:
1. Infection: The most significant risk, as mentioned, is the potential for infection, which can lead to complications such as osteomyelitis (infection of the bone) and may necessitate surgical intervention or even amputation in severe cases.

2. Delayed Healing: Open fractures often heal more slowly than closed fractures due to the complexity of the injury and the potential for compromised blood supply.

3. Nonunion or Malunion: There is a risk that the bone may not heal properly, leading to functional impairment.

To minimize the risk of infection, several strategies can be employed:
- Antibiotic Prophylaxis: Administering antibiotics promptly after the injury and continuing them as prescribed can help reduce the risk of infection.

- Wound Care: Keeping the wound clean and properly dressed is crucial. Regular monitoring for signs of infection (increased redness, swelling, warmth, or discharge) is essential.

- Surgical Intervention: In cases where the fracture is unstable or there is significant soft tissue damage, surgical intervention may be necessary to stabilize the fracture and clean the wound thoroughly. This may involve debridement (removal of dead or contaminated tissue) and fixation (using plates, screws, or external fixators).

- Nutritional Support: Adequate nutrition plays a vital role in wound healing and recovery. A diet rich in protein, vitamins (especially Vitamin C and D), and minerals (like calcium and zinc) can support the healing process. Foods such as lean meats, dairy products, nuts, seeds, fruits, and vegetables should be encouraged. Avoiding processed foods, excessive sugar, and alcohol can also be beneficial.

Decision-Making Regarding Surgery
The decision to proceed with surgery should be made collaboratively between your sister, her orthopedic surgeon, and possibly an infectious disease specialist. If the current medical team expresses uncertainty about the outcome, it may be worth seeking a second opinion from another orthopedic surgeon, particularly one who specializes in trauma or complex fractures.

Conclusion
While the risks associated with surgery for open fractures are significant, they must be weighed against the potential benefits of restoring function and preventing long-term complications. Open fractures do carry a risk of infection, but with appropriate management, including surgical intervention, antibiotic therapy, and diligent wound care, the likelihood of successful healing can be improved.
Ultimately, the best course of action will depend on your sister's specific circumstances, including the extent of her injuries, her overall health, and the expertise of her medical team. Open communication with her healthcare providers and possibly seeking a second opinion can help ensure that she receives the best possible care.

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