Seventy-two-hour Protocol for Achieving Coverage of Complex, Open Fractures

Open fractures, usually resulting from automobile or motorcycle accidents, are often associated with poor long-term outcomes involving loss of function, amputation and mortality. “To preserve the limb, the most important goals are to stabilize the fracture, decontaminate the wound, and preserve or re-establish the blood supply,” explains Henry Boateng, M.D., Penn State Hershey Bone and Joint Institute.

At Penn State Hershey Bone and Joint Institute, a protocol aimed at achieving complete coverage and definitive fixation of open fractures within seventy-two hours after presentation has been aggressively implemented, based on evidence showing they improve patient outcomes.1,2 “At Penn State Hershey, we have a trauma team led by orthopaedists who specifically deal with complex open fractures. The first steps are to assess and decontaminate the wound, followed usually by external fixation of the fracture. On the night of injury, a plastic surgery consult is obtained to assess the wound for coverage. If there’s a vascular injury we work in tandem with vascular surgery. A secondary debridement is often needed. A plan for definitive fixation and coverage is typically established. By the third day after presentation, at the latest, the fracture is definitely fixed and the plastic surgeon uses a free flap or local flap for wound coverage. Certainly, in some cases this isn’t possible and conversely, some cases are covered sooner, but the third day (seventy-two hours) is our goal, when we believe the outcome is much better for the patient,” says Boateng.

Complex Open Fracture

X-rays from a recent patient treated with immediate temporary stabilization followed by repeat irrigation and debridement. At the second irrigation and debridement, the wound was cleaned and definitive fixation was performed, followed by a rotational flap performed by the Penn State Hershey plastic surgery team. The fixation and coverage occurred within seventy-two hours of initial presentation and surgery.

One patient recently treated at Penn State Hershey highlights the importance of achieving a clean, fixed, and well-perfused wound for the optimal patient outcome. This patient had sustained a level 3C injury, marked by an open fracture with vascular loss and soft tissue damage. “The patient faced the possibility of limb amputation, so it was critical to bring Penn State Hershey vascular surgeons on board to reperfuse the limb,” notes Boateng.

Initial decontamination and later secondary debridement of nonviable tissue proved paramount for success. By following the seventy-two-hour protocol, and achieving a clean, covered, and stable fracture, the team was able to preserve the limb. Although the patient has experienced some loss of function, he is able to walk and is working in rehabilitation to achieve a fuller recovery.

Boateng remarks, “The rapid fixation, seventy-two-hour protocol’s success, particularly for this patient who had very complex injuries, really depends on forming a dedicated team of surgeons and trauma professionals who work together, regularly. Team members learn from each other over time, and it leads to better coordination and more effective communication to deliver expedited care.”


Henry Boateng, M.D.Henry Boateng, M.D.
Assistant professor, orthopaedics and rehabilitation
Orthopaedic trauma surgeon
Phone: 717-531-1363
Fellowship: Orthopaedic trauma, Brigham and Women’s Hospital, Boston, Massachusetts
Residency: Orthopaedic surgery, Johns Hopkins Hospital, Baltimore, Maryland
Medical School: Georgetown University School of Medicine, Washington, D.C.


References:

  1. Gopal S, Majumder S, Batchelor AGB, Knight SL, De Boer P, Smith RM. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br, 2000; 82:959-966.
  2. Zalavras CG, Marcus RE, Levin LS, Patzakis MJ. Management of open fractures and subsequent complications. J Bone Joint Surg Am, 2007; 89:884-895.

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