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Open Fractures of Femur

- Discussion of Open Femur Frx: (see open frx menu)
    - see: gun shot wounds
    - rates of wound infection should be < 4 % w/ meticulous debridement of wound;
    - rates of union and the functional results have been comparable with those obtained after nailing of closed fractures;
    - compartment syndrome of thigh after open frx is rare;
    - rate of infection based on gustilo classification:
             - in the study by Yokoyama K, et al (1999), all patients with open fractures received debridement but no antibiotic beads;
             - rate of infection was 2.3% for grade I and II vs 17.6% for grade III;

 - Early vs. Delayed IM roding; (see IM Nailing Menu)
    - work up for IM Nailing / surgical technique
    - multiply injured patient w/ injury severity score > 18 run high risk of pulmonary complications and benifit significantly from early fracture stabilization;
    - frx fixation should be within 24 hrs of injury;
    - improved survival results from lower incidence of sepsis due to a decreased rate of pulmonary and cardiovascular insufficiency;
    - degree of soft tissue necrosis, crush, & periosteal stripping is well detailed in the Gustilo classification;
    - risk of infection vs operative timing:
           - the longer wound remains open, greater chance for wound contamination;
           - this is reflected in Gustilo classification by categorizing any open fracture whose debridement is delayed for more than 8 hrs as a grade III open fracture;
           - Brumback, et al. (1989)
                  - concluded that immediate IM nailing of open femoral frx was contraindicated if debridment procedure was delayed > 8 hrs;
                  - timely, debridment is prerequisite to immediate IM nailing;
           - in the study by Yokoyama K, et al (1999), there was no significant difference in the infection rate between early and delayed fixation of open femoral fractures;
           - in the study by Klemm and Borner (1986), there was a deep infection rate of 8.5% when IM nailing was delayed 7-10 days;
    - references:
           - Immediate Nailing of Open Fractures of the Femoral Shaft.
           - Comparison of mortality of patients with multiple injuries according to type of fracture treatment--a retrospective age- and injury-matched series.
           - Blunt multiple trauma (ISS 36), femur traction, and the pulmonary failure-septic state.
           - Early versus Delayed Stabilization of Femoral Fractures.  A Prospective Randomized Study.
           - Deep infection and fracture healing in immediate and delayed locked intramedullary nailing for open femoral fractures.
           - Immediate interlocking nailing of fractures of the femur caused by low- to mid-velocity gunshots.
           - Femur fractures caused by gunshots: treatment by immediate reamed intramedullary nailing
           - Intramedullary nailing of open fractures of the femoral shaft.
           - Interlocking nailing of complex fractures of the femur and tibia.
                - no pt w/ isolated femoral fracture (ISS < 18) developed pulmonary insufficiency, but 23% of those w/ isolated injuries treated w/ delayed ( > 72 hrs) had abnormal blood gases as compared to 10% of pts whose frx were treated within 24 hrs;
                          - in the multiply injured patients, the difference was even greater;
           - Pulmonary and cardiovascular consequences of immediate fixation or conservative management of long-bone fractures.
           - Early osteosynthesis and prophylactic mechanical ventilation in the multitrauma patient.
           - Incidence of adult respiratory distress syndrome in patients with multiple musculoskeletal injuries: effect of early operative stabilization of fractures.
           - Fat embolism in patients with multiple injuries.

- Guidelines: 
    - antibiotic prophylaxis
    - injury, grade I & grade II open frx w/o gross medullary contamination are best treated by immediate IM nailing;
    - w/ IM rodding: debridment should be separate procedure from nailing; frx site should be isolated from operative field;
    - grade IIIA open femoral frx may be rx'ed w/ immediate IM nailing, if debrided w/ in 8 hrs of injury;
    - if debridment is delayed, or if IIIB injury is present, then temporary external fixation is rx of choice;
          - most grade I, II, and IIIA have low rates of infection, however, grade IIIB will have significant rates of infection (see osteomyelitis);
          - isolated open frx w/ severe contamination require external fixation;
    - grade IIIC: frx associated w/ arterial lesions (see arterial trauma and femoral artery)
          - external fixation is best method of stabilization
          - quickly applied and may be repositioned;
          - if patient is unstable, consider amputation;

   - Wound Management:
    - Wound Dressings
    - Contaminated Wound Care
    - Drains and Closure of Wounds
    - Antibiotic Beads

Immediate Nailing of Open Fractures of the Femoral Shaft.

Comparison of mortality of patients with multiple injuries according to type of fracture treatment--a retrospective age- and injury-matched series.

Early complications in the management of open femur fractures: a retrospective study.

Interlocking nailing for the treatment of femoral fractures due to gunshot wounds

Management of open fractures with sterilization of large, contaminated, extruded cortical fragments

The role of intramedullary fixation in open fractures. 

Open adult femoral shaft fracture treated by early intramedullary nailing. 

The treatment of open femoral fractures with bone loss

Open distal femur fractures treated with lateral locked implants: union, secondary bone grafting, and predictive parameters.