Bariteau JT et al. Sensitivity of the saline load test with and without methylene blue dye in the diagnosis of artificial traumatic knee arthrotomies. 21.02501 1 Td Keller Procedure (resection arthroplasty) indications elderly, low demand patients with significant joint degeneration and loss of motion that allows for rapid rehabilitation contraindications patients with pre-existing rigid hyperextension deformity of 1st MTP joint outcomes good results have been noted in low demand elderly patients Please enable it to take advantage of the complete set of features! )Tj ( and click on the [Reprints and)Tj 2014;72(1):61-9. 2007 Aug;21(7):442-3. doi: 10.1097/BOT.0b013e31812e5186. Setup. Are you sure you want to trigger topic in your Anconeus AI algorithm? Costs of Care for Low-Energy Extremity Gunshot Injuries are Reduced With Standardized Treatment. \240doi:10.2106/JBJS.G.01682 )Tj (Solution Load Test)Tj 2015 May 20;97(10):846-9. doi: 10.2106/JBJS.N.01327. -3.61601 -3.8 Td document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Note: this service is provided by a third party, we do not collect your information in any way. A summarised guide on these often frequently carried out proceduresv - arthrocentesis & arthrotomy. ( 2009;91:66-70. q 1 0 0 1 72 557 cm 0000000616 00000 n Cavus Foot Reconstruction. Are you sure you want to trigger topic in your Anconeus AI algorithm? endobj Cavus Deformities. Traumatic Arthrotomy. q 1 0 0 1 72 471 cm government site. Ligaments, cartilages, and tendons are key structures both around and outside the joint. Injury 2013; 44: 14981501. BT The potential advantage of Initial evaluation of periarticular wounds includes thorough examination of the wound and plain radiographs. Historically, the saline load test has been the diagnostic test of choice for assessing traumatic arthrotomy; however, CT has recently been shown to have excellent sensitivity and specificity for detecting open knee joint injuries. This site needs JavaScript to work properly. 454 0 l endobj Type in at least one full word to see suggestions list. Accessibility endobj 0000003871 00000 n /T1_0 1 Tf FN0370q080p8 QW(&0`fw9m8+#Dc5@ 2 Wounds that violate the joint capsule can result in deep infection and sepsis. A systematic review of the literature. Different countries in which training hospitals use our PASS Enterprise analytics platform. /T1_1 1 Tf A systematic review of the literature. /Im0 Do A saline load test (SLT) is the most common, non-surgical approach and diagnostic test for traumatic knee injuries involving the joint. *A=`vttJx;vEYj;1 |H>$H!lllp"wAAGw^R. GO>G69#x=t4sq^Y\@+P(bt+G[lmmXFO+,,{.iFVN3e+WvbVu%KZ9%Hh0CCC7o=z&MtQFTN 8{^~ ===++kv=zRA~&rBi6lijj*F 4? They concluded that in the absence of IA pathology, IA gunshot injuries do not appear to necessitate surgical debridement to decrease the risk of infection. 102 0 obj Are you sure you want to trigger topic in your Anconeus AI algorithm? Some authors recommend gently ranging the joint to increase visualization of extrusion of fluid. (J Bone Joint Surg Am. <> Evaluation of saline load test for simulated traumatic arthrotomies of the ankle. A knee effusion may result from acute or chronic conditions. 2023 Lineage Medical, Inc. All rights reserved, Ohio Health Orthopedic Trauma and Reconstructive Surgery. proximal . Acta Orthop Traumatol Turc 2016; 50: 597-600. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Brubacher, Dr. Grote, and Dr. Tilley. Generally, primary closure of the wound is contraindicated. Injection sites were randomized to either a superomedial or inferomedial location. Operative Treatment for Resistant Clubfoot. J Orthop Trauma 2007; 21: 442443. PMID: 21768902, Keese GR et al. PMID: Browning BB et al. 96 16 He has some pain with range of motion of his knee but states that his pain is mostly around the area of the laceration. Journal of the American Academy of Orthopaedic Surgeons, Get new journal Tables of Contents sent right to your email inbox, Articles in PubMed by Jacob W. Brubacher, MD, Articles in Google Scholar by Jacob W. Brubacher, MD, Other articles in this journal by Jacob W. Brubacher, MD. Healthcare providers who have registered for our community. Epidemiology. Please enable scripts and reload this page. I feel like inserting a needle and injecting into a joint space would track air into that space and then your CT would not be properly interpretable. 2021 Dec 29;13(12):e20793. 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Introduction Provides exposure to distal tibia ankle joint talar dome Indications include ORIF of pilon fractures ankle arthrodesis total ankle arthroplasty I&D of infected ankles removal of loose bodies Intermuscular plane Intermuscular plane extensor hallucis longus (deep peroneal nerve) extensor digitorum longus (deep peroneal nerve) Preparation may email you for journal alerts and information, but is committed Indications Generally, total knee arthroplasty (TKA) is performed for destruction of joint cartilage either from osteoarthritis, rheumatoid arthritis/inflammatory arthritis, posttraumatic degenerative joint disease, or osteonecrosis/joint collapse with cartilage destruction. ), skin is supplied by perforating arteries which run in the muscular fascia so any medial or lateral skin flaps (if needed) should be just below (deep to) the fascia to avoid. located just lateral to peroneus tertius and superficial peroneal nerve and medial to lateral malleolus can trace out superficial peroneal nerve prior to incision Anterocentral function anterior viewing portal location and technique not commonly utilized due to danger to dorsal pedis artery medial to EDL and lateral to EHL Posterolateral function endstream You are consulted multiple times over the weekend on patients that have sustained gunshot wounds (GSW). -3.028 0 Td Nonoperative management with local wound care, tetanus prophylaxis +/- short course of oral antibiotics is indicated in low-velocity injury with no bone involvement or non-operative fractures. 0 0 m pinning across joint with .062-inch K-wires Ulnar Styloid Fractures Reflects high degree of initial fracture displacement Fractures through base often associated with TFCC rupture and instability In the absence of instability, ulnar styloid nonunions are not associated with worse outcomes Treatment nonoperative cast immobilization indications endobj (\240)Tj 0000001148 00000 n Open Knee Joint Injuriesan evidence-based approach to management. Methods: /T1_1 1 Tf 100 0 obj eCollection 2022. The purpose of the present study was to determine the appropriate volume and needle location for the diagnosis of a traumatic knee arthrotomy and to assess the effect of associated variables, including knee circumference, body mass index, and sex. %%EOF An official website of the United States government. PMID: Keese GR et al. retrospectively reviewed the demographics, interventions, infection rates, and other complications after intra-articular (IA) gunshot wounds. doi: 10.7759/cureus.20793. Knee arthroplasty is indicated for progressive symptoms with severe degenerative disease. Please try again soon. J Orthop Trauma 2007; 21: 442443. HHS Vulnerability Disclosure, Help PMID: 17762473, Konda SR et al. sharing sensitive information, make sure youre on a federal 2023 Lineage Medical, Inc. All rights reserved. /T1_1 1 Tf For GSWs with trans-abdominal trajectories, the laparotomy takes precedence over arthrotomy. Bulletin of the Hospital for Joint Diseases 2014; 72: 61-9. patella can be difficult to evert and is subluxated laterally instead. endobj (Permissions] link. 2023 Lineage Medical, Inc. All rights reserved. TECHNIQUE VIDEO. 97 0 obj Detection of a traumatic arthrotomy in the pediatric knee using the saline solution load test. Attach a 20g needle to a syringe and advance carefully at the site of lidocaine injection. Injury. Bull Hosp Jt Dis (2013). A positive study is clearly evident with either modality (eg SLT with extrusion of fluid, CT with free air in joint). Asi-oqua Bassey Follow. Oct. 8, 2015 0 likes 22,539 views. JAAOS - Journal of the American Academy of Orthopaedic Surgeons28(3):102-111, February 1, 2020. ET Definition: a deep laceration that extends into the joint capsule, exposing the intra-articular surface to the environment, History: Mechanisms that should raise suspicion for violation of the joint capsule include penetrating trauma (knives, sharp objects, gunshot), falls, or other high energy injuries, Traumatic Arthrotomy Workup Flow (epmonthly.com), Bariteau JT et al. /T1_1 1 Tf official website and that any information you provide is encrypted There is little data in the literature about what constitutes a high-risk injury aside from deeply penetrating trauma such as gunshot and stab wounds. You are on your orthopedic trauma rotation at a busy Level 1 trauma center. /T1_1 1 Tf midvastus approach. Given the limitations of the saline loading test, are there additional diagnostic options? 0 g trailer 18.71898 1.00001 Td anteroposterior and lateral), May be up to 100% sensitive for joint violation, Study limited by small numbers, inclusion bias + inadequate gold standard, Could potentially be used instead of or, more likely, in addition to the slide load test in the appropriate clinical setting, Standard tool for assessment of traumatic arthrotomy, Particularly useful if physical examination equivocal or plain radiographs non-diagnostic, Perform arthrocentesis of the joint with a large bore needle (18-20 gauge), Sterile saline is injected into the joint while passive movement is applied to the joint, The laceration site is watched for saline extravasation indicating communication between the joint and external environment, Sensitivity ranges from 34%-99% depending on the study, joint, and the amount of saline used to load the joint (, Aids in distinguishing a true positive from additional bleeding from the wound, Recent studies suggest that the addition of methylene blue does not increase sensitivity if a sufficient amount of saline is used (, Varies depending on the joint in which you are injecting, Higher volumes increase sensitivity but also increase pain for the patient, Irrigate grossly contaminated wounds in the ED, Immobilize the joint to prevent further injury, Obtain early orthopedic evaluation for joint exploration, and washout to be performed within 6-24 hours, Prophylactic antibiotics (best if given within 6 hours), generation cephalosporin (i.e. vancomycin), If significant soft tissue injury, add gram negative coverage like late generation cephalosporin, extended-spectrum penicillin, or aminoglycoside (i.e. ( to use material from this)Tj Please try after some time. PMID: 22215059, Your email address will not be published. Making the correct diagnosis requires a . yj3wNUn%oNd{e]i Answer 3: Trans-abdominal intra-articular GSWs are considered contaminated. 0000001875 00000 n Full article PDFs linked to scientific journals. Confirm entry into the joint with aspiration of synovial fluid (assuming remaining synovial fluid after injury). Effectiveness of the saline load test in diagnosis of traumatic elbow arthrotomies. Required fields are marked *. 454 0 l PMID: Konda SR et al. 0000001272 00000 n Arthroscopy is a surgical technique that can be applied to perform the following types of procedures: Chondral defect repair, including microfracture, controversial whether or not it provides symptomatic relief, but makes figure-four position more difficult, Place tourniquet (important for safety, but often not inflated), Make anterolateral incision over soft spot of knee, have advantage of increased superior-inferior mobility of instruments, have advantage of increased medial-lateral mobility of instruments, advance blade into capsule then follow with trochar, make with knee in flexion, adjacent to patellar tendon over soft spot on joint line, used as the primary instrumentation portal, most common site for aspiration or injection, 1 cm above joint line between LCL and biceps tendon, 1 cm distal to patella and splits the patellar tendon, do not use if performing a bone-patella-bone graft harvest, used for anterior compartment visualization, place where can be best utilized for need, Should systematically check the following locations and structures, with knee flexed to 90 move to medial compartment, with knee in figure-four position finish in lateral compartment, Shoulder Anterior (Deltopectoral) Approach, Shoulder Lateral (Deltoid Splitting) Approach, Shoulder Arthroscopy: Indications & Approach, Anterior (Brachialis Splitting) Approach to Humerus, Posterior Approach to the Acetabulum (Kocher-Langenbeck), Extensile (extended iliofemoral) Approach to Acetabulum, Hip Anterolateral Approach (Watson-Jones), Hip Direct Lateral Approach (Hardinge, Transgluteal), Hip Posterior Approach (Moore or Southern), Anteromedial Approach to Medial Malleolus and Ankle, Posteromedial Approach to Medial Malleolus, Gatellier Posterolateral Approach to Ankle, Tarsus and Ankle Kocher (Lateral) Approach, Ollier's Lateral Approach to the Hindfoot, Medial approach to MTP joint of great toe, Dorsomedial Approach to MTP Joint of Great Toe, Posterior Approach to Thoracolumbar Spine, Retroperitoneal (Anterolateral) Approach to the Lumbar Spine. Bleeding is controlled; the wound base seems appreciable though somewhat limited by maceration of tissue. [1] Understanding the basic anatomy and pathophysiology of knee effusions is essential to make an accurate diagnosis. -72 -557 m timing of flap coverage for open tibial fractures remains controversial, increased risk of infection beyond 7 days, increase by 16% for each day beyond day 7, early studies demonstrated increased infection with delay beyond 72 hours, however recent studies do not support this finding (LEAP study), can proceed with bone grafting after wound is clean and closed, negative-pressure wound therapy may be utilized during debridement until definitive coverage can be achieved (increased risk of infection if open >7 days), open reduction and internal fixation or intramedullary treatment depending on fracture location and morphology, Masquelet technique ("induced-membrane" technique), 1st stage: I&D, cement spacer and temporizing fixation, 2nd stage: placement of bone graft into "induced membrane" and definitive fixation, Studies show optimal time frame for bone grafting to be, fracture-related infection ranges from <1% in type I open fractures to 30% in type III fractures. ( )Tj dedicated hip arthroscopy instruments required. 2020 Mar 2;5(1):2473011420905610. doi: 10.1177/2473011420905610. (The Journal of Bone and Joint Surgery)Tj Irrigation and Debridement of Septic Hip - Approaches - Orthobullets. 150 cc saline load into joint has high negative predictive value and 95% sensitivity in detecting small joint injuries. by the American Academy of Orthopaedic Surgeons. Gun shot wounds (GSWs) are high energy injuries that contribute to extensive soft tissue damage and comminuted bony fractures. 0 1 TD Damage to the synovial joint of one or more of the three . Patella Fractures are traumatic knee injuries caused by direct trauma or rapid contracture of the quadriceps with a flexed knee that can lead to loss of the extensor mechanism. Operative Techniques. Setup, Positioning, and Joint access. /T1_2 1 Tf Answer 4: Local wound care, tetanus prophylaxis, and administration of IV antibiotics have been showed to be appropriate for low-velocity intra-articular GSWs. 0 1.00001 TD Under sterile conditions, fill a 60mL syringe with sterile normal saline (+/- 1-2 cc methylene blue). 0 0 m 15 0 0 15 72 513.99997 Tm 2022 Jan 30;14(1):31909. doi: 10.52965/001c.31909. Q 2023 Lineage Medical, Inc. All rights reserved, TKA - Varus Knee with Anterior Referencing and Gap Balancing Technique. -9.58399 0 Td Data is temporarily unavailable. <> Are you sure you want to trigger topic in your Anconeus AI algorithm? They reported that the incidence of infection after IA gunshot injuries is low with the routine use of antibiotic prophylaxis. 0000003962 00000 n Also known as "traumatic arthrotomy". METHODS: Fifty-six consecutive patients scheduled for knee arthroscopy were enrolled. Epub 2016 Dec 12. [Metzger, Carney, Booher. The preponderance (53% to 91%) of traumatic ar-throtomies occur in the knee1-3, and such injuries occur more commonly in males2,4. Epub 2019 Mar 8. In order to detect 95% of 1-cm inferolateral arthrotomies of the knee with use of the saline solution load test, 155 mL must be injected. Clipboard, Search History, and several other advanced features are temporarily unavailable. Causes range from acute trauma to chronic systemic disease. Diagnosis can be made with plain radiographs of the knee. You can read the full text of this article if you: You may be trying to access this site from a secured browser on the server. Unable to load your collection due to an error, Unable to load your delegates due to an error. -5.416 0 Td al., 2009). Each diagnostic pathway provides useful information when evaluating for traumatic arthrotomy, and when available, the studies in conjunction may add to diagnostic yield. There are no studies that directly compare CT to saline loading in a randomized fashion and no studies that propose a definitive algorithm combining these two modalities to exclude knee joint injury. Inoculation of the joint often results in septic arthritis. /RelativeColorimetric ri 104 0 obj Effectiveness of the saline load test in diagnosis of simulated traumatic ankle arthrotomies. 0000071109 00000 n 10 0 0 10 161.70999 483.99988 Tm Diagnosis is primarily made with plain radiographs of the ankle. [ 38, 39] Arthrotomy is the best. Infection and Complications After Low-velocity Intra-articular Gunshot Injuries. may extend to distal two thirds of femur; incise between rectus femoris and vastus medialis; split underlying vastus intermedius to expose femur; Variations . Considering this information, the prudent EP may be left with a persistent question regarding traumatic arthrotomy and the safety of primary skin closure prior to definitive diagnostics. eCollection 2020 Jan. J Orthop Case Rep. 2021 Mar;11(3):107-112. doi: 10.13107/jocr.2021.v11.i03.2110. Traumatic Arthrotomy (forums.mtbr.com) Definition: a deep laceration that extends into the joint capsule, exposing the intra-articular surface to the environment. Springer, Cham, Metzger et al. Aspirate as the needle is advanced. In the absence of intra-articular pathology, intra-articular gunshot injuries do not appear to necessitate surgical debridement to decrease the risk of infection. Nguyen et al. Computed tomography scan to detect traumatic arthrotomies and identify periarticular wounds not requiring surgical intervention: an improvement over the saline load test. central (abdominal) obesity, dyslipidemia (high triglycerides and low-density lipoproteins), high blood pressure, and elevated fasting glucose levels. <> Incorrect Answers: Answer 2: An arthrotomy is indicated for intra-articular bullet as it may lead to local inflammation, arthritis and lead intoxication (plumbism). (The PDF of the article you requested follows this cover page. Little is known about the volume of injected intra-articular saline solution that is needed to effectively rule in or rule out a traumatic arthrotomy of the knee. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). The knee is comprised of the structures that surround the bony articulations of the femur, tibia, fibula, and patella. . Ferre AC, Emara AK, Maurant MA, Steckler AN, Merryman B, Churchill JL. Antibiotic use is somewhat controversial, however, low-velocity intra-articular (IA) GSWs may be effectively managed with antibiotics. One study found that CT scanning of the joint had superior performance to saline loading test in the detection of joint injury. -15.69098 0 Td your express consent. Injury 2013; 44: 14981501. An intraarticular injection of dilute methylene blue might provide a more easily recognized endpoint, with a smaller volume of injection. Would you like email updates of new search results? more severe Gustillo-Anderson classification. %PDF-1.6 % RT/ Pg`/y, AAEb=*, " q Federal government websites often end in .gov or .mil. (order reprints or request permission)Tj The accuracy of the saline load test in the diagnosis of traumatic knee arthrotomies. Cureus. zosyn), If seawater contamination and concern for vibrio vulnificus, add doxycycline, Functional impairment correlates to the severity of injury, Infection rate from periarticular wounds ranges from 0% to 11.8%, Improved outcomes if diagnosis and treatment is achieved within 24 hours of injury (, Always suspect an open joint if there is a laceration, regardless of size, the lies over joint, Use the Ssaline load test to assess for joint capsule injury. /T1_0 1 Tf Nguyen et al. Sensitivity of the saline load test with and without methylene blue dye in the diagnosis of artificial traumatic knee arthrotomies. A high index of suspicion must be maintained for this injury. <> 0000000016 00000 n Does the saline load test still have a role in the orthopaedic world? Sterilize the skin of the lower extremity from distal quadriceps to proximal calf with betadine or chlorhexidine. The clinician uses a sterile technique to inject saline into the knee (or other joint space) using an 18g needle and syringe (Nord, et. Hip Arthroscopy - Knee & Sports - Orthobullets Knee Evaluation in the Athlete Meniscal injuries Ligament injury Knee Overuse injuries Knee Extensor Mechanism Knee Cartilage Lesions Pediatric Knee Team physician Head & Neck Sports Injuries Updated: Mar 24 2023 Hip Arthroscopy } Matthew J. Steffes MD Experts 66 Bullets 198 Cards 21 Questions 9 Cases Number of times users have rated our content. Browning BB, Ventimiglia AV, Dixit A, Illical E, Urban WP, Jauregui JJ. As saline is injected, inspect joint for saline extrusion. Other studies revealed a false negative rate of 67% with volumes up to 105 mL (saline + methylene blue) and 95 mL (saline alone) and sensitivities of only 36% at volumes of 60 mL. A similar study found 95% sensitivity at a volume of 155 mL. PMID: Your email address will not be published. The knee is a hinge joint susceptible to injury from trauma, inflammation, infection, and degenerative changes. The incidence of infection after IA gunshot injuries is low with the routine use of antibiotic prophylaxis. (\240 )Tj evaluation for traumatic arthrotomy of the knee Treatment Nonoperative urgent IV antibiotics, tetanus prophylaxis, and extremity stabilization and dressing indications initial treatment for all open fractures a soft tissue wound in proximity to a fracture should be treated as an open fracture until proven otherwise ?Yfy{{O0X|}!55566;giR%H?-_jm T+44TvGUUU. They reported that the overall cost associated with isolated low-energy GSWs to the extremity is high. Ohio Health Orthopedic Trauma and Reconstructive Surgery. Drape the knee with sterile towels, exposing only the sterilized skin of the knee. In order to effectively diagnose 50% of the arthrotomies, 75 mL of injected fluid was needed; the volumes that were needed in order to effectively diagnose 75%, 90%, 95%, and 99% of the arthrotomies were 110, 145, 155, and 175 mL, respectively. Saline load with advanced imaging has highest sensitivity for ruling out traumatic arthrotomy. <>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/Type/Page>> Background: Computed tomography scan to detect traumatic arthrotomies and identify periarticular wounds not requiring surgical intervention: an improvement over the saline load test. (Reprints and Permissions)Tj Postoperative Patient Care. When the patella was subluxed laterally, the trochlear groove was used as a bed for the instruments and nail. 18.921 -2.00001 Td 0000001672 00000 n Scientific journals integrated with our learning platform. proximal portion of the arthrotomy extends into the muscle belly of the vastus medialis. Treatment is observation, NSAIDs, tramadol and corticosteroids for minimally symptomatic patients. 2019 Jun;8(3):221-225. doi: 10.1055/s-0039-1683365. PMID: Metzger et al. PMID: Konda SR et al. eCollection 2021 Dec. Patel AH, Wilder JH, Lee OC, Ross AJ, Vemulapalli KC, Gladden PB, Martin MP 3rd, Sherman WF. Additionally, open knee joint injuries have a high rate of associated periarticular fractures (51%). <>>> Hip Anterior Approach (Smith-Petersen) Hip Anterolateral Approach (Watson-Jones) Hip Medial Approach. J Ortho Trauma 2012]. The volume of injected fluid was recorded. -10.94501 0 Td often associated with additional injuries (30%), the presence of an open wound does not preclude the occurrence of compartment syndrome in the injured limb, obtain information regarding mechanism, location, and timing of injury, the size and nature of the external wound may not reflect the damage to the deeper structures, if concern for vascular insult, ankle brachial index (ABI) should be obtained, vascular surgery consult and angiogram is warranted if ABI < 0.9, consider saline load test or CT scan if concern for traumatic arthrotomy, some studies now show CT scan more sensitive than saline load test for the knee, obtain radiographs including joint above and below fracture, evaluation for traumatic arthrotomy of the knee, a soft tissue wound in proximity to a fracture should be treated as an open fracture until proven otherwise, mutlidisciplinary training of open fracture management has been associated with decreased timing to antibiotic administration, antibiotic type indicated by injury pattern and location, ideal time of soft tissue coverage controversial, but most centers perform within 5-7 days, infection rates of open fracture depend on zone of injury, periosteal stripping and delay in treatment, incidence of fracture-related infection range from <1% in type I open fractures to 30% in type III fractures, definitive reconstruction and fracture fixation, once soft tissue coverage is obtained and an adequate sterility is achieved, definitive treatment with internal fixation leads to significantly decreased time to union, improved functional outcomes, and decreased time in the hospital compared to those definitively fixed with external fixation, studies show increased infection rate when antibiotics are delayed for more than, continue for 24 hours after initial injury if wound is able to be closed primarily, continue for 24 hours after final closure if wound is not closed during initial surgical debridement (48 hours for type III wounds), clindamycin or vancomycin can also be used if allergies exist, 1st generation cephalosporin + aminoglycoside, some institutions use vancomycin + cefepime, farm injuries, heavy contamination, or possible bowel contamination, penicillin for anaerobic coverage (clostridium), fluoroquinolones or 3rd or 4th generation cephalosporin, doxycycline + ceftazidime or a fluoroquinolone, toxoid and immunoglobulin should be given intramuscularly with two different syringes in two different locations, guidelines for tetanus prophylaxis depend on 3 factors, complete or incomplete vaccination history (3 doses), splint, brace, or traction for temporary stabilization, decreases pain, minimizes soft tissue trauma, and prevents disruption of clots, remove gross debris from wound, do not remove any bone fragments, place sterile saline-soaked dressing on wound, little evidence to support aggressive irrigation or irrigation with antiseptic solution in the ED, as this can push debris further into wound, recent meta-analysis (GOLIATH study) have, to minimize risk of infection for type III fractures, within 12 hours for type IIIB open tibia fractures, extend wound proximally and distally in line with extremity to adequate expose open fracture, low-pressure bulb irrigation vs. high-pressure pulse lavage, studies have shown that low pressure bulb irrigation is less expensive than high pressure pulse lavage and has no difference in infection rates or union rates, saline vs. saline with castile soap vs. antibiotic solution, studies have shown that saline with castile soap had decreased primary wound healing problems when compared to antibiotic solutions, on average, 3L of saline are used for each successive Gustilo type (i.e 9L for type III), thorough debridement of devitalized tissue is critical to prevent deep infection, bony fragments without soft tissue attachments should be removed, performed at the time of initial debridement, external fixation is temporary initial treatment of choice for majority of high energy open fractures of the lower extremity, significantly contaminated wounds with large soft tissue defects, beads made by mixing methylmethacrylate with heat-stable antibiotic powder, vancomycin and tobramycin most commonly used, early soft tissue coverage or wound closure is ideal.
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