Open Fracture

Q: How many hours is the golden-hour rule that is "currently" followed in Open Fracture to Operative management?

A: Urgent Basis

The 6 hours golden rule probably originated from a 1898 German study on guinea pig (http://www.ejbjs.org/cgi/reprint/88/12/2739.pdf). There are other papers which showed lower infection rate if debridement is done within 6 hours but subsequent studies contradict them.

The current guideline is, it should be done on an urgent basis but the more important management is early (and correct) antibiotics administration. Urgent basis means, if open fracture is seen in ED at night, it would be done first thing in the morning, but will not be done in the middle of the night.

"Single most important fctor in reducing infection rate was the early administration of antibiotics." - Patzakis & Wilkins, Clin Orthop 1989

Review of type of Open Fractures
Gustilo & Anderson Classification

I <1cm, minimal contamination, comminution and soft tissue damage II >1cm, moderate soft tissue damage, minimal periosteal stripping
IIIA severe soft tissue damage and substantial contamination; coverage adequate
IIIB same as IIIA but coverage inadequate
IIIC arterial injury requiring repair

Infection rates:
I 0-2%
II 2-5%
IIIA 5-10%
IIIB 10-50%
IIIC 25-50%

Antibitics:
Type I,II 1st Gen Cephalosporin (usually Cefazolin)
Type III 1st Gen Cephalosporin + Aminoglycoside (Cefazolin + Gentamycin)
High risk of anaerobic contamination (farming, open water injuries) add penicillin or ampicillin