This document discusses the management of open fractures and complications that can arise, including osteomyelitis. It provides guidelines from the British Infection Society and Ministry of Health Malaysia on antibiotic treatment for open fractures, which involves co-amoxiclav or cephalosporins within 3 hours, along with additional antibiotics like gentamicin during and after debridement. Post-traumatic osteomyelitis is described as a common complication where dead tissue leads to bone infection, usually treated with wound cleansing, stabilization, and prolonged antibiotics. Chronic osteomyelitis is also covered, where bone has been destroyed, leading to recurrent pain and discharging sinuses.

2. •
•
•
•
•
•

3. •
•

4. •
•
•
•
•
•
•
•
•
•

5. COMPLETE FRACTURE

6. INCOMPLETE FRACTURE
→
→

11. •

14. -
-
-
-

15. There are two (2) references in managing patient.
1. British Infection Society and The Association of
Medical Microbiologists.
2. National Antimicrobial Guideline 2019 by Ministry
of Health.

16. British Infection Society and The Association
of Medical Microbiologists
• Immediate administration within 3 hours with Co-amoxiclav (1.2 g 8 hourly) / cephalosporins*
(1.5 g 8 hourly) until first debridement/excision.
• Add Gentamicin (1.5 mg/kg) during first debridement, with continuation of the former until
soft tissue closure or 72 hours, whichever sooner.
• Prior 90 mins of skeletal stabilization & wound cover, vancomycin infusion should be started
followed by Gentamicin + vancomycin 1g / teicoplanin 800 mg during anasthesial induction.
• Replace with Clindamycin (600mg IV 6 hourly preoperatively) in patient with anaphylaxis toward
penicilin*.
• Cephalosporins considered safe in patients with lesser allergic reaction and is drug of choice.

17. National Antimicrobial Guideline 2019 by
Ministry of Health Malaysia

20. •
•
•
•

27. •
•
–
–

28. •
–
–
–
–

29. •
•
–
–
–
–

30. –
–
–
–

31. •
•
•
•

32. –
–
–
•
•
•
•

33. –
–
•
•
•
•
–

34. •

35. –
–
•
•
•
•
•
•
•

37. •
–
•
•
•
–
•
•
•
•
–
•
–

39. •
•

40. a)
b)
c)
d)
e)

42. Union Consolidation
Non-tender
-
Clinical
Fracture site
False movement
Attempted angulation
Tender
+
painful Painles
s
Complete
Radiological
Repair
Fracture line
Incomplete
+ -
Callus + (fluffy)
Ensheating callus
in classfied
+ (well-defined)
Classified callus is
ossified

45. General
Complication
2.Disseminated
intravascular
coagulation
3.Fat Embolism 4.Tetanus
1.Hypovalemic
shock

51. □
□
□
□
□

52. ✔
✔
✔

53. Gurd’s Criteria
2 major or 1 major and 4 minor criteria

54. •

56. EARLY
COMPLICATION
S FRACTURE

57. •
•

59. •
•
•

60. □
□

62. •
•
•
✔
✔
✔
✔

64. •
•
•
• ∆
•
•
•

66. •
•
•

68. •
•
•
• can lead to osteomyelitis

69. Post Traumatic Osteomyelitis
• common cause of osteomyelitis in adults.
• Staphylococcus aureus are the usual pathogen, others such
as Escherichia coli, Proteus mirabilis and Pseudomonas
aeruginosa
• Clinical features – feverish, pain and swelling over
fracture site; wound is inflamed and seropurulent
discharge.
• Blood tests- increased CRP levels, leucocytosis, elevated
ESR.

70. • Treatment : prophylaxis – thoroughly cleansing and
debridement of dead and dying tissues, stabilization of the
bone fragments, skin cover of the wound(either by suture
or skin grafting) when it is assuredly clean and antibiotic
administrated.
• Combination of flucloxacillin and benzylpencillin.
• ( sodium fusidate) given 6 hourly for 48 hours.
• Metronidazole for 4 to 5 days to control both aerobic and
anaerobic organisms

71. CHRONIC OSTEOMYELITIS
• Area of bone has been destroyed by the acute infection
leaving sequestra surrounded by dense sclerosed bone.
• The imprisoned sequestra provoke a chronic seropurulent
discharge which escapes through a sinus at the skin surface.
• Usual organisms : S.aureus, E.coli, S.pyogenes, Proteus and
Pseudomonas aeruginosa.
• Clinical features- recurrent bouts of pain, redness, tenderness
at affected site following acute bone infection.
• Classic signs- healed and discharging sinuses

72. • X-ray
features of
bone
rarefaction
surrounded
by dense
sclerosis and
cortical
thickening;
within that
area there
may be an
obvious
sequestrum.

73. Treatment :
• Antibiotics – used to suppress the infection and prevent its
spread to healthy bone and to control acute flares.
Examples : fusidic acid, clindamycin, cephalosporins.
Administered for 4-6 weeks (starting from the beginning of
treatment or the last debridement )
• Local treatment – sinus may be painless and need dressing,
acute abscess may need incision and drainage.
• Operation – external fixation may need to be applied so that
internal fixation devices can be removed , all infected and
dead tissue must be excised.

74. Example of post operative infection leading to osteomyelitis

76. •

77. •
•
•
•
•

78. •
•

81. •
•
□
□
□
□
□
□
□

82. •
□
□
□
□

84. •
□
•
•
•
□

85. MALUNION
•
•
–
–
□
□
•
•

87. •
•
•
•
NON-UNION
TYPES OF NON UNION
•
–
–
•
–
–

89. The bone
• Poor blood supply
• Poor haematoma
• Infection
• Pathological lesion
The surgeon
● Distraction
● Poor splintage
● Poor fixation
● Impatience
CAUSES OF NON UNION

90. •
–
–
–
–
•
–
–
TREATMENT OF NON
UNION

91. •
–
•
–
–
–
–

92. •
▪
•
▪
▪
•
▪
▪
▪
▪

95. •
•
•

96. •
–
–
–
•
–
JOINT INSTABILITY

97. •
□
□
▪
→
□
□
□ →
→

99. •
□
□
□
□
□
•
□
□
□
□
□