Open Fracture Wound Management / Tetanus

Last Updated on by frcemuser

Wound Management 

  • Control hemorrhage if bleeding e.g. direct pressure
  • Give Adequate Analgesia
  • Wound assessment – Examine the wound, surrounding tissue, for any foreign body, contamination, and damage to the underlying structure
  • Assess neurovascular status
  • Reduce gross deformities using gentle traction and splint the injured limb especially  if there is a neurovascular compromise
  • Remove gross contaminants from the wound – clean by profusely irrigating with saline and cover the wound with a sterile dressing
    Apply Dressing
  • Immobilize the limb and Elevate
  • Give tetanus toxoid/ tetanus immunoglobulin if indicated
  • Prophylactic antibiotics
  • X-ray to Rule out fracture/Foreign body
  • Refer to Orthopedics and or plastic surgery

Tetanus Prone Wounds

Five vaccines (N.B. A total of five doses of tetanus vaccine, administered at the appropriate intervals, is considered to give lifelong immunity)

  • The first three doses are given at 2, 3 and 4 months
  • The first booster is given at 3 years and 4 months (preschool)
  • The second booster is given at 14 years of age

Clean wounds are defined as:

  • wounds less than 6 hours old, non-penetrating with negligible tissue damage

Tetanus-prone wounds include:

  • puncture-type injuries acquired in a contaminated environment and likely, therefore, to contain tetanus spores e.g. gardening injuries
  • wounds containing foreign bodies
  • compound fractures
  • wounds or burns with systemic sepsis
  • certain animal bites and scratches – although smaller bites from domestic pets are generally punctured injuries animal saliva should not contain tetanus spores unless the animal has been rooting in soil or lives in an agricultural setting

High-risk tetanus-prone wounds are any of the above with either:

    • heavy contamination with material likely to contain tetanus spores e.g. soil, manure
    • wounds or burns that show extensive devitalised tissue
    • wounds or burns that require surgical intervention that is delayed for more than six hours are high risk even if the contamination was not initially heavy
Immunisation Status Clean Wound Tetanus Prone Wound High Risk Tetanus Prone Wound
Those aged ≥ 11, who have received an adequate priming course of tetanus vaccine with the last dose within 10 years 

Children aged 5-10 years who have received priming course and preschool booster

Children under 5 years who have received an adequate priming course

None Required None Required None Required
Those who have received an adequate priming course of tetanus vaccine but the last dose was > 10 years ago 

Children aged 5-10 years who have received an adequate priming course but no preschool booster

None Required Immediate reinforcing dose of vaccine Immediate reinforcing dose of vaccine & one dose of human tetanus immunoglobulin at a different site
Those who have not received an adequate priming course of tetanus vaccine 

Includes uncertain immunisation status and/ or born before 1961

Immediate reinforcing dose of vaccine Immediate reinforcing dose of vaccine & one dose of human tetanus immunoglobulin at a different site Immediate reinforcing dose of vaccine & one dose of human tetanus immunoglobulin at a different site

High-risk tetanus-prone wounds are those with heavy contamination with material likely to contain tetanus spores (i.e. soil, manure) and/or extensive devitalized tissue.

The dose of human tetanus immunoglobulin is normally 250 IU by intramuscular injection, or 500 IU if more than 24 hours have elapsed.

Tetanus vaccine should be injected at a different site from immunoglobulin so that it is not ‘neutralised’ by the passive immunization

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