Initial evaluation and management of a trauma patient is similar regardless of the mechanism of injury. A detailed history is necessary with special considerations given to various factors such as time elapsed since the injury, mechanism of injury, environment where the injury occurred, and any initial treatments that have been performed. These variables have an impact on treatment decisions and can play a role in the potential for osteomyelitis. Specifically, the type of injury and environmental factors are useful for determining appropriate initial antibiotic coverage (Table 13.2). Tetanus status should be established with puncture wounds and open fractures. Recommended tetanus prophylaxis is dependent upon previous immunization history as described in Table 13.3 [12–14]. A detailed lower extremity physical examination is performed to evaluate soft tissue viability, neurovascular status, tendon function, and extent of open wounds. Radiographs are necessary to evaluate for retained foreign bodies and to identify any fractures. MRI, ultrasound, or CT scans are adjunctive modalities that may be needed to assist in further assessing damage and identifying any foreign objects. Initial laboratory testing for infection is optional depending on the time lapsed since injury which includes complete blood count (CBC) with differential, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). Inflammatory marker labs are useful to follow the progress of therapy if there is concern for infection.

Prompt and thorough irrigation and debridement of open traumatic injuries is a simple and effective approach for infection prevention. Local, regional, or general anesthesia may be necessary, and early determination should be made in the acute care setting regarding the need for surgical treatment in the operating room (OR). Open fractures are considered a surgical emergency, and the care teams should be mindful to reduce the time elapsed between injury and OR management. Historically, debridement of an open fracture was recommended within 6 h of the injury. Recent literature describes timely management is important; however, a larger emphasis is placed on taking into account the grade of the open fracture [15–19]. A recent study by Hull evaluated a series of 364 patients with open fractures and confirmed that higher grade Gustilo–Anderson fractures (Table 13.1) are more likely to develop a deep infection than lower grade fractures. Furthermore, a delay in treatment has a greater effect on these higher grade fractures and those that are grossly contaminated [18]. Thus, heightened awareness of the time to the OR is necessary in the higher grade and grossly contaminated injuries.

Prompt irrigation and debridement allows initial removal of debris or foreign objects and aids in reduction of the total bacterial load [5]. Secondary and staged irrigation and debridement is often indicated to further remove devitalized soft tissue and residual debris. Devitalized soft tissue reduces the effectiveness of the host immune system, thus attempts are made to remove any necrotic or devitalized tissue from the traumatized wound [4, 20]. The viability of skin and soft tissue is determined by color and bleeding, whereas muscle should be inspected for contractility in addition to color and bleeding. Irrigation solution is frequently based on surgeon preference, but adding povidone-iodine solution or antibiotics to normal saline or lactated ringers solution may not add value and perhaps has undesirable side effects [21, 22]. Detergent solutions have been shown to be effective at removing bacteria and dirt from bone [21, 22]. It is our preference to utilize saline alone, with the principle of copious irrigation for removal of bacteria and organic contaminants. Each traumatic wound or open fracture may require a varying amount of irrigation depending on the extent of injury and degree of contamination. Data is lacking to validate the exact volume of fluid that should be utilized for irrigation. Historically, 3 L is recommended for type I fractures, 6 L for type II, and 9 L for type III fractures [23]. Primary wound closure may be performed under conditions of prompt and appropriate antibiotic treatment, thorough debridement with healthy appearance of local tissues post debridement, and a good host immune system [20, 24–28]. Primary closure may prevent secondary contamination; however, the surgeon should not rush to close a wound if it does not appear ready. Inadequate debridement, inadequate antibiotics, and premature primary closure can increase the risk of complications. Early closure in patients with continued wound contamination with dirt, feces, and nonviable tissue can increase the risk of infection with Clostridium. The second stage procedure is planned 2–3 days later allowing secondary irrigation and debridement with hopeful partial or complete closure. The surgeon should not hesitate to perform staged procedures. Ideally, soft tissue coverage is performed within 3 days as a delay in closure beyond 7–10 days increases the risk of infection [29, 30]. Fracture management may be performed acutely or delayed depending on the fracture pattern and condition of the soft tissues. External fixation is useful for temporary stabilization in an unstable fracture when there is concern regarding the soft tissue envelope. If primary closure cannot be achieved, alternative coverage options such as negative pressure wound therapy (NPWT) may be valuable in patients with extensive loss of soft tissue followed by staged skin grafting at a later date. Case examples with treatment protocols are presented below regarding management of puncture wounds, open fractures, and crush injuries associated with industrial, recreational, and lawn mower injuries with the intent to avoid poor outcomes associated with posttraumatic osteomyelitis.

Puncture wounds represent unique traumatic injuries as the wound is small, but there is potential for heavy contamination, internal injury, and retained foreign bodies. Secondary osteomyelitis can develop acutely due to direct inoculation of bacteria into bone or in a delayed manner due to contiguous spread of infection from local abscess formation. Pedal puncture wounds are common injuries that account for 7 % of lower extremity trauma emergency department visits [31]. The majority of puncture wounds heal without complications, but a delay in medical treatment may lead to problems including cellulitis, abscess formation, septic arthritis, and osteomyelitis. The location of the injury, type of footwear worn at the time of injury, and time elapsed before initial treatment will influence the incidence of infection development and osteomyelitis. The Patzaki classification system for puncture wounds divides the foot into three zones: zone 1 extends from the metatarsal neck to the toes, zone 2 is from the metatarsal neck to the distal calcaneus, and zone 3 includes the calcaneus [1]. The risk of osteomyelitis associated with plantar puncture wounds has been described as 0.1–2 %, with a greater prevalence in forefoot injuries (zone 1) through athletic shoes [8]. The distance between the soft tissue and bone is narrow in this weight bearing portion of the foot, and it is common for puncture wounds in this location to cause direct inoculation to a bone or joint depending on the length, rigidity, and sharpness of the penetrating object. Pedal puncture wounds are particularly concerning in the diabetic population since neuropathic patients frequently have a delay in treatment which commonly results in increased morbidity associated with puncture wounds [32]. Diabetic patients are five times more likely to have multiple operations and 46 times more likely to have lower extremity amputations after puncture wounds [33].