OPEN (compound) FRACTURES

Prof. M. Ngcelwane2013

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OBJECTIVES

MUST BE ABLE TO DIAGNOSE OPEN FRACTURES

RECOGNIZE THAT THERE MAY BE ASSOCIATED INJURIES

BE ABLE TO CLASSIFY OPEN FRACTURE

PRINCIPLES OF EARLY MANAGEMENT

DEFINITIVE MANAGEMENTCOMPLICATIONS

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WHAT IS A FRACTURE

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OPEN (COMPOUND) FRACTURE

FRACTURE

XR: A break in the continuity of boneClinically: swollen, deformed, tender, loss of fx

COMPOUND FRACTURE

Fracture where there is a skin wound communicating with the fracture

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Examples of open fractures

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IMPORTANCE OF SOFT TISSUES

An open fracture is a severe soft tissue injury in which bone is also broken.

Extent of damage to soft tissue determine the prognosis

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Gustilo and Anderson classification of open

fractures

I < 1cm clean wound, simple fracture patternII > 1cm, no extensive soft tissue damage, no flaps/avulsion, simple fracture fractureIII (A) Extensive wound, bone adequately covered. (B) Bone exposed, usually contaminated. (C) Arterial injury.

NB 7

Causes

High energy traumaLook for other injuries

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Anatomic considerations

Commonest long bone open fracture is tibia

Most studied bonePoor soft tissue coverCf. femur

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CLINICAL APPROACH TO PATIENT WITH OPEN

FRACTURE1. Assess life threatening injuries

• ABC of resuscitation• Physical and neurologic exam• Emergency Surgery (decision)

2. Assess limb (a) Vasculature pulse doppler angiogram (b) Soft tissues Skin - site - bruising contamination muscles periosteum (c) Neurology Plantar skin sensation3. Fracture pattern XR

NB 10

Neurovascular assessment (tibia)

Vascular:- Dorsalis pedis- Posterior tibial

Motor:- all compartments of the leg: toe flexures, toe dorsiflexors, ankle evertors, plantar flexors

Sensory:- Tibial n: plantar surface of foot- Deep peroneal n: dorsal web space 1st and 2nd toe- Superficial peroneal n: dorsolateral- Saphenous n: medial

REMEMBER - NOT POSSIBLE IN ALL PATIENTS

11NB

Treatment

MAIN COMPLICATION OF OPEN FRACTURES IS INFECTION

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Open Tibial Fractures

A Open Fractures: Challenges1. Management of traumatic wound2. Achieving bony stability3. Decision making -limb salvage

vs. amputation4. Achieving soft tissue coverage5. Achieving fracture union

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PRINCIPLES OF

TREATMENT

B1. Wound debridement2. Antibiotic therapy3. Bony stabilization 4. Wound coverage5. Maintain vascularization

14NB

Emergency Room

Treatment

C1. Reduce and splint the limb2. Document neurologic and vascular

status3. (Lavage wound)4. Sterile compression dressing,

do not open again5. (photograph)6. Start I/V antibiotics7. Tetanus prophylaxis8. X-ray evaluation9. To surgery as soon as possible

< 6 hours

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I II IIIA IIIB IIIC * * * * *

* * *# # #

INTRAVENOUSANTIBIOTICS

Cefazolin AminoglycosidePenicillin

Type open fracture

# Soil contamination (clostridia)

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MANAGEMENT

Limb - specific treatment(a) debride/decontaminate• No tornique• Remove all dead tissue • Save bone

(b) Skeletal stabilization(c) Soft tissue cover(d) Bone reconstruction(e) Rehabilitation

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Sepsis cannot occur if good bleeding tissue

is present

“The solution to pollution is dilution”

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Principles of

DebridementD.

1. Classification determined at time of debridement of future surgeries

2. Extend wounda. Visualise entire zone of

injury and where hematomatraveled

3. Debride wound in a systematic waya. Skin edges subcutaneous

muscle bone 4. Remove foreign material

5. Debride necrotic skin, fat, muscle, bonea. Skin: conservativeb. Fat and fascia: radical

6. Prophylactic fasciotomy ofcompartment exposure

7. Muscle: debride non-viable tissuea. Colorb. Consistencyc. Contractilityd. Capacity to bleede. Response to hemostasis 19NB

MUSCLE DEBRIDEMENT

Colour: red/brownConsistency: feels like

muscle/softCapillary circulation: does it

bleed?Contractility: does it contract

with cautery or pinching

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COVER EXPOSED

9 a Neurovascular structuresb Tendonc Boned Articular surface

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BONE STABILIZATION

EXTERNAL FIXATORReason: be able to clean/dress

wound; difficult to eradicate infection with internal fixation/plate

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COMPLICATIONS

NeurovascularCompartment syndromeINFECTION (prophylaxis NB!!)Loss of limb

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Mangled Extremity Severity Score

“MESS”Skeleton Soft Tissue PointsLow energy, simple fx, low velocity GSW 1Medium, moderate comminution 2High energy (close range shot gun, etc) 3Massive crush 4

Shock

Normotensive (SBP>90) 0Transient hypotension 1Persistent hypotension 2IschemiaNone 0Decreased pulses 1*No pulse, slow cap refill, paresthias 2*Cool pulseless, insentiate 3*

Points double if ischemia > 6 hrsAge< 30 Yr 030-50 1>50 2

MESS > 6 Amputation24

Not for studying purposes

MANAGEMENT

1. General supportive measures (a) cover wounds (b) fluid resuscitation/blood (c) Antibiotics - Cephosporin (2nd generation) 2. Limb - specific treatment

(a) debride/decontaminate• No tornique• Remove all dead tissue • Save bone

(b) Skeletal stabilization(c) Soft tissue cover(d) Bone reconstruction(e) Rehabilitation

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EndThank you 26