Open Fracture Management P. Blachut Division of Ortho Trauma Vancouver General Hospital University...
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Transcript of Open Fracture Management P. Blachut Division of Ortho Trauma Vancouver General Hospital University...
Open Fracture Open Fracture ManagementManagement
P. BlachutDivision of Ortho Trauma
Vancouver General Hospital
University of British Columbia
•Introduction•Assessment•Classification•Management
Open fracturesOpen fractures
Goals of Fracture Management
1 Fracture healing with satisfactory length and alignment
2 Avoidance of complications•infection•nonunion•malunion•stiffness
3 Early restoration of function
Fracture Healing
•Biologic factors•Biomechanical factor
•No necrotic tissue•No dead space•No contamination•Well vascularized tissue
Avoidance of Complications (Infection)
•Early mobilization–Stable fixation–Early wound healing
•Avoid excessive scarring–Early wound coverage with quality tissue
•Preservation of “critical tissues”
–Nerves–Tendons
Early Restoration of Function
•The soft tissues are paramount to the successful management of fractures
Therefore:
•A bone healing complication with good soft tissues is easier to deal
with than a complication with poor soft tissues
• healing potential• resistance to infection
•contamination
Consequences of an Associated Soft Tissue Injury
•Look for associated life threatening injuries!!!
•Carefully assess and document neurovascular status
Assessment
•Primary SurveyA irwayB reathingC irculationD isabilityE xposure
•Secondary Survey
ATLS (Advanced Trauma Life Support)
Compartment SyndromeCompartment Syndrome
• Always look for in fractures with soft tissue injuries
• Open fractures - up to 10% have compartment syndrome
Amputation vs. Salvage
• Multidisciplinary decision
• Based on the assessment of likely ultimate function of limb compared to function with amputation
Factors Favoring Amputation
1 Warm ischemia time > 8 hrs2 Severe crush
• minimal remaining functional tissue
3 Chronic debilitating disease4 Severe polytrauma5 Mass casualty6 complexity of
reconstruction
Classification
•Reflection of amount of energy imparted and consequently, the prognosis1Skin wound size2Level of contamination3Extent of soft tissue
injury/ periosteal stripping
4Fracture configuration
Classification - Open Fractures
•Classification can really only be done at the completion of debridement
Classification - Open Fractures
•Open injuries
–Gustilo & Anderson
–AO
Classification - Open Fractures
•Type I–Small wound– Inside out–No/minimal contamination
–Minimal soft tissue trauma
–Low energy fracture pattern
Open Fracture - Gustilo Classification
•Type II–Moderate wound–Some contamination–Some muscle damage–Moderate energy fracture pattern
Open Fracture - Gustilo Classification
•Type III–Large wound–Significant comtamination
–Major soft tissue trauma•crushing•periosteal stripping
–High energy fracture pattern
Open Fracture - Gustilo Classification
• IIIA–enough soft tissue to cover
bone
• IIIB– insufficient soft tissue–need flap (local, free)
• IIIC– vascular injury requiring
repair
Open Fracture - Gustilo Classification
•Type III - Additional Factors–Barnyard–Shotgun–High velocity gunshot–Displaced segmental
fracture–Neglected open fracture (>
8 hrs)–Bone loss
Open Fracture - Gustilo Classification
•First aid•Emergency Room
•Definitive•Rehabilitation
Management
•Control bleeding–direct pressure
•Realign– further soft tissue
damage/ compromise
•Splint–comfort– further damage
First Aid
•First aid if not already given
•Remove gross debris/irrigate/dress/ splint
•Tetanus prophylaxis - if necessary
•Antibiotics
Emergency
•The open wound should be assessed and documented only once
Emergency
Antibiotics
• ? Prophylactic vs. treatmentClosed with operative RxCephalosporinGrade I
Grade II / III Add aminoglycoside
High Risk Add penicillin
Antibiotics
• Antibiotics can not compensate for an inadequate surgical management
Timing of Administration of Antibiotics
• The Prevention of Infection in Open Fractures An Experimental Study of
the Effect of Antibiotic TherapyWorlock, et al JBJS 1988
No antibiotics
1-4 hrs post-inoculation
1 hr. pre-inoculation
91% infection
51% infection
30% infection
Antibiotics
• The Role of Antibiotics in the Management of Open Fractures
Patzakis, et al JBJS, 1974
Control
Pen./Streptomycin
Cephalothin
13.9% infection
9.7% infection
2.3% infection
Definitive Treatment
1 Wound excision2 Wound extension3 Debridement4 Irrigation5 Bone stabilization6 Wound dressing7 +/- re-debridement8 Early wound
closure/coverage
Timing of Operative Intervention
• General standard - within 6-8 hours
• Not evidence based!!
Operating Room
• Scrub/remove gross debris/ irrigate
• Double setup1 debridement/irrigation2 bone stabilization if
internal fixation planned
• Tourniquet• apply/not inflated• in case of bleeding
Wound Excision
• Excise crushed/ contaminated skin edge
Wound Extension
• Sufficient extension to fully evaluate and treat soft tissue injury (approximately 1 diameter of limb)
• Anticipate incisions for bony stablization/soft tissue reconstruction
• Avoid incision that will compromise skin further
Wound Extension
Debridement
• Layer by layer• Remove all
devitalized and contaminated tissue (including bone)
Debridement - Objective:
• To leave a wound with:1 No/minimal
contamination2 Well vascularized
tissue for healing and to resist infection
Debridement
• “When in doubt, take it out”
Irrigation
• 10 litres for significant wounds– saline
• ? antibiotics• ? pulsed lavage• ? detergent
Irrigation
1 Improves visualization
2 Float out necrotic tissue
3 Flush out debris4 Reduce bacterial
population
Irrigation
• The solution to pollution is dilution
Stabilization
The Prevention of Infection in Open Fractures: An
Experimental Study of the Effect of Fracture Stability
Worlock, et al Injury 1994
Bony Stabilization
• Second prep if internal fixation
• Principles1 Minimize further trauma2 Sufficient stability to allow
early rehab3 Should not impede subsequent
soft tissue management4 Restoration of anatomy
Bony Stabilization
• Diaphyseal Fractures
• Humerus• Forearm
• Femur• Tibia
ORIF
IM nail
Bony Stabilization
• Articular Fractures• primary ORIF• spanning external fixator
+ / - articular ORIF delayed ORIF
• external fixation
Open Wound Management
• Can close extensions• Occasionally close open wound
primarily1 No crush2 No contamination3 Small wound4 No dead space5 Closure without tension
• Keep wound moist - ? bead pouch
Price of Primary Open Wound Closure
Gas Gangrene
Limb Loss Limb Loss DeathDeath
Open Wound Management
leave open
Open Wound Management
Antibiotic beads
• Depo of local antibiotics
• ? efficacy• ? toxicity
Antibiotic Bead Pouch VGH Experience
85 open tibial shaft fractures
• 59 antibiotic bead pouch• 26 no bead pouch
• No statistical difference in:– age, sex, ISS, time to
wound coverage
Keating, et al
Antibiotic Bead Pouch VGH Experience
• Infection
Keating, et al
No Bead Pouch
Bead Pouch
p value
Type II Type III TOTAL
16%
0%
<0.03
11%
3%
0.35
15%
2%
<0.06
Redebridement
• High grade injury• Severe contamination• Questionable tissue viability
– ? adequacy of debridement
• Q 24-48 hours until wound is Q 24-48 hours until wound is viableviable
Wound Closure/Coverage
• ? Immediate• Optimally by 3-7 days• Principles
1 Durable coverage2 Well vascularized
soft tissue envelope for bone
3 Fill dead space
Wound Closure/Coverage
1 Secondary intent2 Delayed primary
closure3 Skin graft4 Flap
– local– distant - free
Wound Closure/Coverage
Role of VAC yet to be delineated
Rehabilitation
1 Splint joints in functional position pending soft tissue healing
2 Swelling control3 ROM/Muscle rehabilitation as
soon as wound healing permits
4 Wound management to minimize scarring
Summary
• The soft tissues are critical to the successful management of all fractures
Summary
• Aggressive, systematic management is required for fractures with significant soft tissue injuries
THANK THANK YOU !!YOU !!
Open fracturesOpen fractures
ARS31 yr old man•Ped struck•Isolated injury
The most critical componentof this man’s treatment is:
1. Antibiotics2. Tibial fixation3. Avoidance of reaming4. Soft tissue management5. Early fracture stabilization
Open fracturesOpen fractures
ARS31 yr old man•Ped struck•Isolated injury
After management of the softtissues the bone is best stabilized by:
1. Cast2. External fixator3. Plate4. Reamed IM nail5. Unreamed IM nail
Open fracturesOpen fractures
ARS31 yr old man•Ped struck•Isolated injury
How would you grade this injury?
1. I2. II3. III A4. III B5. III C
Open fracturesOpen fractures
ARS31 yr old man•Ped struck•Isolated injury
The most critical componentof this man’s treatment is:
1. Antibiotics2. Tibial fixation3. Avoidance of reaming4. Soft tissue management5. Early fracture stabilization
Open fracturesOpen fractures
ARS31 yr old man•Ped struck•Isolated injury
After management of the softtissues the bone is best stabilized by:
1. Cast2. External fixator3. Plate4. Reamed IM nail5. Unreamed IM nail