Open Fractures Principles of Management
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Transcript of Open Fractures Principles of Management
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Prof. Mamoun KremliAlMaarefa College
Open FracturesPrinciples of Management
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Historical fact … until WW ITreatment of open fractures was “Amputation”
Mortality rate ~ 75%
Function in “survivors” was poor
Alois Karlbauer
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ObjectivesDefinition of an open fracture
Important points in history of an open fracture
Classification
Management:Initial treatmentImportance of surgical debridementBone treatment initial & definitiveSoft tissue coverage
Factors affecting outcome
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DefinitionOpen fracture is a fracture where the skin
coverage overlying is breachedeven a small puncture wound
Another name: compound fracture
www.merryshannon.com
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History in open fracturesMechanism of injury
Date, time, type, method of impact, …
Consciousness
Size of wound
Amount of bleeding
Other injuries: often missed
Anti-Tetanus status
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Type of injuryDetermines amount of energy and
Extent of soft tissue injury
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Type of injuryFall: height is important
Sport: stronger impact
Heavy object falling: direct injury – soft tissue
Road traffic accident (RTA)): more severeCar (MVA) , motorcycle, pedestrian
Assault & firearms: severe
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Mechanism of InjuryTry to determine if injury was caused by:
Low velocityHigh velocityCrushing under objects
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Mechanism of InjuryField of injury:
Relatively cleanContaminated soil
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Mechanism of InjuryOpen injury from:
In-out: usually cleanerOut-in: usually more contamination and dirt
www.aofoundation.org
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Mechanism of InjuryPenetrating Missiles
Low velocity < 300 m/s - damage along the tractComminution
High velocity: >300m/s - sever comminutionComminution with wide soft tissue damageSome fragment insideSome flip insideVacuum phenomena - cavitation
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Signs of high energy injurySegmental fracture
Bone loss
Compartment syndrome
Crush syndrome
Extensive de-gloving
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A. Karlbauer
ExamplesLow energy High energy
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Approach – clinical examGeneral medical condition should be evaluated
to exclude shock and brain injury
Vital signs should be observed and followed up
Look:special attention is to be paid to wounds
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Approach – clinical examFeel:
Sensory and motor deficitsPulse distal to injuryCompartment syndrome
Tense compartment
Move:With care, if necessary!
www.medicinabih.info
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Approach – clinical examExamination of the viscera
Rib fracturesLung, liver and spleen
Pelvic fracturesUrinary bladder and urethra
Head and spinal injuryNeurological examination
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Management of open fracturesInitial management
Classifying the injury
Definitive treatment
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Initial managementit is essential that the step-by-step approach in
advanced trauma life support not be forgotten
Treat the patient, not the fracture! (A B C)
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Initial managementit is essential that the step-by-step approach in
advanced trauma life support not be forgotten
When the fracture is ready to be dealt with:The wound is carefully inspectedAny gross contamination is removedThe wound is photographedThe area then covered with a saline-soaked dressingThe patient is given antibioticsTetanus prophylaxis is administeredThe limb circulation and distal neurological status
checked repeatedly
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Grades of open fractureImportant to grade severity of open injuries and
soft tissue injuriesTo treat according to guidelinesTo have an idea about prognosis
Several classificationsMost widely used: Gustilo Classification
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Gustilo ClassificationGrade 1:
Low-energy, minimal soft-tissue damage(wound < 1cm)
Grade 2:Higher energy, no flaps / crushingmoderate contamination (wound > 1cm)
Grade 3:High-energy, flaps / crushingsignificant contamination.
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Gustilo ClassificationSub-Types of Grade III:
Type 3A : Adequate soft-tissue covercan cover skin primarily
Type 3B: Inadequate covercan not cover skin primarilymay need skin graft or flap
Type 3C: Vascular injuryRequires vascular repair
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Gustilo Grade ILow energy
Simple fracture
Skin open by fragment pressure within – out
Wound < 1 cm
No / little contamination
www.orthopaedicsone.com/
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Gustilo Grade IIHigher energy
Laceration > 1 cm
No flap / No contusion
Minimal contamination
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Gustilo Grade IIIAHigh-energy,
Adequate soft-tissue cover
Contamination
Comminution or segmental fracture
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Gustilo Grade IIIBHigh-energy,
Extensive soft-tissue stripping
Inadequate cover,
Massive contamination
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Gustilo Grade IIIA or IIIBAn intra-operative decision
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Gustilo Grade IIIA or IIIB? Adequate soft tissue coverage
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Gastilo Grade? IIIC
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Problem of open fracturesInfection – skin is breached
Primary: from the fieldMassive contaminationDebris and foreign bodiesDevitalized tissues
Secondary infection after internal fixationInitial bacterial contaminationProper debridement not doneInternal fixation is a foreign body
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Principles of treatmentAll open fractures, no matter how trivial they
may seem, must be assumed to be contaminated
The basic guidelines:Antibiotic prophylaxisUrgent and proper wound and fracture debridementStabilization of the fracture – ? External FixationEarly definitive wound cover
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Primary surgeryThe aims of primary surgery are:
Preservation of life and limbDefinitive injury assessmentStaged wound debridement
May need to repeat after 48-72 hoursFracture stabilization
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Primary surgery – DebridementTrim skin edges
Remove foreign material
Remove all dead muscles and lacerated tissues
Remove fully detached small bone pieces
Saline wash: 5 Liters (wash–wash–wash)
? Delayed secondary closure
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Primary surgery – Debridement
www.us.elsevierhealth.com / Principles of Fracture Treatment
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Alois Karlbauer
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Alois Karlbauer
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Alois Karlbauer
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Alois Karlbauer
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“The solution to pollution is Dilution”
Alois Karlbauer
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Surgical DebridementSurgical debridement demands meticulous
excision of all dead and devitalized tissues
Start from outside working inwards:SkinFatMuscleBoneNeurovascular
Alois Karlbauer
Leaving dead tissue
invites infection
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Treatment guidelinesGustilo I and II:
Can treat by primary internal fixationRate of infection low – if follow guidelines
Alois Karlbauer
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Treatment guidelinesGustilo IIIA
Usually defer internal fixation until soft tissue condition allows
Gustilo IIIBExternal fixationLater, internal fixation
Gustilo IIICVascular repair is a priorityExternal fixator
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Higher infection rateIncreased contamination:
Exposure to soil Exposure to water Exposure to fecal material Exposure to oral material Gross contamination Delay > 12 hours
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Case example - 126y male, motorbike accident, stable
Gustilo Type?
Management:Swab takenAntibiotics, anti- tetanusDebridement, skin closureExternal fixatorLater on, Intramedullary nail
Tadashi Tanaka, Chiba, Japan
IIIA / IIIB
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Case example - 1
Tadashi Tanaka, Chiba, Japan
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Case example - 232y old, sever car accident, hit by a truck on
bridge and car fell into canal
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Case example - 2Sever contamination, commination, and crushingUn-salvaged after several attempts
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SummaryDefinition of open fracture
Important points in history of an open fracture
Gustilo classification
Management:Importance of early surgical debridementBone treatment initial & definitiveSoft tissue coverage