Open Fractures

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Open Fractures

  1. 1. October 19, 2013 Open Fractures Mohammad Alsofyani Teaching Assistant – Orthopedic Department Surgery Block - 6th MBBS 1
  2. 2. 2 Syllabus Open Fracture Definition Mechanism General Considerations Diagnosis Classification Management Compartment Syndrome Definition Types Pathophysiology Diagnosis Management Surgery Block - 6th MBBS October 19, 2013
  3. 3. 3 Open Fracture Surgery Block - 6th MBBS October 19, 2013
  4. 4. 4 Open Fracture  Definition: as one in which a break in the skin and underlying soft tissues leads directly into or communicates with the fracture and the hematoma Surgery Block - 6th MBBS October 19, 2013
  5. 5. 5 Open Fracture  Mechanism:  Occurs most commonly after high-energy limb injuries. Surgery Block - 6th MBBS October 19, 2013
  6. 6. 6 Open Fracture  General Considerations:  one of the true orthopedic emergencies.  Such a fracture is suspect to contamination by the environment at the time of injury.  Can present as isolated injuries or in the context of a multiply injured patient. Surgery Block - 6th MBBS October 19, 2013
  7. 7. 7 Open Fracture  Diagnosis:  Soft tissue injuries may be threatening to life or limb.  Clinical examination is required BEFORE obtaining the X-ray.  it is essential to check for neurological and vascular compromise.  Diagnosed clinically and often difficult to appreciate on X-rays.  Soft tissue should be assessed on x-rays. Surgery Block - 6th MBBS October 19, 2013
  8. 8. 8 Open Fracture  Diagnosis: Surgery Block - 6th MBBS October 19, 2013
  9. 9. 9 Open Fracture  Classification:  The classification of open fractures as described by Gustilo and Anderson.  Type I:  Skin wound less than 1 cm.  Clean.  Simple fracture pattern. Surgery Block - 6th MBBS October 19, 2013
  10. 10. 10 Open Fracture  Classification:  Type II:  Skin wound more than 1 cm.  Soft-tissue damage not extensive.  No avulsions.  Simple fracture pattern. Surgery Block - 6th MBBS October 19, 2013
  11. 11. 11 Open Fracture  Classification:  Type III:  High-energy injury involving extensive soft-tissue damage  Or multifragmentary fracture, segmental fractures, or bone loss irrespective of the size of skin wound  Or severe crush injuries  Or vascular injury requiring repair  Or severe contamination including farmyard injuries Surgery Block - 6th MBBS October 19, 2013
  12. 12. 12 Open Fracture  Classification:  Type III:  More than 10 cm.  Is subdivided based on the degree of contamination, the extent of periosteal stripping, and the presence of vascular injury. Surgery Block - 6th MBBS October 19, 2013
  13. 13. 13 Open Fracture  Classification:  Type IIIA: Adequate soft-tissue cover of bone despite extensive soft-tissue damage Surgery Block - 6th MBBS October 19, 2013
  14. 14. 14 Open Fracture  Classification:  Type IIIB:  Extensive soft-tissue injury with periosteal stripping and bone exposure.  Major wound contamination. Surgery Block - 6th MBBS October 19, 2013
  15. 15. 15 Open Fracture  Classification:  Type IIIC:  High-energy injury involving extensive soft-tissue damage.  Major arterial injury. Surgery Block - 6th MBBS October 19, 2013
  16. 16. 16 Open Fracture  Classification: Classification Size Inadequate Soft Tissue Covering I <1cm ✗ ✗ ✗ ✗ II >1 cm ✗ ✗ ✗ ✗ III >10 cm IIIA ✗ ✓ ✗ ✗ IIIB ✓ ✓ ✓ ✗ IIIC ✓ ✓ ✓ Surgery Block - 6th MBBS Soft Tissue Contamination Damage Vascular Injury ✓ October 19, 2013
  17. 17. 17 Open Fracture  Management:  The treatment aims of open fracture is to: 1. Prevention of infection. 2. Soft-tissue coverage. 3. Fracture stabilization. Surgery Block - 6th MBBS October 19, 2013
  18. 18. 18 Open Fracture  Management: 1. Prevention of infection:  In all open fracture injuries, the patient must receive anti-tetanus prophylaxis and appropriate antibiotic coverage.  Antibiotics should be given intravenously as soon as possible. Classification I 0–2% II 2 – 10 % III Surgery Block - 6th MBBS Infection Risks 10 – 50 % October 19, 2013
  19. 19. 19 Open Fracture  Management: 1. Prevention of infection: Classification I Likely organisms Coverage Antibiotics (I.V) II Gram + Cocci 1st Generation Cephalosporin III Gram + Cocci and Gram Rod 1st Generation Cephalosporin + Gentamicin Surgery Block - 6th MBBS October 19, 2013
  20. 20. 20 Open Fracture  Management: 2. Soft tissue coverage:  Debridement of open fractures is one of the single most important principles in management of open fractures.  The recommended time for debridement within 6 hours has for long been considered critical in prevention of infection.  Irrigation is very important principle in open fracture management with amount around 6 liters. Surgery Block - 6th MBBS October 19, 2013
  21. 21. 21 Open Fracture  Management: 2. Soft tissue coverage:  Surgical incisions performed during initial debridement can be closed primarily and original open fracture wound left open.  Assisted wound closure using antibiotic bead pouch or vacuum assisted dressings are useful methods. Surgery Block - 6th MBBS October 19, 2013
  22. 22. 22 Open Fracture  Management: 3. Fracture stabilization:  External fixation is the mainstay of treatment in severe open fracture. Allowing easy access to management of soft tissues injuries. Surgery Block - 6th MBBS October 19, 2013
  23. 23. 23 Open Fracture  Management: 3. Fracture stabilization:  Definitive fixation is considered, when: 1. The patients clinical status is optimized 2. The wounds are healthy and the soft-tissue envelope will allow for chosen surgical approach 3. A good preoperative plan has been created. Surgery Block - 6th MBBS October 19, 2013
  24. 24. 24 Compartment Syndrome Surgery Block - 6th MBBS October 19, 2013
  25. 25. 25 Acute Compartment Syndrome  Definition:  Is a true surgical emergency with increasing in tissue pressure prevents capillary blood flow and produces ischemia in muscle and nerve tissue. Surgery Block - 6th MBBS October 19, 2013
  26. 26. 26 Acute Compartment Syndrome  Types:  Compartment of the leg:  Anterior compartment.  Posterior superficial compartment.  Posterior deep compartment.  Lateral compartment. Surgery Block - 6th MBBS October 19, 2013
  27. 27. 27 Acute Compartment Syndrome  Types:  Compartment of the forearm:  Anterior (Flexor).  Posterior (Extensor).  Mobile wad of henry (Medially). Surgery Block - 6th MBBS October 19, 2013
  28. 28. 28 Acute Compartment Syndrome  Pathophysiology: Arterial Damage Direct Injury Surgery Block - 6th MBBS Ischemia Reduced Blood Flow Edema Compartment Pressure October 19, 2013
  29. 29. 29 Acute Compartment Syndrome  Diagnosis:  Muscles:  3-4 hours: reversible changes.  6 hours: variable damage.  8 hours: irreversible change.  Nerves:  2 hours: looses nerve conduction.  4 hours: neuropraxia.  8 hours: irreversible changes. Surgery Block - 6th MBBS October 19, 2013
  30. 30. 30 Acute Compartment Syndrome  Diagnosis:  The key to successful treatment of compartment syndrome is early diagnosis and decompression.  The hypoxic muscle will become necrotic within hours.  Any peripheral nerve passing through the compartment is likely to suffer permanent functional impairment. Surgery Block - 6th MBBS October 19, 2013
  31. 31. 31 Acute Compartment Syndrome  Diagnosis:  Muscle, once infarcted, can never recover and replaced by inelastic fibrous tissue (Volkmann’s ischemic contracture). Surgery Block - 6th MBBS October 19, 2013
  32. 32. 32 Acute Compartment Syndrome Surgery Block - 6th MBBS October 19, 2013
  33. 33. 33 Acute Compartment Syndrome  Diagnosis: Arterial Damage Ischemia Reduced Blood Flow • Direct Injury Surgery Block - 6th MBBS Edema Volkmann’s ischemia  Painful.  Pale.  Pulseless.  Paresthesi as.  paralysis Compartment Pressure October 19, 2013
  34. 34. 34 Acute Compartment Syndrome  Diagnosis:  Clinical:  The classical signs (5P)  Pain. (out of proportion on passive stretch of the muscles compartment).  pallor.  Parasthesia.  Paralysis.  Pulselessness.  These signs and symptoms are subjective. Surgery Block - 6th MBBS October 19, 2013
  35. 35. 35 Acute Compartment Syndrome  Diagnosis:  Intercompartmental pressure monitoring.  Incase of disturbance of level of conscious, impose the use of objective methods Surgery Block - 6th MBBS October 19, 2013
  36. 36. 36 Acute Compartment Syndrome  Management:  Remove cast or dressing  Place at level of heart  decompress the affected compartment ( Fasciotomy ) Surgery Block - 6th MBBS October 19, 2013
  37. 37. 37 Chronic Compartment Syndrome  Definition:  Occurs in young active patients after intense muscular activity. Surgery Block - 6th MBBS October 19, 2013
  38. 38. 38 References Textbook of Orthopedics (John Ebnezar). Aply’s System of Orthopedics and Fractures. Essential of Orthopedics (RM Shenoy). Essential Orthopedics (J.Maheshwari). Field Guide to Fracture Management (Richard B. Birrer).  Current Diagnosis and Treatment of Orthopedic (Harry B. Skinner).  Essential Orthopedic and Trauma (David J. Dandy)  Pocket of Orthopedics and Fractures. (Ronald McRae).      Surgery Block - 6th MBBS October 19, 2013

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