Surgical Approach To Open Fractures by Dr Sarah Murniati

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This topic has been presented by my lovely wife during her Orthopaedic rotation in HRPZ. My challenge is to redesign the slide using Zen approach. And Alhamdulillah it went very well. Good job Honey.

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  • Do we even need to do operative debridement?*Orcutt S, Kilgus D, Ziner D. The treatment of low-grade open fractures without operative debridement. Read at the Annual Meeting of the Orthopaedic Trauma Association; 1988 Oct 28; Dallas, TX.**Yang EC, Eisler J. “Treatment of Isolated Type 1 Open Fractures: Is Emergent Operative Debridement Necessary?”ClinOrthopRelat Res 2003. 410: 289-294.
  • “Thorough operative debridement is the standard of care for all open fractures.”“Even if the benefits of formal I&D were insignificant for low grade fractures, operative debridement is still required for proper wound classification.”“Open fractures graded on the basis of superficial characteristics are often misclassified.”
  • timing of initial surgical intervention has wide variance within the literature.
  • Challenges can arise when striving to adhere to this time limit including operating under conditions that are less than ideal (i.e., nonorthopedic surgical teams, poor implant availability, surgeon and personnel fatigue, etc.). This unfortunately can result in adverse events with patient outcomes.
  • In certain scenarios more emergent debridements may be needed. Eg. Type III injuries with vascular injury and/or gross fecal or soil contamination (insert pics). If surgery for an open fracture is to be delayed, temporizing treatment should include sterile and antiseptic coverage (i.e., with Technicare soap solution or iodine-derivative) provisional splinting with attention paid to basic length, rotation, and alignment. A preliminary fracture reduction may need to be performed in the emergency room.
  • (i.e., with Technicare soap solution or iodine-derivative)
  • Surgical Debridement & Irrigation
  • Kiv remove this slide
  • Small wounds should be extended & excised to allow adequate exposure
  • Small wounds should be extended & excised to allow adequate exposure
  • To complete labelling
  • To complete labelling
  • Could not find more info on paratenon
  • For type II & III #, irrigate with 5-10 litres of saline (Orthoteers)
  • Protocol*3L (one bag) for type 1 (Gustillo Anderson)6L (two bags) for type 2 9L (three bags) for type 3
  • Lack of evidence-based recommendations in the literature to guide surgeons on the appropriate additives for irrigations.**
  • Compare CHD, H2O2, PI, saline
  • Equipment used for irrigation includes bulb syringes, piston syringes, pressure canisters, whirlpool agitator, whirlpool hose sprayer, irrigation fluid in plastic containers with a pour cap or nozzle, and pulsed lavage (eg, jet lavage, mechanical lavage, pulsatile lavage, mechanical irrigation, high-pressure irrigation).Continuous irrigation is the uninterrupted stream of irrigant to the wound’s surface. Pulsed irrigation is the intermittent or interrupted pressurized delivery of an irrigant, typically measured by the number of pulses per second. Power-pulsed lavage is a wound irrigation system that uses an electrically powered pump system to deliver a high volume of irrigation solution under pressure. Outcomes of pulsed versus continuous pressure appear to be similar.
  • http://www0.sun.ac.za/ortho/webct-ortho/general/exfix/exfix.html
  • Amputation rates for open fractures that require vascular repair (classified as Gustilo type IIIC[10]) range from 40% in a study reported by Helfet et al[11] to 88%, as reported by Georgiadis et al.[5] Russell et al[3] consider a type IIIC fracture with nerve injury an absolute indication for amputation. In this same spirit, Lange et al[8] recommend amputation for patients with posterior tibial nerve impairment.Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 24:742-746, 1984
  • Used to select lower extremity injury that warrant primary amputationAllows evaluation of patients with normal perfusion Vascular injury has not been clearly definedHas been widely referenced as the trauma limb-salvage index for lower extremity trauma
  • Score doubles for ischaemia >6 hours
  • Gun shot wound
  • Surgical Approach To Open Fractures by Dr Sarah Murniati

    1. 1. surgical approach
    2. 2. surgical wound debridement approach primary fixation vs external fixation Intraoperative irrigation
    3. 3. surgical wound debridement approach primary fixation vs external fixation intraoperative Irrigation
    4. 4. Do we even need to do operative debridement?
    5. 5. Orcutt et al.: No significant difference, BUT* 50 type 1 & 2 open fractures less infection in non-op group (3% vs 6%) less delayed union in non-op group (10% vs 16%) Yang et al.: 0% infections ** 91 type 1 open fractures treated without formal debridement *Orcutt S, Kilgus D, Ziner D. The treatment of low-grade open fractures without operative debridement. Read at the Annual Meeting of the Orthopaedic Trauma Association; 1988 Oct 28; Dallas, TX. **Yang EC, Eisler J. “Treatment of Isolated Type 1 Open Fractures: Is Emergent Operative Debridement Necessary?” Clin Orthop Relat Res 2003. 410: 289-294.
    6. 6. “Even if the benefits of formal I&D were insignificant for low grade fractures, operative debridement is still required for proper wound classification.” *Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am. 2006 Dec; 88(12):2739-48. Huge risk not to explore and debride! “Open fractures graded on the basis of superficial characteristics are often misclassified.”
    7. 7. When to go in?
    8. 8. “Historically, the 6-hour rule has been employed as the time limit within which an open fracture should be taken to the operating room for initial debridement*” *Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. Gustilo RB, Anderson JT J Bone Joint Surg Am. 1976 Jun; 58(4):453-8.
    9. 9. Several studies suggest that the timing of surgery is less important than the adequacy of debridement and early use of antibiotics. Gustillo and Anderson's classic article concluded “Open fractures require emergency treatment, including adequate debridement and copious irrigation.” Patzakis and Wilkins documented infection rates of (6.8%) of 396 for wounds debrided within 12 h, and (7.1%) of 708 for those debrided after 12 h. Bednar and Parikh reviewed 82 adult open fractures and found no statistically significant difference in deep infection rates for those treated within 6 h compared with those treated within 24 h.
    10. 10. Influencing factors surgeon availability patient's physiologic status operating room availability
    11. 11. Strict adherence to the emergent 6-hour rule does not seem to be justified based on empiric evidence available in the literature* *Review Timing of débridement of open fractures. Pollak AN J Am Acad Orthop Surg. 2006; 14(10 Spec No.):S48-51.
    12. 12. however….
    13. 13. In certain scenarios….. Eg. Type III injuries with vascular injury and/or gross fecal or soil contamination.
    14. 14. If surgery for an open fracture is to be delayed, temporizing treatment should include • sterile and antiseptic coverage • provisional splinting with attention paid to basic length, rotation, and alignment. • A preliminary fracture reduction may need to be performed in the emergency room.
    15. 15. The goals of treatment for open fractures are to prevent infection, get the broken bones to heal, and restore function. Open fractures should be taken to the operating room in an urgent manner using appropriate surgical judgment.
    16. 16. Irrigation and
    17. 17. Objectives Detection & removal of foreign material Detection & removal of nonviable tissues Reduction of bacterial contamination Creation of a wound that can tolerate residual bacterial contamination & heal without infection
    18. 18. Beginning with skin & subcutaneous fat -> methodical, layer-by-layer debridement Wounds should be extended & excised to allow adequate exposure One must be conservative in excision of skin, particularly at a premium Any non-viable, damaged, or contaminated fascia excised
    19. 19. Beginning with skin & subcutaneous fat
    20. 20. Beginning with skin & subcutaneous fat -> methodical, layer-by- layer debridement Methodical, layer-by- layer debridement
    21. 21. Beginning with skin & subcutaneous fat -> methodical, layer-by- layer debridement Any nonviable, damage d, or contaminated fascia excised
    22. 22. skin subcutaneous tissue muscle bone
    23. 23. Muscle : Viable? (4C’s)Indicator Description Colour • least reliable sign for muscle viability • surface tissue may be discoloured due to contusion or local vasocontriction • Non-viable: dark-coloured Consistency • ability to rebound to initial shape after grasping with forceps (may be most reliable early sign) • Viable: firm • Non-viable: mushy, soft Contractility • assessed by observing retraction with pinch of forceps or by observing stimulus with electrocautery device Circulation • may be difficult to detect early due to vasospasm • Non-viable: absence of bleeding from its cut surface
    24. 24. Significant function retained even if 10% of a muscle belly & its tendon preserved Certain wounds may require serial debridements
    25. 25. Where coverage of tendons by soft tissue not possible, paratenon is essential for tendon survival – do not debride paratenon but copiously irrigate
    26. 26. If not obviously contaminated, & if contribute to reconstruction of #, bone can be retained as bone graft  Unattached bone should be discarded Bone debridement initially can be conservative - if infection intervenes, early aggressive redebridement important Critical to preserve periosteum where bone will not be immediately covered by soft tissue
    27. 27. surgical wound debridement approach primary fixation vs external fixation intraoperative irrigation
    28. 28. surgical wound debridement approach primary fixation vs external fixation Intraoperative irrigation
    29. 29. “The removal of contaminating debris and the decrease of potentially infective bacterial loads decrease the chances of acute and chronic infection” *Review Wound irrigation in musculoskeletal injury. Anglen JO. J Am Acad Orthop Surg. 2001 Jul-Aug; 9(4):219-26.
    30. 30. Protocol* *Review Wound irrigation in musculoskeletal injury. Anglen JO. J Am Acad Orthop Surg. 2001 Jul-Aug; 9(4):219-26. 3L 3L 3L 3L 3L 3L
    31. 31. Low to medium pressure lavage device is recommended as higher-pressure devices have been associated with added tissue or bone damage* *High and low pressure irrigation in contaminated wounds with exposed bone. Bhandari M, Thompson K, Adili A, Shaughnessy SG Int J Surg Investig. 2000; 2(3):179-82.
    32. 32. Lack of evidence-based recommendations in the literature to guide surgeons on the appropriate additives for irrigations.** **Comparison of soap and antibiotic solutions for irrigation of lower-limb open fracture wounds. A prospective, randomized study. Anglen JO. J Bone Joint Surg Am. 2005 Jul; 87(7):1415-22.
    33. 33. Normal Saline isotonic and the most commonly used wound irrigation solution due to safety(lowest toxicity) and physiologic factors. A disadvantage is that it does not cleanse dirty, necrotic wounds as effectively as other solutions.
    34. 34. contains no antimicrobial or bacteriostatic agents or added buffers. often used in irrigation particularly in developing countries, as a less expensive alternative to hypotonic and may cause hemolysis readily absorbed by the tissues during surgical procedures; therefore, its use under such conditions is not recommended. Sterile Water
    35. 35. in the event that normal saline or sterile water are not available. a few studies have shown potable water to be as effective at reducing bacterial counts as normal saline. Potable Water
    36. 36. broad spectrum antimicrobial solution effective against a variety of pathogens including Staphylococcus aureus. - similar wound infection rates have been reported in adult and pediatric populations with saline irrigation versus 1% povidone- iodine*. A disadvantage is its cytotoxicity to healthy cells and granulating tissues. The solution dries and tends to discolor skin. It may also cause local irritation to the periwound skin. *Chisholm CD, Cordell WH, Rogers K, Woods JR. Comparison of a new pressurized saline canister versus syringe irrigation for laceration cleansing in the emergency department. Ann Emerg Med. Nov 1992;21(11):1364-7. *Watt BE, Proudfoot AT, Vale JA. Hydrogen peroxide poisoning. Toxicol Rev. 2004;23(1):51-7. Povidone Iodine
    37. 37. Controversial use Several studies have shown hydrogen peroxide to be ineffective in reducing bacterial count* Cytotoxic to healthy cells and granulating tissues** *Leyden JJ. Bartelt NM. Comparison of topical antibiotic ointments, a wound protectant and antiseptics for the treatment of human blister wounds contaminated with S. aureus. J Fam Pract. Jun 1987;24(6):601-4 **Lineaweaver W, Howard R, Soucy D, et al. Topical antimicrobial toxicity. Arch Surg. Mar 1985; 120(3):267-70 Hydrogen Peroxide
    38. 38. American Medical Association: the effervescing cleansing action may act as a chemical debriding agent to help lift debris and necrotic tissue when used at full strength If used, irigation with NS is recommended* Hydrogen Peroxide *Rodeheaver GT. Wound cleansing, wound irrigation, wound disinfection. In: Krasner D, Kane D, Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 2nd. Wayne, PA: Health Management Publications, Inc; 1997:97-108
    39. 39. is it relevant?
    40. 40. Lee et al. studied pre- and post debridement cultures of open wounds* Only 8% of organism cultured eventually caused infection. Conversely 7% of patients with negative cultures eventually become infected. *Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res 1997; 339:71-5
    41. 41. Study of wound infections after open fractures by Carsenti-Etesse et al. 92% of infections after open fractures were caused by nosocomial bacteria, rather than by the initially cultured organism* *Carsenti-Etesse H, Doyon F, Desplaces N, et al. Epidemiology of bacterial infection during management of open leg fractures. Eur J Clin Microbiol Infect Dis 1999; 18:315-23
    42. 42. Routine cultures of traumatic or clean surgical wounds are not recommended *Bhandari M et al. (2012) Evidence-based orthopedics. Oxford. Blackwell Publishing Ltd Superficial wound swab cultures of a suspected wound infection are of little value Intraoperative deep cultures if positive can help guide antibiotic therapy if an organism is isolated
    43. 43. surgical wound debridement approach primary fixation vs external fixation intraoperative irrigation
    44. 44. surgical wound debridement approach primary fixation vs external fixation Intraoperative irrigation
    45. 45. Role For skeletal stability to minimise further soft tissue insult
    46. 46. Clean, healthy wound Mild, minimal soft tissue injury Early presentation <6H Primary Fixation
    47. 47. Joint can be reduced and stabilised temporarily in an adequate position while awaiting decrease of any swelling and allows soft tissue healing Can be applied almost always and everywhere Severe soft tissue damage and contamination External Fixation
    48. 48. Advantages Disadvantages Easy and quick Pin track infections Relatively stable fixation Malalignment No further damage done Delayed union Avoids hardware in the open wound Allows wound care
    49. 49. A surgeon may consider amputating a limb that has sustained (1) a high-grade open fracture (2) severe vascular injury (3) significant nerve damage
    50. 50. Amputation rates for open fractures that require vascular repair (Gustilo type IIIC) range from 40% in a to 88%*. Russell et al. consider a type IIIC fracture with nerve injury an absolute indication for amputation**. In this same spirit, Lange et al. recommend amputation for patients with posterior tibial nerve impairment***. *Helfet DL, Howey T, Sanders R, et al: Limb salvage vs amputation: preliminary results of the MESS. Clin Orthop 256:80-86, 1990 **Russel WL, Sailors DM, Whittle TB, et al: Limb salvage vs traumatic amputation: a decision based on a seven-part predictive index. Ann Surg 213:473-481, 1991 ***Lange RH, Bach AW, Hansen ST Jr, et al: Open tibial fractures with associated vascular injuries: prognosis for limb salvage. J Trauma 25:203-208, 1985
    51. 51. Mangled Extremity Severity Score (MESS) Used to select lower extremity injury that warrant primary amputation Allows evaluation of patients with normal perfusion – Vascular injury has not been clearly defined Has been widely referenced as the trauma limb-salvage index for lower extremity trauma
    52. 52. V-elocity of injury I-schaemia S-hock A-ge “VISA gives you double frequent flyer points after 6 hours” Score doubles for ischaemia >6 hours

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