Management of  Open Fractures Department of Orthopaedic Surgery  Faculty of Medicine Siriraj Hospital Mahidol University
Fractures <ul><li>Closed </li></ul><ul><li>Open (compound) </li></ul><ul><li>Fracture exposed to  </li></ul><ul><li>enviro...
  Open Fracture
Diagnosis of Open Fracture <ul><li>Clinical findings </li></ul><ul><ul><li>Fracture associated with wound  </li></ul></ul>...
Open Joint Injury <ul><li>Free air </li></ul><ul><li>in the knee </li></ul>
Importance of Open Fracture <ul><li>Emergency in orthopaedics </li></ul><ul><li>Infection </li></ul><ul><li>Soft tissue in...
Classification of Open Fracture (Gustilo and Anderson)
Factors   (that modified classification to type III) <ul><li>Contamination </li></ul><ul><ul><li>Exposure to soil </li></u...
Factors  (that modified classification to type III) <ul><li>Signs of high-energy mechanism </li></ul><ul><ul><li>Segmental...
Importance of Classification <ul><li>Determine choices of treatment </li></ul><ul><li>Incidence of complication </li></ul>...
Principle of Treatment <ul><li>Initial treatment (ER) </li></ul><ul><ul><li>Primary survey and resuscitation </li></ul></u...
Principle of treatment <ul><li>Initial treatment (OR) </li></ul><ul><ul><li>Irrigate & systematic debridement </li></ul></...
  Objectives of debridement    (and irrigation) <ul><li>Extension of the traumatized wound </li></ul><ul><li>  identificat...
Wound Irrigation <ul><li>NSS (+/- antibiotic or antiseptic solution) </li></ul><ul><li>Initial 2 L at ER </li></ul><ul><li...
  Principle of Debridement <ul><li>Wound exploration and  systematic  debridement </li></ul><ul><li>Adequate  removal of d...
  Systematic Debridement <ul><li>Skin (2mm from wound edge) </li></ul><ul><li>Subcutaneous tissue </li></ul><ul><li>Fascia...
Assessing the Extent of Injury <ul><li>Extending the wound => longitudinal </li></ul><ul><li>Systematic exploration </li><...
Repair Damaged Structures <ul><li>Skin :  + </li></ul><ul><li>Subcutaneous tissue : - </li></ul><ul><li>Muscle :  + </li><...
  Fracture Stabilization <ul><li>External splinting </li></ul><ul><ul><li>slab, cast </li></ul></ul><ul><ul><li>traction  ...
External Fixator
Internal Immobilization   Screws
Internal Immobilization   Plate and Screws System
Internal Immobilization   Locking Plate
Internal Immobilization   Intramedullary Nailing
Wound Coverage <ul><li>Direct suture </li></ul><ul><li>Skin graft </li></ul><ul><li>Flap </li></ul>
  Antibiotic <ul><li>Type I & II 1 St  gen. cephalosporin </li></ul><ul><li>Type III </li></ul><ul><ul><li>Add aminoglycos...
  Complications <ul><li>Infection </li></ul><ul><li>Damaged structures </li></ul><ul><li>Soft tissue coverage </li></ul><u...
 
<ul><li>Diagnosis </li></ul><ul><li>Initial treatment </li></ul><ul><li>Definitive treatment </li></ul>
Determine Amputation <ul><li>MESS at least 7 </li></ul>
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ortho 01 management of open fracture-update by kk 31052010

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Transcript of "ortho 01 management of open fracture-update by kk 31052010"

  1. 1. Management of Open Fractures Department of Orthopaedic Surgery Faculty of Medicine Siriraj Hospital Mahidol University
  2. 2. Fractures <ul><li>Closed </li></ul><ul><li>Open (compound) </li></ul><ul><li>Fracture exposed to </li></ul><ul><li>environment </li></ul>
  3. 3. Open Fracture
  4. 4. Diagnosis of Open Fracture <ul><li>Clinical findings </li></ul><ul><ul><li>Fracture associated with wound </li></ul></ul><ul><ul><li>Bleeding with fat globule </li></ul></ul><ul><li>Radiographic findings </li></ul><ul><ul><li>Free air located in the joint or </li></ul></ul><ul><ul><li>around the fracture </li></ul></ul>
  5. 5. Open Joint Injury <ul><li>Free air </li></ul><ul><li>in the knee </li></ul>
  6. 6. Importance of Open Fracture <ul><li>Emergency in orthopaedics </li></ul><ul><li>Infection </li></ul><ul><li>Soft tissue injury </li></ul><ul><ul><li>Wound coverage </li></ul></ul><ul><ul><li>Muscles, tendons </li></ul></ul><ul><li>Neuro-vascular injury </li></ul><ul><li>Bone defect (bone loss) </li></ul>Loss of Limb or Function
  7. 7. Classification of Open Fracture (Gustilo and Anderson)
  8. 8. Factors (that modified classification to type III) <ul><li>Contamination </li></ul><ul><ul><li>Exposure to soil </li></ul></ul><ul><ul><li>Exposure to water (pool, lake/ stream) </li></ul></ul><ul><ul><li>Exposure to fecal material (barnyard) </li></ul></ul><ul><ul><li>Exposure to oral flora (bite) </li></ul></ul><ul><ul><li>Gross contamination on inspection </li></ul></ul><ul><ul><li>Delayed in treatment > 8-12 hours </li></ul></ul>
  9. 9. Factors (that modified classification to type III) <ul><li>Signs of high-energy mechanism </li></ul><ul><ul><li>Segmental fracture </li></ul></ul><ul><ul><li>Bone loss </li></ul></ul><ul><ul><li>Crush mechanism </li></ul></ul><ul><ul><li>Shotgun wound </li></ul></ul><ul><ul><li>High velocity gunshot wound </li></ul></ul><ul><ul><li>Compartment syndrome </li></ul></ul><ul><ul><li>Extensive degloving of subcutaneous fat and skin </li></ul></ul><ul><ul><li>Requires flap coverage (any size of wound) </li></ul></ul>
  10. 10. Importance of Classification <ul><li>Determine choices of treatment </li></ul><ul><li>Incidence of complication </li></ul><ul><li>Result of treatment </li></ul>
  11. 11. Principle of Treatment <ul><li>Initial treatment (ER) </li></ul><ul><ul><li>Primary survey and resuscitation </li></ul></ul><ul><ul><li>Bleeding control </li></ul></ul><ul><ul><li>Temporary immobilization of the fracture and gross decontamination and wound dressing </li></ul></ul><ul><ul><li>Tetanus prophylaxis </li></ul></ul><ul><ul><li>Determine antibiotic administration </li></ul></ul>
  12. 12. Principle of treatment <ul><li>Initial treatment (OR) </li></ul><ul><ul><li>Irrigate & systematic debridement </li></ul></ul><ul><ul><li>+/- tissue culture </li></ul></ul><ul><ul><li>Assess the extent of injury </li></ul></ul><ul><ul><li>(definite diagnosis) </li></ul></ul><ul><ul><li>Repair the damage structures </li></ul></ul><ul><ul><li>Reduce and stabilize the fracture </li></ul></ul><ul><ul><li>Wound coverage </li></ul></ul>
  13. 13. Objectives of debridement (and irrigation) <ul><li>Extension of the traumatized wound </li></ul><ul><li> identification of the zone of injury </li></ul><ul><li>Detection and removal of foreign material </li></ul><ul><li>Detection and removal of nonviable tissues </li></ul><ul><li>Reduction of bacterial contamination </li></ul><ul><li>Creation of a wound that can tolerate the residual bacterial contamination and heal without infection </li></ul>
  14. 14. Wound Irrigation <ul><li>NSS (+/- antibiotic or antiseptic solution) </li></ul><ul><li>Initial 2 L at ER </li></ul><ul><li>6-8 L at OR (pulsatile irrigation) </li></ul>
  15. 15. Principle of Debridement <ul><li>Wound exploration and systematic debridement </li></ul><ul><li>Adequate removal of devitalized tissue </li></ul><ul><li>and foreign body (contamination) </li></ul>
  16. 16. Systematic Debridement <ul><li>Skin (2mm from wound edge) </li></ul><ul><li>Subcutaneous tissue </li></ul><ul><li>Fascia </li></ul><ul><li>Muscles and tendons </li></ul><ul><ul><li>Color, consistency, contractility, capability of bleeding </li></ul></ul><ul><li>Neurovascular structures </li></ul><ul><li>Periosteum and bone </li></ul>(Which one is the most specific character…..?)
  17. 17. Assessing the Extent of Injury <ul><li>Extending the wound => longitudinal </li></ul><ul><li>Systematic exploration </li></ul><ul><li> Reparation </li></ul>
  18. 18. Repair Damaged Structures <ul><li>Skin : + </li></ul><ul><li>Subcutaneous tissue : - </li></ul><ul><li>Muscle : + </li></ul><ul><li>Fascia : - (prophylaxis fasciotomy) </li></ul><ul><li>Tendon : + </li></ul><ul><li>Nerve : - (+) </li></ul><ul><li>Vessel : + </li></ul><ul><li>Bone : + </li></ul>
  19. 19. Fracture Stabilization <ul><li>External splinting </li></ul><ul><ul><li>slab, cast </li></ul></ul><ul><ul><li>traction </li></ul></ul><ul><li>External fixator </li></ul><ul><li>Internal fixation </li></ul><ul><ul><li>Pin, wire, plate & screws, nail etc. </li></ul></ul><ul><li>Pin incorporate cast </li></ul>
  20. 20. External Fixator
  21. 21. Internal Immobilization Screws
  22. 22. Internal Immobilization Plate and Screws System
  23. 23. Internal Immobilization Locking Plate
  24. 24. Internal Immobilization Intramedullary Nailing
  25. 25. Wound Coverage <ul><li>Direct suture </li></ul><ul><li>Skin graft </li></ul><ul><li>Flap </li></ul>
  26. 26. Antibiotic <ul><li>Type I & II 1 St gen. cephalosporin </li></ul><ul><li>Type III </li></ul><ul><ul><li>Add aminoglycoside </li></ul></ul><ul><ul><li>Add Pen.G </li></ul></ul><ul><li>Duration : 3-5 days </li></ul>
  27. 27. Complications <ul><li>Infection </li></ul><ul><li>Damaged structures </li></ul><ul><li>Soft tissue coverage </li></ul><ul><li>Compartment syndrome </li></ul><ul><li>Bone defect, delayed and nonunion </li></ul>
  28. 29. <ul><li>Diagnosis </li></ul><ul><li>Initial treatment </li></ul><ul><li>Definitive treatment </li></ul>
  29. 30. Determine Amputation <ul><li>MESS at least 7 </li></ul>

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