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Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
Compound fractures
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Compound fractures

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  1. COMPOUND FRACTURES OFLOWER LIMB- PRINCIPLESOF MANAGEMENT
  2. 04/22/13DefinitionDefinitionA FRACTURE IN WHICH FRACTURE HAEMATOMAA FRACTURE IN WHICH FRACTURE HAEMATOMACOMMUNICATES WITH EXTERIORCOMMUNICATES WITH EXTERIOR
  3. 04/22/13Gustillo Classification• Grade I:        - wound less than 1 cmw/ minimal soft tissue injury;  - wound bed is clean 
  4. 04/22/13Gustillo Classification• Grade I:        - wound less than 1 cm w/minimal soft tissue injury;   woundbed is clean 
  5. 04/22/13Type IIType II :: greater than 1cm in lengthgreater than 1cm in length moderate amount of soft tissue damagemoderate amount of soft tissue damage higher energy trauma.higher energy trauma.(Usually confined to one compartment(Usually confined to one compartmentand amount of debridement required is minimal)and amount of debridement required is minimal)ClassificationClassification[Gustillo & Anderson][Gustillo & Anderson]
  6. 04/22/13¤ Type III¤ Type III ::Wound longer than 10cmWound longer than 10cmwith extensive muscle devitalisationwith extensive muscle devitalisation
  7. 04/22/13Type IIIaType IIIa ::Limited stripping of periosteum and softLimited stripping of periosteum and softtissues from bone.tissues from bone.adequate soft tissue coverage for bone,adequate soft tissue coverage for bone,tendons and neurovascular bundle.tendons and neurovascular bundle.
  8. 04/22/13¤¤ Type IIIbType IIIb : Extensive stripping of soft: Extensive stripping of softtissue and periosteum from bone.tissue and periosteum from bone.Requires a local flap or free tissue transferRequires a local flap or free tissue transfer
  9. 04/22/13¤¤ Type IIIcType IIIc : A major vascular: A major vascularinjury requiring repairinjury requiring repair((AA tibia # with disruption of ant. tibialtibia # with disruption of ant. tibialarteryarterybut preservation of post. tibial artey isbut preservation of post. tibial artey isnot Type IIIc)not Type IIIc)ClassificationClassification[Gustillo & Anderson[Gustillo & Anderson
  10. 04/22/13Depending on mechanisma. Compounding from with inb. Compounding from with out
  11. 04/22/13MANAGEMENTEMERGENCYGOLDEN HOUR CONCEPTAIM:-To convert contaminated wound into clean woundTo convert contaminated wound into clean woundTo convert the open # into a closed one.To convert the open # into a closed one.To establish a union in a good positionTo establish a union in a good positionTo prevent pyogenic and clostridial infection.To prevent pyogenic and clostridial infection.
  12. 04/22/13MANAGEMENTORDER OF PRIORITY1. PATIENT2. LIMB3. WOUND4. FRACTURE
  13. 04/22/13PATIENTPOLYTRAUMARESUSCITATIONLIMBVASCULAR STATUSNEUROLOGICAL STATUSCOMPARTMENT SYNDROME
  14. 04/22/13WOUNDCLEANSTERILE DRESSINGCULTURE SWAB?FRACTUREDONOT REDUCEPOSITION AND SPLINTANTIBIOTICSBROAD SPECTURM
  15. 04/22/13PRINCIPLES OF MANAGEMENTSURGICAL TECHNIQUETOURNIQUETUsesUsesDisadvantagesDisadvantagesNever use as a routineNever use as a routine
  16. 04/22/13SKIN AND S/C TISSUESKIN AND S/C TISSUEExpose entire zone of injuryExpose entire zone of injuryMeticulous hemostasisMeticulous hemostasisElliptical wound preferredElliptical wound preferredWound extensionsWound extensionsBe conservativeBe conservative
  17. 04/22/13FASCIAFASCIAExcise contaminated fasciaExcise contaminated fasciaEnlarge small rents in fasciaEnlarge small rents in fasciaProphylactic fasciotomyProphylactic fasciotomy
  18. 04/22/13MUSCLEMUSCLEMechanism of injuryMechanism of injuryNecrotic muscle : pabulum of infectionNecrotic muscle : pabulum of infection““When in doubt,take it out” is approachWhen in doubt,take it out” is approach10 % muscle belly is enough10 % muscle belly is enough
  19. 04/22/13Vascular anatomyVascular anatomyViability of muscle :4 C’sViability of muscle :4 C’sLook beyond superficial layerLook beyond superficial layer
  20. 04/22/13FACTORS OF VIABILITY1. COLOUR2. CONSISTENCY3. CONTACTILITY4. CAPACITY TO BLEED
  21. 04/22/13TENDONSTENDONSNot a pabulum of infectionNot a pabulum of infectionAdequate coverageAdequate coverageRepairRepairUsually preservedUsually preserved
  22. 04/22/13BONEBONERetain bones with soft tissueRetain bones with soft tissueattachmentattachmentDebridementDebridementViabilityViabilityAdequate coverageAdequate coverage
  23. 04/22/13JOINTSJOINTSArthrotomyArthrotomyIrrigation and debridementIrrigation and debridementLoose fragmentsLoose fragmentsTight closure of capsuleTight closure of capsule
  24. 04/22/13NERVES AND VESSELSNERVES AND VESSELSLayer by layer hemostasisLayer by layer hemostasisDelayed repair if contaminatedDelayed repair if contaminatedTotal loss of blood supply-moreTotal loss of blood supply-morethan 8 hrs:AMPUTATIONthan 8 hrs:AMPUTATIONEmergency repairEmergency repair
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  41. 04/22/13Wound coverWound coverTypesTypes1)Split thickness free skin graft1)Split thickness free skin graft2)full thickness free skin graft2)full thickness free skin graft3)Local flap graft3)Local flap graft4)fasciocutaneous flaps4)fasciocutaneous flaps
  42. 04/22/135)Myo-cutaneous flaps5)Myo-cutaneous flaps6)Pedicle flaps6)Pedicle flaps7)Free micro vascularised muscle flap7)Free micro vascularised muscle flapBiological dressingsBiological dressings
  43. 04/22/13STABILIATION OF OPEN FRACTURESTABILIATION OF OPEN FRACTUREMETHODSMETHODS1.1. PLASTER IMMOBILISATIONPLASTER IMMOBILISATION2.2. PINS &PLASTERPINS &PLASTER3.3. SKELETAL TRACTIONSKELETAL TRACTION4.4. EXTERNAL FIXATIONEXTERNAL FIXATION5.5. INTERNAL FIXATIONINTERNAL FIXATION6.6. HYBRID FIXATIONHYBRID FIXATIONtrade-off between bony stabilityand foreign body response
  44. 04/22/13External fixatorsExternal fixatorsMethod of choice in most open fracturesMethod of choice in most open fracturesADVATAGESADVATAGES•Easily appliedEasily applied•Good skeletal & soft tissue stabilityGood skeletal & soft tissue stability• Anatomical reduction.Anatomical reduction.• No additional traumaNo additional trauma
  45. 04/22/13ADVATAGES of EX.FIXADVATAGES of EX.FIX•Risk of infection is comparatively less.Risk of infection is comparatively less.•Allows wound inspection & wound dressing.Allows wound inspection & wound dressing.•Temporarizing frame ,restoring the limb to lengthTemporarizing frame ,restoring the limb to lengthuntil definitive fixation.until definitive fixation.•Allows transportationAllows transportation•Better nursing careBetter nursing care
  46. 04/22/13INTERNAL FIXATIONINTERNAL FIXATIONCONTROVERSIALCONTROVERSIALIndicationIndication1.1. Type- I #Type- I #2.2. Type-II # - 5-8% infectionType-II # - 5-8% infection3.3. Type III # - 26-43 % infectionType III # - 26-43 % infection4.4. Intra articular #Intra articular #5.5. Reimplantation surgeryReimplantation surgery6.6. Vascular repairsVascular repairs7.7. Old patientsOld patients8.8. Polytrauma patientsPolytrauma patients
  47. BONE GRAFTINGBONE GRAFTINGINDICATIONSINDICATIONS1.1. Bone lossBone loss2.2. High velocity traumaHigh velocity trauma3.3. Severe comminutionSevere comminutionTimingTimingtype-I immediatetype-I immediatetype II &III 6-12 weekstype II &III 6-12 weeks
  48. 04/22/13AMPUTATIONAMPUTATIONIndicationsIndications1.1.vascular injury – norepair possiblevascular injury – norepair possible2.functional outcome better with prosthesis2.functional outcome better with prosthesis3. Life saving to arrest bleeding3. Life saving to arrest bleeding4. Associated diseases OVD- DM etc.4. Associated diseases OVD- DM etc.
  49. 04/22/13COMPLICATIONSCOMPLICATIONSEARLYEARLY                               1. Gas gangrene1. Gas gangrene                2. Tetanus                2. Tetanus                3. Crush syndrome                3. Crush syndrome  1.1.Chronic osteomyelitisChronic osteomyelitis2.Delayed union & Non union2.Delayed union & Non union3.Joint stiffness3.Joint stiffnessLATELATE
  50. 04/22/13OPEN FRACTURES IN CHILDRENOPEN FRACTURES IN CHILDRENdiffer from those in adultsdiffer from those in adults1.1. healing capacity of the soft tissues & bonehealing capacity of the soft tissues & boneexcellentexcellent2.2. No bone grafting neededNo bone grafting needed3.3. Infection rareInfection rare4.4. External fixation left in place until unionExternal fixation left in place until union5.5. social and psychological impactsocial and psychological impact
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