1] Review the common bacteria encountered with open fractures. 2] Note the distinction between the primary infections which occur due to inoculation of bacteria (above) at the time of injury and secondary infections acquired after hospitalization.
Definition• Break in the skin and underlying softtissue leading directly into orcommunicating with the fracture andits hematoma.
open fractureclassification• Provides guidelines on prognosis andtreatment– Fracture healing, infection and amputation ratecorrelate with the degree of soft tissue injury• Gustilo upgraded to Gustilo anDanDerson• ao open fracture classification• Host classification of open fractures
type 1 open fractures• Small less than 1cm• Clean puncture throughwhich a bone spike protrudesout.• Minimal soft tissue damage• No crushing• Not comminuted(low-energyfracture)
type 3b open fractures• Large wound• Cannot be covered bysoft tissue• Severly comminuted• Extensive muscledevitalization• High energy• Requires a flap forbone coverage andsoft tissue closure• Periosteal stripping
type 3c open fractures• High energy• Increased risk ofamputation andinfection• Any grade 3 withmajor vascular injuryrequiring repairregardless the wound.
common bacteriaencountereD witH openfracturesBlunt Trauma, Low Energy GSW Staph, StreptFarm Wounds ClostridiaFresh Water Pseudomonas, AeromonasSea Water Aeromonas, VibriosWar Wounds, High Energy GSW Gram Negative
InItIal assessment &manaGement• ABC’s• Assess entire patient• Careful Physical examn• Antibiotics and tetanus prophylaxis• Local irrigation 1-2 liters• Sterile compressive dressings• Realign fracture and splint• Do not culture wound in the ED*– 8% of bugs grown caused deepinfection– cultures were of no value and not tobe done• Recheck pulse, motor and sensation.
the 4 essentIals are :• Wound debridement• Antibiotic cover• Stabilization of the fracture• Early wound cover
Eckman JB Jr, Henry SL, Mangino PD, Seligson D. Wound and serum levels of tobramycin with the prophylactic use of tobramycin-impregnated polymethylmethacrylate beads in compound fractures. Clin Orthop Relat Res. 1988; 237:213-5.
systemIc debrIdement• Muscle viability determined by 4 C’s:• COLOR• CONSISTENCY• CONTRACTILITY• CAPACITY TO BLEED WHEN CUT
soaps In theIrrIGatIon ?• Surfactants (i.e. Soaps)– Less bacteria adhesion– Emulsify and removedebris– No significant differencein infection or bonehealing compared tobacitracin solution, butmore wound healingproblems in bacitracingroup
how to delIver theIrrIGatIon?• Bulb Syringe vs Pulsatile Lavage– Pulsatile lavage• Detrimental for early bone healing– this is no longer present at 2 wks*• More soft tissue destruction**• More effective in removingparticulate matter and bacteria***• High or low pressure?– Higher pressure• Better bone cleaning• Worse soft tissue cleaning• Slows bone healing
antIbIotIcs In theIrrIGatIon?No provenbenefit!*Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS 2001. 9: 219-226.
sterIlIty andantIbIotIc cover• Wound should be covered until reachingthe OT• Type 1 & 2 - Cefazolin 1gm IV 6 hours• Type 3 - Aminoglycosides(gentamicinIV)• Farm or soil injury - + Metronidazole
Wound closure• Type 1 – sutured without tension• All others should be left open.Lightly packedwith sterile gauze and inspected after 2 days.If clean – sutured or skin graft(delayedprimary closure)• Type 3 – debridement more than once.
When to cover theWound?• ASAP after wound adequately debrided.• “Fix and Flap”– For Type IIIB & IIIC open tibia fracturesTiming of flap placement Infection rate< 72 hours 6%> 72 hours 30%
contraindications toprimary closure• Inadequate debridement• Gross contamination• Farm related or freshwater immersion injuries• Delay in treatment >12 hours• Delay in giving antibiotics• Compromised host or tissue viability
VAC• Vacuum assisted wound closure– Recommended for temporary management– Mechanically induced negative pressure in a closedsystem– Removes fluid from extravascular space– Reduces oedema– Improves microcirculation– Enhances proliferation of reparative granulationtissue• Open cell polyurethane foam dressing ensures aneven distribution of negative pressure-
types of fracturestabilization• splint– Good option if operativefixation not required• internal fixation– Wound is clean and softtissue coverage available• external fixation– Dirty wounds or extensivesoft tissue injury
aftercare• Elevation of limb• Continuation of antibiotic cover• If open wound –inspected every 2 – 3 days.-cultures are obtained
We can do both, salvage & amputate.• Vascular surgery can revascularizewith bypass graft– Generally before fracture stabilization• Plastics can provide soft tissuecoverage• However, in the tibia, the severityto soft tissue envelope and bonemay result in infected nonunion• If salvage…. long course ofrepeated surgical procedures– Painful and psychologically distressing– Functional outcome may be poor andno better than amputation
How to decide, salvage or amputate?• Important factors in decision making:*– General condition of the patient (shock)– Warm ischemia time (>6hours)– Age (>30 years)– Cut to crush ratio (blunt injuries has a large zoneof crush)Howe HR Jr, Poole GV Jr, Hansen KJ, Clark T, Plonk GW, Koman LA, Pennell TC: Salvage of lower extremities following combinedorthopedic and vascular trauma. A predictive salvage index. Am Surg. 1987 Apr;53(4):205-8.
Advances…• BMPs– 40% decreased infection rate with BMP in type 3open tibia fractures*• Antibiotic Laden Bone Graft**– Tobramycin-impregnated calcium sulfate pelletswith demineralized bone matrix– Animal study: successful in preventing infection
Closed fraCturesIt’s broken bone that does not penetrate theskin.Treatment requires manipulation to improveposition of fragments , splintage ,preservation of joint movement andfunction.
Closed fraCtureClassIfICatIoNtsCHerNe(1984) :• Grade 0 – simple fracture with little or no softtissue injury• Grade 1- fracture with superficial bruising orabrasion of skin and subcutaneous tissue• Grade 2 – severe fracture with deep soft –tissue contusion and swelling• Grade 3 – marked soft tissue damage andthreatened compartment syndrome
reduCe• Adequate apposition and normal alignment ofbone fragments• 2 types :open and closed• Closed usually for minimally displacedfractures.
Hold reduCtIoNContinuous tractionCast splintageFunctional bracingInternal fixationExternal fixation
traCtIoNs• Reduction of fractures and dislocation• Immobilising a painful inflamed joint• Prevention of deformity by counteractingmuscle spasms• Correction of soft tissue contractures• Types : traction by gravity• skeletal traction• skin traction
ComplICatIoNs oftraCtIoN• Circulatory embarassement• Nerve injury• Pin site infection
Cast splINtage• Pop• Stiffness can be minimised by :• delayed splintage ie.by using traction untilmovement is regained and then only applyinga plaster• Starting with a conventional cast and later afunctional brace – permits joint movement
INterNal fIxatIoN• Indications• Types : 1. interfragmentory screws2.wires(transfixing , cerclage,tension –band)3.plates and screws(metaphysealfractures of long bones and diaphysealfractures of radius and ulna)4.intramedullary nails
When to use IM nails?• Treatment of choice for mostdiaphyseal fractures of thelower extremity• Inserted without disruptingthe already injured soft tissueenvelope• Preserves the remaining extraosseous blood supply tocortical bone• Malunion is uncommon
When to use external fixation? Severe soft tissuedamage Assoc nerve orvessel damage Severlycomminuted andunstable Fractures ofpelvis notcontrollable byother methods
• Infected fractures for which internal fixationmight not be suitable• Sever multiple injuries where earlystabilization reduces the risk of seriouscomplications.
Ex-fix: Weigh the pros and cons!• Historically was definitive treatment• Now, more commonly as temporary fixation• Can be applied almost always and everywhere• Severe soft tissue damage and contamination• Advantages:– Easy and quick– Relatively stable fixation– No further damage done– Avoids hardware in theopen wound• Disadvantages:– Pin track infections– Malalignment– Delayed union– Poor patientcompliance