Open fractures - introduction OPEN FRACTURES ARE ALSO KNOWN AS COMPOUND FRACTURES
Definition Open fracture implies communication between external environment and the fracture. A soft tissue injury complicated by a broken bone.
Components of open fracture Fracture Soft-tissue damage Neurovascular compromise Contamination Extent of each component must be assessed individually in order to achieve a comprehensive understanding of the injury, upon which the treatment plan can be based.
History A century ago, the high mortality of patients with open fractures led to early amputations to prevent death. Trueta recommended open wound treatment and subsequent enclosure of extremity in a cast In 1943, the use of Penicillin reduced the rate of wound sepsis Hampton recommended closure between 4th-7th day after injury
Mechanism of injury Open fractures occur as a result of direct high energy trauma either from Road traffic collisions or falls from height.
Epidemiology Diaphyseal fractures were more common than metaphyseal fractures. Highest rate of diaphyseal fractures were seen in tibia(21.6%) followed by femur(12.1%), radius and ulna(9.3%), and humerus(5.7%)
Microbiology Poor tissue oxygenation and devitalization of the surrounding tissues including the bone provide a perfect medium for infection and bacterial multiplication. When left open >2weeks – prone to nosocomial infection such as pseudomonas species and gram negative bacteria. This phenomenon of hospital acquired infection emphasizes the importance of a strict protocol for in-hospital management and early wound coverage.
Open fractures - complications WHY OPEN FRACTURES CAN BE DANGEROUS
Hypovolemic shock - management Two large-bore IV lines should be started. Once IV access is obtained, initial fluid resuscitation is performed with an isotonic crystalloid, such as Ringer lactate solution or normal saline. An initial bolus of 1-2 L is given in an adult (20 mL/kg in a pediatric patient), and the patient's response is assessed.
Hypovolemic shock Type of fluid- Colloid – albumin, dextran, plasma Crystalloid – NS, D5, RL Blood – uncrossed ‘O’ –ve Based on 3:1 rule when using crystalloids Eg. If blood loss is 100cc the patient should receive 300cc of normal saline or Ringer lactate 1:1 rule for colloids
Compartment syndrome Classically 5 "Ps" associated with compartment syndrome — Pain out of proportion to what is expected Paresthesia Pallor Paralysis Palpable pulse
Measurement of compartment syndrome-gauging pressure by introducing needle into compartments Stryker 295 quick-pressure monitor set
Compartment syndrome Treatment - Fasciotomy
Fat embolism Definition - Occlusion of small vessels by fat globules Types- 1. cerebral – drowsy, restless and disoriented 2.pulmonary – tachypnea, tachycardia, petechial rash(in front of neck, ant axillary fold, chest and conjuctiva)
Fat embolism Diagnosis – signs of retinal artery emboli(striate hemorrhages and exudate) may be present. Sputum and urine may reveal presence of fat globules. X-ray of chest shows patchy pulmonary infarcts. Blood Po2 <50mm
Fat embolism Treatment- Respiratory support Heparinization Intravenous low-molecular weight dextran and corticosteriods
ARDS Is caused by release of inflammatory mediators which cause disruption of pulmonary vasculature. Signs and symptoms – Tachypnea, low BP, Cyanosis Treatment – 100% oxygen
Injury to blood vessels Absent peripheral pulses in an injured limb should be considered to be due to vascular damage unless proved otherwise. hard signs of arterial injury (a) absent pulses (b) active hemorrhage (c) expanding hematoma, and (d) bruit or thrill.
Vascular injury Investigations- Colourdoppler study Arteriography Treatment- Arterial reconstruction Bypass grafts Timing- loss of total blood supply to the limb for > 8 hours nearly always results in amputation.
Nerve injury Nerve repair should be done within 3 weeks of injury for better results
Open fractures – grading and classification TO ACCURATELY DESCRIBE SIMILAR INJURIES IN ORDER TO PROVIDE A BASIS FOR TREATMENT, TO ESTIMATE PROGNOSIS AND TO ENABLE COMPARISON BETWEEN CENTERS.
Gustilo and Anderson
Gustilo and Anderson
Tscherne Grade I – small puncture without associated contusion, negligible contamination, low-energy mechanism of fracture. Grade II- small laceration, skin and soft tissue contusions, moderate bacterial contamination Grade III- large laceration with heavy bacterial contamination, extensive soft tissue damage Grade IV- incomplete or complete amputation with variable
Hannover fracture scale Total score - This considers every detail of the injury to the involved extremity and is made up as a checklist. The fracture type according to the AO classification, the skin laceration, the underlying soft tissues, the vascularity, the neurological status, the level of contamination, a compartment syndrome, the time interval between injury and treatment, and the overall severity of the injury to the patient are added up to prove the total score.
Hannover fracture scale Interpretation minimum score: 0 maximum score: 22 The higher the score the worse the injury. A score ≥ 11 indicates significant trauma, with amputation recommended.
Io 1 – skin breakage from inside out
Io 2- skin breakage from outside in <5cm, contused edges
Io3 – skin breakage from outside in >5cm, increased contusion, devitaised edges
IO 4 – Considerable, full thickness contusion, abrasion, extensive open degloving, skin loss
IO5 – extensive degloving
Neurovascular injury - AO
Muscle/tendon injury – AO
Ganga hospital score Interpretation: The total score was used to address the question of salvage and the outcome was measured by dividing the injuries into four groups (Group I - < 5; II - 6-10; III - 11-15 and IV - 16 and above of the total score) All limbs in Group IV and one in Group III underwent amputation
Mangled extremity severity index
Mangled extremity severity score(MESS)
LSI- limb salvage index
minimum score: 0
maximum score: 14
The higher the score the more severe the injury.
Predictive salvage index
Interpretation minimum score: 3 (based on the point assignments; if no vascular, bone or muscle injury then the score could reach 1, but then it would not be a seriously injured limb) maximum score: 13 The higher the score the worse the chances for a successful limb salvage.
NISSSA Parameters N = nerve injury I = ischemia S = soft tissue contamination S = skeletal injury S = shock A = age of the patient
NISSSA Interpretation minimum score: 0 maximum score: 19 The higher the score, the more severe the injury. A score ≥ 7 was 100% sensitive for amputation, but with specificity of 46%. A score ≥ 11 had a 100% specificity and positive predictive value for amputation.
Open fractures - management THE TREATMENT OF HIGH ENERGY INJURIES AIM TO PRESERVE LIFE, LIMB AND FUNCTION.
Goals of treatment The intermediate objectives are- Prevention of infection Fracture stabilization Soft-tissue coverage
Stages of care
Initial assessment Important components in assessing traumatized extremity History and mechanism of injury Neurovascular status Size of skin wound Muscle crush or loss Periosteal stripping or bone loss Fracture pattern, fragmentation Contamination Compartment syndrome
Irrigation Supplements systemic debridement in removing foreign material and decreasing bacterial load.
Irrigation 2 adages…. If a little does some good, a lot will do a great deal more solution to pollution is dilution
Irrigation NS normally used for irrigation. Antibiotic solution is no better than soap for open fracture irrigation Antiseptic solutions have been not shown to decrease infection rates. Surfactant(non sterile soap) same effectiveness, less tissue damage n more economical.
Timing of debridement and irrigation Most guidelines recommend debridement within 6 hrs. Serial debridement may be necessary every 24-48hrs until the wound viability is ensured
Antibiotics Systemic administration:
Antibiotics Local antibiotics: In gustilo type III fractures additional use of local aminoglycoside impregnated polymethylmethacrylate(PMMA) beads reduces overall infection rate.
Tetanus prophylaxis Tetanus Toxoid(TT), dose is 0.5ml i.m. regardless of age Immunoglobulin 75IU <5yrs of age 125IU 5-10yrs 250IU >10yrs
Primary surgery Timing : Surgical emergency Operating room with 6-8hrs of injury – contaminated wounds not treated within this time will have sustained bacterial multiplication to result in early infection.
Primary surgery Fracture stabilization: As soon as primary wound care is completed, treatment should proceed to fracture reduction and fixation. Surgeon should rescrub, regown and reglow. Different set of instruments than those used for debridement is necessary.
Relative Indications for Type of Skeletal Fixation in Open Fractures External fixation Severe contamination any site Periarticular fractures Definitive Distal radius Elbow dislocation Selected other sites Temporizing Knee Ankle Elbow Wrist Pelvis Distraction osteogenesis In combination with screw fixation for severe soft tissue injury
Relative Indications for Type of Skeletal Fixation in Open Fractures Internal fixation Periarticularfractures Distal/proximal tibia Distal/proximal femur Distal/proximal humerus Proximal ulnar radius Selected distal radius/ulna Acetabulum/pelvis Diaphyseal fractures Femur Tibia Humerus Radius/ulna
Plates Open diaphyseal fractures of the radius and ulna as well as the humerus are best managed with plate fixation. The plate fixation of lower extremity diaphyseal fractures is generally not recommended due to higher rate of infections.
Intramedullary nailing Locked intramedullary nailing has been established as the treatment of choice for most diaphyseal fractures in lower extremity. The technique has particular value for open fractures. Intramedullary nails can be inserted with no further disruption of the already injured soft-tissue envelope and preserves the remaining extra osseous blood supply to cortical bone.
IM nailing Data showing that solid intramedullary nails inserted without reaming have a lower risk of infection. On the other hand reamed intramedullary nails can reliably maintain fracture reduction with regards to angulation, rotation, displacement, and length. Prospective randomised trails that compared reamed with unreamed interlocked IM nails did not show any significant difference concerning outcome and risk of complication.
External fixation Advantages of ext Fixation- Can be applied relatively easily and quickly It provides relatively stable fracture fixation There is no further damage done if applied correctly It avoids implantation of hardware in open wound.
Ext fixator Major problems with external fixation are related to pin tract infection, malalignment , delayed union, poor patients compliance. External fixators are particularly useful in fractures with severe damage and contamination, where metallic implants – with risk of bacterial adherence – are best avoided. Ring fixators may be an option in diaphyseal fractures
Types – Ring fixators Joint spanning external fixator
Open wound coverage after primary surgery
Primary Closure If it is to be done, the following criteria must be met: The original wound must have been fairly clean, and not have occurred in a highly contaminated environment. All necrotic tissue and foreign material have been debrided. Circulation to the limb is essentially normal. Nerve supply to the limb is intact. The patient's general condition is satisfactory and allows careful postoperative assessment. The wound can be closed without tension. Closure will not create a dead space. The patient does not have multisystem injuries.
Delayed primary closure closure before the fifth day is termed delayed primary closure As long as closure is achieved before the fifth day, wound strengths at 14 days are comparable with those in wounds closed on the first day leaving the wound open minimizes the risk of anaerobic infection, and the delay allows the host to mount local wound defensive mechanisms that permit safer closure than is possible on the first day.
Current standard of care for all open fracture wounds is to be left open initially. Delayed closure is accomplished within 2-7days VAC assisted wound closure is presently recommended for temporary management of open fracture wounds.
VAC The wound bed is exposed to mechanically induced negative pressure in a closed system . The system removes fluid from extravascular space, reduces edema, improves micro circulation and enhances the proliferation of preparative granulation tissue. Polyurethane foam dressing is placed in wound and ensures an even distribution of negative pressure.
Antibiotic bead pouch technique
References AO principles of fracture management 2nd Ed Rockwood and green – fractures in adults 7thEd Campbell - operative orthopedics 11th Ed. Management of open fractures by Dr. TSE Lung Fung Various sources on Internet