open fracture ug lecture gmc bhopal

1. MANAGEMENT OF OPEN
FRACTURES
Dr Abhishek Pathak
Asso Prof
Orthopaedics
GMC Bhopal

2. OPEN FRACTURES
• Fracture- Discontinuity of
bone
• An open fracture is one in
which break in the skin
and underlying soft tissue
leads to communication
of fracture hematoma to
external environment.
• Open fractures are also
known as compound
fracture

3. ETIOLOGY

4. HIGH ENERGY TRAUMA
• Caused by high energy
trauma most commonly
from direct blow by road
traffic accident or fall
from hieght.
• These fractures can be
caused by high energy
twisting injuries.

5. CRUSH INJURY
• a force is applied to an immobilized portion of
the body.
• Causes Muscle ischaemia due to occlusion of
blood vessels by pressure
• When blood flow is restored causes
reperfusion injury – due to circulation of
myoglobin –can damage kidney, brain & lung
function
• CRUSH Syndrome

6. Gun Shot injury
• Effectiveness depends
on dissipation of energy
to local soft tiisue
• Most of time extent of
soft tissue damage
more than size of
wound

7. Blast Injury
• Supersonic shock wave
causing extensive
damage
• Higher severity score
• Shear forces ripping
muscle tendon nerves
vessels apart

8. Epidemiology
• Usually diaphyseal
• Tibia commonest

9. Etiology
• High energy trauma so
– Severe bony and soft tissue involvement
– Decreased blood supply
– Contamination
– Degloving

10. Open Fractures
Treatment = amputation
Mortality 75%
Function in “survivors” poor

11. Prognosis
• Outcome is improved
– Intensive care management
– Availablity of powerful antibiotics
– Radical debridement
– Immidiate bony stablisation
– Early soft tissue involvement

12. CLASSIFICATION
The classification of open fractures is most reliably done in
the operating room at the completion of primary wound
care and debridement.

13. Gustilo and Anderson classification
• relatively simple
• It has been validated with regard to time to
union, incidence of nonunion, and the need
for bone grafting.
major disadvantage
• not accurate
• Subjective nature of injury description
resulting in high interobserver variability

14. Gustilo and Anderson classification
Grade 1 < 1 cm clean wound, with a
simple fracture pattern.
Grade 2. > 1 cm wound and a low
energy fracture pattern
Grade 3 high-energy or crush injuries
with extensive muscle
damage.

15. Gustilo and Anderson classification
Grade 3A
.
has adequate bone coverage
by local soft tissues.
Grade 3B has soft-tissue loss over the
bone with some contamination
or periosteal stripping, which
requires a local or free tissue
transfer.
Grade 3C is an arterial injury, requiring
repair, associated with any
fracture pattern

16. Goals in the treatment of open fractures
• The treatment of high-energy injuries aims at
preserving life, limb, and function, in that
order of priority.
• The intermediate objectives are:
• Prevention of infection
• Fracture stabilization
• Soft-tissue coverage

17. • Evaluation entire patient
– injury protocols (ATLS)
• Evaluation limb
– complete evaluation (as possible)
– wound covered & limb splinted- “one look”
– antibiotics
– tetanus “prophylaxis”
ANALGESIA
• Preoperative planning

18. Stages of care

19. Initial assessment
• Important components in assessing traumatized
extremity
1. History and mechanism of injury
2. Neurovascular status
3. Size of skin wound
4. Muscle crush or loss
5. Periosteal stripping or bone loss
6. Fracture pattern, fragmentation
7. Contamination
8. Compartment syndrome

20. Primary surgery

22. Irrigation
• Supplements systemic debridement in
removing foreign material and decreasing
bacterial load.
Fracture type Vol of fluid used for irrigation
Type I 3 L
Type 2 6L
Type 3 9L

23. Irrigation
2 adages….
• If a little does some good, a lot will do a great
deal more
• solution to pollution is dilution

24. 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.

28. Timing of debridement and irrigation
• Most guidelines recommend debridement
within 6 hrs.
• Scientific evidence for 6 hour rule is lacking
and a little delay for better team coordination
improves results
• Serial debridement may be necessary every
24-48hrs until the wound viability is ensured

31. extent of wound & degree of contamination
injury environment
practice protocols
cephalosporin
+ aminoglycoside (or alternative gram (-) coverage for gross soft tissue damage
+ metronidazole (farm/soil/ischemia)
Antibiotics

32. Antibiotics
• Early administration of antibiotics is
associated with improved outcome (<3 Hrs)
• Antibiotics should be continued for atleast 24
hours after primary wound closure in type I
and II fracture and 72 hours in type III
fractures.

33. Tetanus prophylaxis
• Tetanus Toxoid(TT), dose is 0.5ml i.m.
regardless of age
• Immunoglobulin
• 75IU <5yrs of age
• 125IU 5-10yrs
• 250IU >10yrs

34. RE-prep & drape between 1, 2, 3
Stages of surgical treatment—the plan
• gross decontamination
• irrigation & debridement
• stabilization of fracture
• final inspection wound culture ??
• initial wound coverage

35. Operative treatment: “extend the
wound"
• zone of injury
• may need atypical incisions
• consider
– fracture treatment options
– soft tissue coverage & reconstruction options
• REMEMBER— I & D is 1st priority

36. Zone of injury
• Wound is merely a window through which a
wound communicates with exterior
• Zone of injury may be much larger

37. Systematic wound debridement
• remove debris
• remove non-viable soft tissues
• layer by layer
• tourniquet used only if major bleeding
• Experienced surgeon!
• inexperience  under-debridement

38. • The initial surgical management should be
performed by an experienced surgeon:
inadequate initial debridement has been
shown to contribute to poor outcomes
following open fractures.

39. Bone debridement
• Remove avascular, contaminated fragments
• Protect soft tissue attachments
• Retain key bone fragments ?
– articular surface
• Re-evaluate “crucial tissues” at 2nd debridement

40. Gravity Irrigation
Minimum six liters
Choice of fluid is probably
irrelevant
The solution to pollution is
dilution
Operative treatment: irrigation

41. Initial fracture stabilization
• Choice of stabilization technique depends on
many factors
– anatomic site of injury
– degree of contamination
– status of the wound and soft tissue(s)
– other associated injuries & treatment
– experience of surgeon & surgical team
– implant availability

42. Fracture stabilization—external fixation
Allows easy access to soft tissues but may
interfere with subsequent flap placement
Safest option in cases with severe
contamination or when there is a delay in
presentation
Fast application allows speedy vascular injury
repair
Speed of application is advantageous in
cases of poly-trauma

43. Goal of external fixation
• definitive fracture treatment ?
• temporary?
– until soft-tissue stabilization
– then change to another fixation method

44. Fracture stabilization - Intramedullary fixation
• Literature
– supports use in open shaft fractures
– IM “better” than ex fix for definitive
treatment
– timing
– reamed vs unreamed—no clear evidence
– Do NOT treat with immediate ORIF
unless you are sure of adequate debridement
and you are SURE of getting definitive
soft tissue cover with 72 hours

45. antibiotic bead pouch
VAC dressing
Initial wound management
• Goal: cover nerves, vessels, tendons, bone
• Avoid: dead tissues & space, wound tension

46. Antibiotic bead pouch
• Antibiotic-PMMA beads
• Occlusive dressing
• Useful in large wounds
– dead space control
– high local antibiotic concentration
– seal wound from external contamination

47. Closed system
Ongoing debridement
wound size
 tissue edema
Excellent for staged coverage
VAC Dressing

48. Mangled Extremity

50. Second stage management
• antibiotics 24–48 hrs
• repeat debridement 48–72 hrs as needed

51. Open fracture with arterial injury
• The factors that are important in the decision
making include:
• General condition of the patient (the presence of
shock)
• Warm ischemia time (more than 6 hours)
• Age of the patient (older than 30 years)
• Cut to crush ratio (blunt injuries have a large zone
of crush)

52. Open fracture with arterial injury
• Fasciotomy is usually mandatory following an
arterial repair, as reperfusion will result in
swelling and can cause a compartment
syndrome. Fasciotomy early in the procedure
is recommended as this facilitates surgical
exposure of vessels and bone.

53. Summary: open fractures
• Evaluation of patient and injury
• Initial debridement!
• Soft tissue management!
• Fracture stabilization
• Early soft-tissue closure/coverage
• Bone & soft tissue reconstruction PRN
• Rehabilitation

54. THANKS