# Management of Open Fractures and Pathological Fractures: An Overview #
If you have recently sustained a fracture, whether due to a traumatic injury or underlying medical condition, you may be wondering how best to manage the situation. This article will provide an overview of the management of open fractures and pathological fractures, two types of fractures that require special attention and treatment.
## What are Open Fractures and Pathological Fractures? ##
Before we delve into their management, let's first define what open fractures and pathological fractures are.
### Open Fractures ###
An open fracture, also known as a compound fracture, is a type of fracture in which the broken bone protrudes through the skin, exposing it to the outside environment. This type of fracture is considered a medical emergency because of the high risk of infection, and it requires prompt medical attention.
### Pathological Fractures ###
A pathological fracture is a type of fracture that occurs due to an underlying medical condition, such as osteoporosis or bone cancer. These fractures can occur with little to no trauma and are often a sign of an underlying health issue that requires treatment.
## Management of Open Fractures and Pathological Fractures ##
Now that we understand what open fractures and pathological fractures are, let's explore how they are managed.
### Management of Open Fractures ###
Open fractures require prompt medical attention to prevent infection and promote proper healing. The following steps are typically taken in the management of open fractures:
1. Stop any bleeding: If there is any bleeding, it should be stopped immediately to prevent excessive blood loss.
2. Clean the wound: The wound should be cleaned thoroughly with sterile saline solution or another appropriate antiseptic.
3. Stabilize the fracture: The broken bone should be stabilized to prevent further damage and promote proper healing.
4. Administer antibiotics: Antibiotics may be prescribed to prevent or treat infection.
5. Monitor for complications: Patients with open fractures should be monitored closely for signs of infection or other complications.
### Management of Pathological Fractures ###
The management of pathological fractures depends on the underlying medical condition that caused the fracture. In general, the following steps are taken:
1. Treat the underlying condition: The underlying condition that caused the fracture should be treated to prevent future fractures.
2. Stabilize the fracture: The broken bone should be stabilized to prevent further damage and promote proper healing.
3. Pain management: Pain medications may be prescribed to manage pain associated with the fracture.
4. Monitor for complications: Patients with pathological fractures should be monitored closely for signs of complications, such as infection or nerve damage.
15. Initial Management
• Patient assessment: ABC
• Rule out cervical injuries, chest, abdominal injuries, head injuries
in polytrauma patients.
• Identify skeletal injuries and obtain necessary radiographs
• IV Tetanus
• IV Antibiotics
16. Primary Surgery
• Objectives of initial surgical management
• Preservation of life and limb
• Wound debridement
• Definitive injury assessment
• Fracture stabilization
17. Debridement
• Most important step.
• Aim - Removal of dead tissue and foreign material to ensure
good blood supply.
• Debridement done as soon as possible. (within 6 hours of
initial injury)
• With delay risk of infection increases
18. Irrigation
• Usual irrigation fluid used is normal
saline
• High volume low pressure repeated
lavage is performed.
• Volume of fluid used varies- usually
about 3 L is used for grade 1 ; 6-10 L is
used for grade 2 or 3
19. Limb salvage and Amputation
• Limb is nonviable as evidenced by
• irreparable vascular injury
• warm ischemia time >8 hrs
• severe crush injury with minimal remaining viable tissue.
20. Skeletal Stabilization
• Done once vascular repair is completed and limb salvaged or
once irrigation and debridement is done.
• Restoring the length, rotational, and angular alignment has
many benefits for healing of soft tissues.
21.
22. Wound Closure
• Wounds without skin loss: tension free primary closure after
thorough debridement.
• Contraindications for primary closure
• Delayed presentation >12 hrs.
• Deep seated contamination
• Nerve injury
• Inability to achieve tension free suture
• High risk of anaerobic contamination like farm yard injuries.
• Wounds with skin loss: healing by secondary intention. Delayed
primary closure, split skin grafts, free flaps
26. • Common metastatic
cancers-
– Breast
– Lung
– Prostate
– thyroid
– kidney
• Common sites of
metastasis-
– Spine
– Pelvis
– Ribs
– Skull
– proximal femur
– Proximal humerus.
27. Lab
• CBC
• ESR
• Electrolytes
• BUN
• Serum glucose
• Liver function tests
• Total protein
• Albumin
• Calcium, phosphorus,
and alkaline
phosphatase.
29. • N-telopeptide and C-telopeptide are markers
of bone collagen breakdown measured in
serum and urine.
– Confirm increased destruction caused by bone
metastasis
– Measure the overall extent of bone involvement
Demers LM, Costa L, Lipton A. Biochemical markers and skeletal metastases. Clin
Orthop Relat Res. 2003;(415):S138–S147.
30.
31.
32.
33. Management considerations
• Treatment of local bone lesion-
• Surgical stabilisation +/- resection: large lytic
lesion at risk of fractures/pathologic fractures.
• Radiation: Adjuvant local treatment for entire
operative field.
• Functional bracing
• Bisphosphonates: inhibit osteoclast mediated
bone resorption.
34.
35. Operative treatment
• Intramedullary device or modular prosthesis
provides better stability.
• Bone cement-
– Increases the strength of fixation
– Should not be used to replace segment of bone
• Goal should be to stabilize as much of the
bone as possible.
36.
37. A 58-year-old man with a pathologic fracture of
the distal femur due to lung cancer
