Extern orthopedics conference at Maharaj Nakornrachasima hospital by Ext.Torpathom Pruekprasert 29 May 2017

1. Orthopedic conference
Ext. Torpathom Preukprasert

2. Case
A 12 year old boy
No underlying disease
CC.Motorcycle accident 3 hr PTA
P.I. ผู้ป่วยโดนรถจักรยานยนต์เฉี่ยวขณะซ้อนมอเตอไซค์ ผู้ป่วยล้มลงขา
กระแทกพื้น ผู้ป่วยยังมีสติแต่ไม่สามารถยืนและทรงตัวได้ มีอาการเจ็บ
บริเวณขาซ้ายและมีแผลเปิดขนาดประมาณ 1cm ที่หน้าแข้งข้างซ้าย

3. Primary Survey
A. Can talk, No neck pain, can move neck, not tender along c-spine
B. No wound, no dyspnea, clear breath sound, no adventitious sound,
trachea in midline
C. BP 114/72mmHg, HR 84/min cap. Refill <2 sec, no active bleeding
wound ,pelvic compression negative
D. E4V5M6, pupil 3mm RTLBE
E. Deep wound ~1 cm at left shaft tibial

4. Secondary survey
• Allergy : no history
• Medication : no current medication
• Past history : no underlying disease
• Last meal : 4 hr PTA

6. Physical exam
• GA: Thai boy, good conciousness
• VS : BP 114/72mmHg HR 84/min RR18/min
• HEENT : normal conjunctivae, anicteric scerlae
• Heart : normal S1S2, no murmur
• Lungs : clear both lung
• Abdomen : soft, not tender
• Neurological : grossly intact

7. • Left tibia : lacerated deep
wound, minimal bleeding,
marked tenderness at shaft
left tibia, limit ROM of knee
joint due to pain, full ROM at
ankle and thumb, cap refill <2
sec, dorsalis pedis and
posterior tibial pulse 2+ ,
intact pin prick sensation
Physical exam

8. • Thoracolumbar spine : no tenderness along T-L spine,
no pain on flexion and extension
Physical exam

9. Investigation : FilmX-ray leg Ap, Lateral

10. Diagnosis
• Open fracture shaft left tibia

11. Gustilo and Anderson classification
• Type I :wound < 1 cm
• Type II: wound size 1-10cm
• Type III A :wound size > 10 cm, high energy, adequate tissue for
coverage includes segmental / comminuted fractures even if wound
<10cm
farm injuries are automatically Gustillo III
• Type IIIB :extensive periosteal stripping and requires free soft tissue
transfer
• Type IIIC :vascular injury requiring vascular repair

13. Grade I Grade II

14. Grade IIIA

15. Grade IIIB Grade IIIC

16. Evaluation of open fracture
1.Characteristic of wound : cut wound lacerated,
burn
2.Size , Depth, location
3.Contamination
4.Degree of soft tissue injury
5.Neurovascular status
ประกอบการประเมิณโดยใช้ Gustilo and Anderson
classification

17. Management of open fracture
• Initial in the emergency room
1. ATB and Tetanus prophylaxis
2. Control bleeding
3. Assessment neurovascular and soft tissue injury
4. Dressing : remove gross debris and soak sterlie NSS
on the wound

18. Antibiotic Indications for Open Fractures
1. Gustillo I and II :1st generation cephalosporin
2. Gustillo III :1st generation cephalosporin + aminoglycoside
3. With farm injury :1st generation cephalosporin + aminoglycoside +
PCN , add PCN for clostridia
4. Duration :initiate as soon as possible
• increased infection rate when delayed > 3 hours from time of injury
• continue for 72 hours after I&D

19. Management in OR
1. Aggressive debridement and irrigation :Type I: 3, Type II: 6L, Type
III: 9L
• surgical debridement 6-8 hours after time of injury
• grossly contaminated wounds are irrigated in emergency
2. bony fragments without soft tissue attachment can be removed
3. Fracture stabilisation: internal or external fixation
4. Can place antibiotic bead-pouch in open dirty wounds

20. Open reduction internal fixation with plate
and screw

21. Wound closure
• 1. Primary closure : clean and no necrotic tissue or
foreign material
• 2. Secondary closure : flap and graft
• 3. Delayed primary closure : high infected rate (Class
III)

22. Rehabilitation
• Elevation การยก Extremities ให้สูงหลังผ่าตัดสามารถลดอาการบวมได้
แต่ไม่ควรยกสูงเกิน 10cm
• Benefit
1. ป้องกัน Muscle atrophy
2. ป้องกัน joint stiffness
3. เพิ่ม circulation, venous, lymphatic return

23. Thank you for your attention