AO basic course

1. AOTrauma Principles CourseRobert Vander Griend, US
Management of open fractures

2. An open fracture is a soft-tissue injury
which also involves the bone

3. The management of open fractures
The assessment of an open injury:
• Immediate management of the open fracture
• Importance of a radical surgical debridement
• Choices for skeletal stabilization
• Choices for soft-tissue closure

4. Open fractures
• Treatment = amputation
• Mortality = 75%
• Function in survivors poor

5. Goals in the treatment of open fractures
• Preservation of viable soft tissues
• Prevent infection
• Achieve fracture union
• Restore function

6. Factors affecting outcome
• Type of injury
- High-energy vs low-energy
• Location and extent of injury(s)
- To the soft tissues
- To the bone
• Degree of contamination
• Health status of the patient
• Initial treatment

7. Management of open fractures
• Accident scene and transport
• Emergency room
• Operating room for emergency procedure
– Treatment of the wound
– Treatment of the bone
• Secondary/tertiary reconstruction
• Rehabilitation

8. Emergency room
Evaluation entire patient
• Injury protocols (ATLS)
Evaluation limb
• Complete evaluation (as possible)
• Wound covered and limb splinted - one look
• Antibiotics
• Tetanus “prophylaxis”
Preoperative planning

9. Antibiotics
• Extent of wound and degree of contamination
• Injury environment
• Practice protocols
- Cephalosporin
- Aminoglycoside or alternative gram negative coverage
- Penicillin (farm/soil/ischemia)

10. Classification: open fractures
• Gustilo and Anderson 1976, 1984
- Open fracture classification
• Tscherne and Oestern 1982
- Open and closed fracture classification
• AO
• OTA

11. Gustilo and Anderson
• Type I Low-energy, minimal soft-tissue damage,
wound < 1cm
• Type II Higher energy, laceration > 1cm minimal
contamination
• Type IIIA High-energy, adequate soft-tissue cover
• Type IIIB High-energy, extensive soft-tissue stripping,
inadequate cover, massive contamination
• Type IIIC Vascular injury requiring repair

12. Interobserver agreement on classification
Brumback et al 1994
• Other factors/variables influence treatment options:
• May underestimate zone of injury
• Inter-observer variability
• Agreement on simple vs complex
Low grade injury High grade injury

13. Stages of surgical treatment—the plan
• Gross decontamination
• Irrigation and debridement
• Stabilization of fracture
• Final inspection wound culture
• Initial wound coverage
• Re-prep and drape between 1, 2, 3

14. Operative treatment: extend the wound
• Zone of injury
• May need atypical incisions
Consider:
• Fracture treatment options
• Soft-tissue coverage and reconstruction options
• Remember—irrigation and debridement is 1st priority

15. Systematic wound debridement
• Remove debris
• Remove nonviable soft tissues
• Layer by layer
• Tourniquet used only if major bleeding
• Experienced surgeon
- Inexperience → under debridement

16. Soft-tissue debridement
• Skin
• Subcutaneous
- Fascia
- Fat
• Muscle viability 4 C’s
- Contractility
- Capacity to bleed
- Color
- Consistency

17. Bone debridement
• Remove avascular, contaminated fragments
• Protect soft-tissue attachments
• Retain key bone fragments
- Articular surface
• Re-evaluate crucial tissues at 2nd debridement

18. Operative treatment: irrigation
• Gravity irrigation
• Minimum six liters

19. Initial fracture stabilization
• Temporary vs definitive
• External vs internal fixation vs combination
• Anatomical site of injury
- Degree of contamination
- Status of the wound and soft tissues
- Other associated injuries and treatment
- Experience of surgeon and surgical team
- Implant availability

20. External fixation
• Soft-tissue management
• Severe contamination
• Extensive bone loss
• Vascular injury
• Unstable
- Dislocation or fracture dislocation
• Complex periarticular fracture
• Polytrauma

21. Goal of external fixation
• Definitive fracture treatment
• Temporary spanning external fixator
- Until soft-tissue stabilization
- Then change to another fixation method
• Early fracture healing
- Then change to another fixation method

22. Intramedullary fixation
Literature
• Supports use in open
shaft fractures
• IM better than external fixator
for definitive treatment
• Timing
• Reamed vs unreamed

23. Plate fixation
• Intraarticular and
metaphyseal fractures
• Upper extremity
(forearm and humerus)
• Femur in ARDS
• Plate techniques
- Standard
- MIPO
- LISS
- Locked
- Periarticular

24. Initial wound management
• Goal: Cover nerves, vessels, tendons, bone
• Avoid: Dead tissues and space, wound tension
• Loose re-approximation of skin flaps
• Antibiotic bead pouch
• VAC dressing
• Biological dressing

25. Antibiotic bead pouch
• Antibiotic-PMMA beads
• Occlusive dressing
• Useful in large wounds
- Dead space control
- High local antibiotic
concentration
- Seal wound from
external contamination

26. VAC Dressing
• Closed system
• Ongoing debridement
• Wound size
• Tissue edema
• Excellent for
staged coverage

27. Biological dressings
• Semipermeable films
• Epigard
• Allograft and enografts

28. Second stage management
• Antibiotics 24–48 hrs
• Repeat debridement 48–72 hrs as needed
• Repeat antibiotics 24–48 hrs with repeat surgery

29. Soft-tissue coverage
• Condition of the wound
• Location
• Size of the defect
• Tissue available
• Other reconstruction
- Bone
- Joints
- Soft-tissues
• Patient factors
- Age and general health
- Smoking
- Associated vascular
disease
• Expertise of surgical team

30. Soft-tissue coverage options
• 1° vs 2° closure
• Skin graft
• Flaps fasciocutaneous muscle pedicle
• Tissue transfer
• Goal: coverage < 5–7 days

31. Early flap coverage
M Godina: Early microsurgical reconstruction of complex
trauma of the extremities; Plast Recon Surg
• < 72 hrs
- Flap failure 1/134
- Infection 2/134 (1.5%)
• 72 hr to 90 days
- Flap failure 20/167
- Infection 29/167 (17%)

32. Staged reconstruction
• Definitive fixation
• Secondary bone procedures
- Bone grafting
- Exchange nailing/fixation
- Bone defect reconstruction
- Joint reconstruction/salvage
• Secondary soft-tissue reconstruction
- Tendon
- Nerve

33. Rehabilitation
• Of the limb
• Of the injury
• Of the patient
• Of the family

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