HIPPOCRATES – “ SURGEONS CAN ONLY FACILITATE HEALING THEY CANNOT IMPOSE IT”.
ABCDE Compressive bandages - Open, actively bleeding wounds. Associated injuries. Spine , Chest & Pelvis A careful examination of the extremities to diagnose fractures and dislocations
Assess neurovascular status Documentation of wound Photograph IV antibiotics, Tetanus prophylaxisCan I take pictures with my phone and send it to my senior?
Local irrigation with saline Sterile compressive dressing and splint – Betadine soaked Repeat wound examinations associated with higher infection rate Do not culture wound in casualtyTscherne et al, Fractures with Soft Tissue Injuries. 1984
Pierre JosephTiming At the earliest Within 6 hours from time of injury
Retrospective Study 47 Grade II/III open fractures Initial debridement Less than 5 hours - 7% infection rate More than 5 hours - 38% infection rateKindsfater et al, J Orth Trauma, Apr 1995,9(2) p121-7
Remove foreign material Detection and removal of nonviable tissue Reduction of bacterial contamination Creation of wound that can heal without infection and promote fracture healing Fasciotomy as indicated
Not in CASUALTY but in THEATRE 5 to 10 liters of saline Pulse lavage preferable Iodine/Hydrogen peroxide not beneficial Tourniquet used – may interfere with evaluation of muscle viability
Extensile incision extend wound in longitudinal direction both proximally and distally Expose: fracture, damaged tissue, and healthy tissue “wound should be equal in length to the diameter of the limb at that level”
Color, Consistency, Contractility, and Capacity to bleed Necrotic muscle is culture medium for infection, especially anaerobic “when in doubt, take it out”
Tendons Left if clean, and preserve blood supply Cover properlyBone If devoid of soft tissue attachments, must be removed Soft tissue attachments to remaining bone must be preserved
Minimal contamination 1st gen Cephalosporins Moderate contamination, higher energy Amikacin (5mg/kg) IV Q 24 Soil contamination/severe contamination Penicillin Metrogyl
Clinical decision Type I wounds 12 – 24 hours Type II and III wounds 2-3 days No role for prolonged use of antibiotics
>10 Liters Normal Saline results in lower incidence of infection Pulse lavage is more effective than bulb syringe with NS resulting in 100 fold decrease in Staph Aureus in the woundAnglen et al, J Ortho Trauma,2008 :390-396
Provides high local concentration of antibiotics in the wound Prepared in the OR PMMA with Tobramycin made into bead shapes, threaded on large non-absorbable suture, placed directly in the wound and covered with impervious dressing, creating “bead pouch”
Splint Good option if operative fixation not required Synthetic splints preferredExternal Fixation (Damage Control Orthopaedics in polytrauma patients) Great option in contaminated wounds, or extensive soft tissue injuryInternal fixation Usually appropriate if wound clean, and soft tissue coverage available
• Easily and rapidly applied• Excellent stability obtained• Damage Control Surgery• Reasonable anatomic reduction possible
Risk of infection minimized Ability to convert to internal fixation when wound is clean with adequate soft tissue coverage available Facilitates bone transport/acute shortening
Grade I to IIIA: Early –Internal fixation Late – External. Convert to Internal fixation at the earliest Grade IIIB: External fixation. Convert to Internal fixation when possible
Nail preferrable Stable biological fixation – Plate or Nail Supplement with bone grafts
Delayed Primary Closure Local Soft Tissue Flap Free Tissue Transfer Best if wound is covered or closed within 5-7 days Decreases infection rate
“Saving a functionallimb versus savingthe patient” Decision to be made early (48 – 72 hrs) Mangled Extremity Score Ganga Hospital Score
1. Treat open fractures as emergencies.2. Perform a thorough initial evaluation to diagnose life-threatening and limb-threatening injuries.3. Begin appropriate antibiotic therapy in the emergency department or at the latest in the operating room, and continue treatment for 2 to 3 days only.
4. Immediately debride the wound of contaminated and devitalized tissue, copiously irrigate, and repeat debridement within 24 to 72 hours5. Stabilize the fracture with the method determined at initial evaluation.6. Leave the wound open (controversial).
7. Perform early autogenous cancellous bone grafting.8. Rehabilitate the involved extremity aggressively.
Provide Airway and Urgent resuscitation Immobilise injured extremity and cover wound with sterile dressing Prophylactic IV antibiotics Urgent optimum wound debridement External fixation for damage control, definitive internal fixation at the earliest Early bone grafting Delayed wound closure with SSG/Flap
GAS GANGRENE TETANUS THROMBO EMBOLIC COMPLICATION LATE COMPLICATION DELAYED UNION NON-UNION MAL-UNION CHRONIC INFECTION
Rockwood and Green’s fractures in adults- 6th Campbells Operative orthopaedis- 11th edn Text book of orthopaedics – Kulkarni Anglen et al, J Ortho Trauma,2008 :390-396Dr Shahid Latheef+917795664142