Help in management of open wound

1. OPEN FRACTURES
G.M. WERU
Lecturer clinical medicine

2. INTRODUCTION
 They are associated with high risk of
infection, delayed union and non union
They have higher morbidity and motarity
compared to closed fractures

3. CLASSIFICATION
GUSTILLO ANDERSON CLASSIFICATION
 Classification based on:
1) Size of the wound
2) Level of contamination
3) Extent of soft tissue loss
4) Degree of fracture of comminution

4. Classification cont.
 TYPE I(Gustillo I)
- Wound less< 1cm
- Minimal soft tissue loss
- No crushing and the fracture is not
comminuted
- Minimal contamination
- Caused by low energy force

5. Gustillo I

6. Cont.
 TYPE II(Gustillo II)
- Wound more > 1cm but < 10cm
- Minimal soft tissue loss
- Minimal contamination
- Moderate crushing or comminution of the
fracture
- Caused by low to moderate force

7. Gustillo II

8. Cont.
 TYPE III(Gustillo III)
- Wound > 10cm
- Extensive soft tissue loss
- Moderate to severe contamination
- Moderate to severe crushing or comminution
- Caused by high energy force

9. Cont.
 TYPE IIIA(Gustillo IIIA)
- Extensive soft tissue loss
- Severe contamination
- Severe comminution of the fracture
- Adequate soft tissue coverage using local
tissues
- Caused by high energy force

10. Gustillo IIIA

11. Cont.
 TYPE IIIB(Gustillo IIIB)
- Extensive soft tissue loss with periosteal
stripping
- Severe contamination
- Fracture cover not possible with use of local
tissues.
- Caused by high energy force

12. Gustillo IIIB

13. Cont.
 TYPE IIIC(Gustillo IIIC)
- Any open fracture with vascular damage that
requires repair regardless of the amount of
other soft tissue damage.

14. Gustillo IIIC

15. TREATMENT OF OPEN FRACTURES
PRINCIPLES OF TREATING OPEN FRACTURES
1) Resuscitation ( ATLS)
• Airway patency
• Breathing
• Circulation
• Dysfunction of CNS/disability/ drugs
2) Antibiotic prophylaxis
3) Immunization( Tetanus toxoid)
3) Urgent wound and fracture debridement
4) Stabilization(immobilization) of the fracture
5) Definitive wound cover

16. Antibiotics prophylaxis
Should be started as soon as the patient
arrives in casualty
Best within the first three hours of injury
Risk of infection increases with the severity of
injury (0-2%, 2-10%, and 10-50% in types I, II,
and III respectively)

17. Antibiotics cont.
Choice of antibiotic
Type I fracture – 1st gen. Cephalosporin (Cefazolin)
Type II fractures – Cefazolin
Type III fractures – Cefazolin + Gentamycin
Fractures caused by farm equipments and gun
shorts; add penicillin due to risk of clostridial
myonecrosis

18. Immunization
Tetanus toxoid 0.5ml stat
 For clean wound
Has not completed 3 doses of toxoid
Had no booster in the last 10yrs
 Contaminated wound
Has not completed 3 doses of tetanus toxoid
Had no booster in the last 5 yrs.

19. Debridement
Done in the theatre under anaesthesia
Extend the traumatic wound
Thorough washout with normal saline solution
Remove all foreign bodies
Remove necrotic tissue
May pack the wound with antibiotic
impregnated beads
Repeat debridement in 48-72hrs

20. Fracture stabilization/immobilization
 Goals of stabilization
Restore length and alignment of bones
Restore articular surfaces displaced by
fracture
Allow access to traumatic wound
Facilitate further reconstruction
Allow early use of the limb
Facilitate fracture union and early return of
function

21. Cont.
Methods of stabilization
 Type I
- POP with a window to enable wound care
 Type II, III, IIIA, IIIB, IIIC
- Internal fixation if thorough debridement has
been guaranteed.
- External fixation; it is the preferred method

22. Definitive wound cover
Don’t close traumatic wounds primarily
 Options of cover
Most can be covered with Split- thickness skin
graft (STSG)- It’s a graft that includes the
epidermis and part of the dermis
Tissue flaps