management and classification for compound fractures

1. OPEN FRACTURES
LIMB- TO SAVE OR NOT TO SAVE, THAT IS THE QUESTION?
By Dr. Vinay Samant
Resident
Seth GSMC and KEMH
MUMBAI

2. The ER Management

3. INITIAL MANAGEMENT
(THE ER)
• Every open injury is an orthopedic
emergency.
• ATLS protocol is a must and should be
done first.
• Airway breathing circulation must be
assessed
• Estimated blood loss must be
undertaken quickly and resuscitated if
necessary

4. INITIAL
MANAGEME
NT (THE ER)
• After patient stabilization detailed history
should be documented-
• A) time of injury
• B) mode of injury
• C) LOC
• D) h/o Head Chest Abdo injury
• E)Comorbidities if any.
• F)h/o smoking/medication/ allergies

5. INITIAL
MANAGEMENT (THE
ER)
• 1) undress the patient
adequately and examined for all
injuries.
• 2) All constructive clothing must
be removed and vascularity and
movements of all limbs must be
examined.

6. INITIAL
MANAGEMENT (THE
ER)
• Size and severity of wound and
relationship of the wound to the
fracture must be examined.
• In ER, wound examination should
include-
• 1) size
• 2) location of wound
• 3) orientation of wound (longitudinal,
transverse, irregular)
• 4) depth of wound with bone tendon
muscle exposed.
• 5) skin condition surrounding the
wound

7. INITIAL
MANAGEME
NT (THE ER)
• Photographic documentation of the wound
must be taken

8. THE ER
• Probing and further handling of wound must be avoided as it
may provoke unnecessary bleeding and increases chances of
secondary contamination and nosocomial infection

9. • Following initial assessment and documentation, wound must
be totally covered with sterile dressing.

10. DRESSING IN THE ER
• Strict sterility to be maintain
• Use only normal saline with sterile gauze piece for ER dressing.
• Don’t use H2O2.
• Closed dressing with wet saline gauze.
• Avoid closing wounds with Stitches in ER.

11. BLEEDING IN THE ER?S
• Significant bleeding controlled by application of compressive
dressing and firm bandages with elevation of limb
• in the emergency room ,the resident should not attempt to blindly clamp a
bleeding vein or artery as this may result in the inadvertent clamping of an
adjacent major neurovascular structure and lead to permanent and
irreversible neurologic deficit
• Uncontrollable bleeding from a wound can be arrested with the help of a
tourniquet.

12. VASCULARITY OF THE
LIMB?
Hard Signs
• Absent or significant difference in pulsations compared with normal side
• Expanding or pulsatile hematoma
• Bruit or thrill
Associated Signs
• Associated numbness and neurologic deficit
• Difference in skin temperature distal to injury
• Absence of venous filling
• Absence of pulse-oximeter reading. No capillary blanching

13. • If pulses are absent, one must re-examine the limb after the limbs are
anatomically aligned and splinted as shortening and angulation of the
fractured skeleton may result in kinking and occlusion of the vessels.
• If the pulses are still absent, a vascular injury must be suspected
unless proven otherwise.

14. THE ER
• A diagnosis of vascular spasm shouldn’t be made.
• Distal neurological status documentation
• Once bleeding controlled wound cover with saline dressing
limb should be properly splinted and iv antibiotics can be
administered.
• The patient should then be taken to the operating room as quickly as
possible.

15. ANTIBIOTIC PROTOCOL IN ER

16. DEBRIDEMENT AN ORTHOPLASTIC
APPROACH

17. DEBRIDEMENT:
Coined by desault in 18th century-
“Procedure that involves surgical extension of wound and removal of all
necrotic and contaminated tissue”.

18. NOT JUST WOUND WASHING
• Foreign material + contaminated tissue + suspected avascular
tissue
(removed)
+
Minimize dead space/hematoma
Vascularised living tissue devoid of contamination

19. SOME TRADITIONS ARE WORTH FORGETTING
• Misconception -To debride within 6 hrs of contamination.
• And hence debridement was being done without an
experienced work force or without proper planning.
• Current literature suggest debridement perform within 6 hrs
has no clear advantage over that done between 6-24 hrs of
injury.

20. SOME TRADITION ARE WORTH FORGETTING
Thoroughness of
debridement
Timing of
debridement

21. AN ORTHOPLASTIC
APPROACH

22. INSIDE THE OT- SEQUENCE TO BE FOLLOW
1. Thorough washing in highly contaminated wounds with copius Saline advisable before
draping of limb.
2. Application of torniquet
3. Pre debridement photos in different photos.
4. Wound lavage
5. Superficial debridement
6. Deep debridement
7. Repeat wound lavage.
8. Plan further wound management.

23. TOURNIQUET- A
CONTROVERSY
• Misconception that injures
already hypoxic tissue.
• Interferes with muscle
viability.

24. TOURNIQUET- A CONTROVERSY
• However limb without vascular deficit there is no evidence that
tourniquet has any deleterious effects on viable tissue.
• creates a blood less field help to identify contamination , protect the
vital structures , explore the joint cavity.
• Minimizes blood loss in patient already in shock.
• Viable muscle appear pale under tourniquet and blush immediately
on release.
• Dead tissue appeared dark red throughout.
• At the end of debridement the tourniquet is released and viability of
all retained tissues confirmed.

25. WOUND LAVAGE
• Solution for pollution is dilution
– clears debris and hematoma.
• Directly reduces bacterial
population.
• Addition of H2O2, Alcohol,
Iodine, antibiotics or any other
chemical agents offer no
advantage and can be counter
productive.

26. AN IDEAL WOUND LAVAGE…
• Typically 9 liters of fluid for type IIIB fracture.
• low pressure pulsatile (14psi at 550pulsation/min) is preferred.
• 70psi at 1050 pulsation/min (high pressure pulsatile lavage )
can cause microscopic damage to bone soft tissue and may
push bacterial contamination inside.
• Lavage to be done before and after debridement.

27. SUPERFICIAL DEBRIDEMENT
• Initial assessment
• Incision extension to visualize deeper tissues (specially joints and
severely contaminated wounds)
• debridement of skin must be undertaken without tourniquet as
extend of skin resection decided by bleeding skin edges.
• Indiscriminate removal of skin flap to be avoided
• Whenever in doubt, retain the skin for debridement during secondary
procedure .
• Doubtful non viable fascia to be excised

28. DEEP DEBRIDEMENT
• Agressvie approach for muscle debridement.

29. 4 “C’S” OF MUSCLE VIABILITY.
colour consistency contractability
Capacity to
bleed

30. BONE DEBRIDEMENT
• Bone ends and medullary cavity carefully examined and
debrided
• All diaphyseal fragments regardless of size without soft tissue
attachments should be excised.
• Cancellous bone involving articular surface is usually retain.

31. NEED FOR SECOND-LOOK DEBRIDEMENT
• Delayed presentation > 12 hrs.
• Evidence of infection during debridement.
• Initial debridement considered unsatisfactory.
• High energy blast injuries
• Severe contamination , farmyard and sewage contamination.

32. TAKE HOME MESSAGE
• During debridement the surgical team should focus only on
adequacy of debridement without being concerned about the
ease of reconstriction .
• A large clean wound as higher chances of successful
reconstruction than a smaller inadequately debrided wound.

33. OUTCOME
1 Primary closure
2 Delayed closure
3 Primary flap
4 Delayed flap
5 VAC Dressing

34. Thank you