Requires free or local flap for bone coverage</li></li></ul><li>Gustilo type IIIC<br /><ul><li>Any open fracture that is associated with an arterial injury that must be repaired regardless of the degree of soft tissue injury</li></li></ul><li>Management<br /><ul><li>Prevent Infection
Soft tissue and bone healing without complications
Rehabilitate the involved extremity. </li></li></ul><li>This is a surgical emergency<br /><ul><li>Treatment of open fracture is second only to life threatening and arterial injury.
It is imperative to immediately treat open fracture in order to reduce or prevent wound sepsis.
All open fractures of more than 8 hours should be considered infected.</li></li></ul><li>Antibiotic therapy<br /><ul><li>Prevention of wound sepsis is the primary objectives in the treatment of open fracture
Both gram-negative and aerobic gram positive are major pathogens in open #
Penicillin is added for Agricluturalinjuries.</li></li></ul><li>Common pathogen<br />
Wound excision<br />Wound excision to be under taken under strict aseptic condition, must be systematic and complete.<br />Lavage is done with normal saline or distilled water. For final irrigation mixture of bacitracin and polymyxin solution is preferable.<br />Wound incision must be large enough to facilitate exposure and inspection.<br />The following structures are debrided : <br />skin, fascia and tendons,muscles, and bones.<br />
Low pressure versus high pressure (pulse lavage)
Saline alone versus additives (antiseptics, antibiotics, or soap/detergents)</li></li></ul><li>Wound management<br /><ul><li>“If there is the slightest doubt in the surgeon’s mind as to whether there has been adequate debridement of the wound after an open fracture, the wound should not be closed regardless of the type of open fracture. For the surgeon who manages only an occasional open fracture, the safe rule is not to close the wound”
Gustilo and Anderson JBJS 1974</li></li></ul><li>VAC system<br /><ul><li>Provides closed suction system
Infection rates decreased from 12.0% to 3.7% in 1085 fractures (Ostermann JBJS 1995)</li></li></ul><li>Repeat Debridement<br /><ul><li>Can include opening a wound that was primarily closed (eg subcutaneous border of the tibia)
Remember that this does interfere with fracture healing to some degree
Repeat 24-48 hours until wound viable</li></li></ul><li>Wound Coverage and closure<br /><ul><li>For type I and type II open fracture delayed primary closure or skin graft can be accomplished in 3 to 5 days.
For type III B and III C open fracture with significant soft tissue loss and exposed bone often require two or three debridement before flap coverage.</li></ul>Early soft tissue converge is key to minimize woundsepsis.<br />
Allows early mobilisation and rehabilitation of the patient</li></li></ul><li>Skeletal traction<br /><ul><li>Skeletal traction is indicated for type I and type II open fracture of femoral shaft.
Wound is allowed to heal followed by internal fixation in 10 to 14 days.</li></li></ul><li>External Fixation<br /><ul><li>Safe and reliable method of achieving bony stability in open fracture.
Major disadvantage is pin tract infection, but can be considerably reduced with proper pin insertion and care.</li></li></ul><li>Amputation<br />Can a functional,viable extremity be achieved ? <br />Can the the time and expense of saving the extremity be justified ?<br />Absolute indication of amputation :<br /> Type III C injury with posterior tibial nerve disruption.<br /> Type III C injury with soft tissue loss, massive contamination with severely comminuted segmented fracture or massive bone loss.<br />
Rehabilitation<br /><ul><li>Immediate objectives of rehabilitation are to prevent muscle atrophy, prevent joint stiffness and improve circulation in the extremity.
The ultimate objective, of course, is to restore the extremity to the greatest degree of function of which it is capable.
A well-organized rehabilitation program initiated early will help return the patient to a functional status.</li>