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AO-SEC Principles in Operative Fracture Management<br />for Operating Room Personnel<br />Oct 1-2, 2010 | RDEC Bhaban, Dhaka, Bangladesh <br />

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Open Fractures<br />Prof. Muhammad Shahiduzzaman<br />Head, Department of Orthopaedics & Traumatology<br />Dhaka Medical College<br />

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Objectives<br /><ul><li>Open fracture classification

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Patient evaluation

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Surgical management

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In the emergency department

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First visit to the OT

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Definitive management

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Soft tissue

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Fracture</li></li></ul><li>Definition<br />“An open fracture is one that communicates with the outside environment.”<br />

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Classification<br />

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Gustilo type I<br /><ul><li>Wound less than 1cm

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Minimal soft tissue injury

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Minimal contamination

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Fracture usually simple transverse, short oblique fracture

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Low energy injury</li></li></ul><li>Gustilo type II<br /><ul><li>Wound greater than 1 cm

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Moderate soft tissue injury

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Slight or moderate crush

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No extensive soft tissue damage, flaps or avulsions

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Simple transverse short oblique fracture with moderate comminution</li></li></ul><li>Gustilo type IIIA<br /><ul><li>Adequate soft tissue coverage of the bone

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Includes segmental and severely comminuted fractures</li></li></ul><li>Gustilo type IIIB<br /><ul><li>Extensive periosteal stripping and bone exposure

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Massive contamination

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Severe comminution with high energy injury

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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

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Soft tissue and bone healing without complications

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Restoration of function

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Infection

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Delayed and Non union

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Loss of extremity</li></li></ul><li>Emergency assessment<br /><ul><li>Assessment of patient

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ATLS guidelines

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Manage life threatening injuries first.

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Examination of the injury

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Wound (photos)

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Neurological status

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Vascular status

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Compartments :Open fractures can still develop compartment syndrome</li></li></ul><li>Emergency assessment…<br />

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Emergency Management<br /><ul><li>Bleeding – control with direct pressure

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Remove gross debride, gentle small volume irrigation, sterile dressing (normal saline)

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Reduce bone or joint

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Splint limb

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Intravenous antibiotics</li></li></ul><li>Principle of treatment<br /><ul><li>Treat any open fracture as an emergency.

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Evaluate the patient to diagnose other life threatening injury.

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Institute appropriate and adequate antibiotic.

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Adequate wound excision.

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Stabilize the fracture.

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Perform delayed closure of the wound within 3-7 days.

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Decide on early amputation.

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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.

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It is imperative to immediately treat open fracture in order to reduce or prevent wound sepsis.

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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

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Tetanus prophylaxis is indicated.

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Both gram-negative and aerobic gram positive are major pathogens in open #

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Penicillin is added for Agricluturalinjuries.</li></li></ul><li>Common pathogen<br />

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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 />

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Debridement<br /><ul><li>Prior to irrigation

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Requires extension of the wound

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Longitudinal

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Systematic fashion

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Skin

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Subcutaneous fat

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Fascia

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Muscle

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Bone</li></li></ul><li>Debridement-skin<br /><ul><li>Prior to irrigation

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Requires extension of the wound

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Longitudinal

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Systematic fashion

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Skin

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Subcutaneous fat

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Fascia

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Muscle

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Bone</li></li></ul><li>Debridement-muscle<br /><ul><li>Open the fascial compartments to see the extent of injury

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Remove muscle that is dead or necrotic

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Based on colour and turgor of muscle (bleeding not as good)

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If in doubt can leave and relook in 24 to 48 hours</li></li></ul><li>Debridement-bones<br /><ul><li>Remove bone that has no soft tissue attachment

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Keep large articular fragments

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consider fixing at the initial debridement</li></li></ul><li>Irrigation<br /><ul><li>After the debridement

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Options:

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Low pressure versus high pressure (pulse lavage)

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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”

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Gustilo and Anderson JBJS 1974</li></li></ul><li>VAC system<br /><ul><li>Provides closed suction system

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Reduces oedema and bacterial counts

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Enhances granulation tissue

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Carefully does not prevent primary wound closure

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Not a substitute for early definitive coverage

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Plastics & Reconstructive Surgery 2008</li></li></ul><li>Antibiotic bead pouch<br /><ul><li>Antibiotic cement beads

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Fill dead space

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High local antibiotic concentration

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Seal wound from further contamination

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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)

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Remember that this does interfere with fracture healing to some degree

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High grade injury

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Severe contamination

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Questionable tissue viability

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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.

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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 />

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Soft tissue Coverage<br /><ul><li>Primary closure

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Delayed primary closure

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Skin graft

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Local flaps

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Fasciocutaneous flaps

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Muscle pedicle

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Free flaps

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Standard (eg lat dorsi)

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Fasciocutaneous (eg lateral thigh flap)</li></li></ul><li>Stabilization of open fracture<br /><ul><li>Plaster immobilization

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Skeletal traction

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Internal fixation with implant

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External fixation</li></li></ul><li>Stabilization of open fracture…<br /><ul><li>Achieving fracture stability is just as important as wound excision.

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Stable fracture fixation preserves the integrity of the remaining soft tissues, muscles and neurovascular structures.

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Facilitates care of the wound and contributes to the well-being of the whole patient.

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Allows joint motion and muscle exercise program.</li></li></ul><li>Fixation<br /><ul><li>Important to protect the soft tissues from additional injury by fracture fragments

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Aids in wound care

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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.

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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.

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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 />

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Rehabilitation<br /><ul><li>Immediate objectives of rehabilitation are to prevent muscle atrophy, prevent joint stiffness and improve circulation in the extremity.

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The ultimate objective, of course, is to restore the extremity to the greatest degree of function of which it is capable.

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A well-organized rehabilitation program initiated early will help return the patient to a functional status.</li>