This includes the basics of open fracture including classifications and treatment. References are from the latest edition of rockwood and greens fracture in adults.

1. OPEN FRACTURES
PRESENTER: Dr Rajesh Meena
MODERATOR: Dr Hemanth Raj
FACULTY: Dr V.K.Verma
Date: 14/9/2020
(Reference : Rockwood and Green’s Fractures in Adults 8th ed)

2. QR code for attendance

3. OUTLINE FOR DISCUSSION
1. Introduction
2. Assessment of open fractures
3. Use of Antibiotics
4. Imaging and other diagnostic studies
5. Classifications and scores for open fractures
6. Treatment

4. INTRODUCTION
• Open fracture: Fracture and fracture hematoma communicate with
external environment through a traumatic defect in the surrounding
soft tissue and overlying skin.
• Lower limb > upper limb
• Commonest: Open tibial diaphyseal fractures
• Other: open femoral diaphyseal, distal femoral and proximal tibial
fracture

5. Cont.
• high energy injury
• Frequently associated with
olife-threatening polytrauma
oSkin degloving
oSoft tissue crushing
oContamination with dirt and debris
• Therefore, associated with high risk of complications, including
amputations

6. Few facts that require emphasis
• Size and nature of external wound may not reflect damage to deeper
structures.
• Compartment syndrome can occur even in open fractures
• Extent of injury to soft tissue and bone may not be fully exposed on
day of injury
• Open fracture is just not a simple combination of a fracture and a
wound.

7. After secondary
Debridement
After 3 days
(Source: Rockwood and Green’s Fractures in Adults 8th ed)

8. ASSESSMENT OF OPEN FRACTURES
Initial Evaluation
• Patient must be thoroughly assessed for
• Airway
• Breathing
• Circulation
• Acidosis, hypothermia and coagulopathy are often present as a triad
in open injury -> identified and corrected quickly.

9. Cont.
• Once patient is stabilized the following should be done:
• Get patient’s detailed history
• Document comorbidity
(Source: Rockwood and Green’s Fractures in Adults 8th ed)

10. Cont.
Examination
• Patient should be adequately undressed, especially important in
unconscious and intoxicated patients.
• Vascularity and movements in of all four limbs must be examined

11. (Source: Rockwood and Green’s Fractures in Adults 8th ed)

12. Cont.
• Limbs must be examined for signs of compartment syndrome
• Tenting of skin should be noted
• Wound of any size in the same region should be considered indicative
of open fracture.
(Source: Rockwood and Green’s Fractures in Adults 8th ed)(Source: https://app.figure1.com/)

13. Cont.
• Wound -> fat globules -> indicates discharging fracture hematoma
• The following should be documented for wound:
• Size
• Location
• Depth
• Exposed bone, tendon, muscle
• Photographic documentation of the wound should ideally be
undertaken

14. Cont.
• Initial assessment and documentation -> cover wound with saline
soaked sterile dressing
• If significant bleeding -> compression dressing with firm bandages
and limb elevation.
• The practice of obtaining routine cultures from the wound either pre-
or post- debridement is no longer advocated.

15. ANTIBIOTICS IN OPEN FRACTURES
Evidence supports
• Intravenous antibiotics at the earliest, preferably in the emergency
room.
• Use of metronidazole and aminoglycosides in severely contaminated
wounds.
• Equivalent efficacy of oral to parenteral antibiotics during the follow-
up (when necessary).

16. Cont.
Evidence does not support
• Prolonged and continuous use of antibiotics.
• Continuing antibiotics as long as the drains are in.
• Continuation of the empirical antibiotic regime till wound drainage is
present.
• Prophylactic antibiotics to prevent pin tract infections.
• Antibiotic therapy as a substitute for debridement in presence of
necrotic and contaminated material.

17. (Source: Rockwood and Green’s Fractures in Adults 8th ed)

19. IMAGING AND OTHER DIAGNOSTIC STUDIES
• AP and lateral radiographs of injured bone including one joint above
and below should be done.
• Radiographic evidence of open injury:
• Air in subcutaneous tissues, intramuscular planes and joint cavities
• Presence of foreign bodies
• CT scan may prove helpful particularly in intra-articular fractures of
the ankle and knee joint.

20. (Source: Rockwood and Green’s Fractures in Adults 8th ed)

21. Cont.
Role of Biochemical Markers
1. Serum Lactate

22. 2. Interleukin-6

23. 3. C – reactive protein

24. CLASSIFICATIONS AND SCORES FOR OPEN FRACTURES
• Gustilo and Anderson classification is the most commonly followed
classification worldwide.
• The Gustilo – Anderson classification divides soft-tissue wounding of
open fractures into three grades – I, II & III.
• This was largely for lower leg injuries, but now also used for
injury's to other anatomical sites.

25. Cont.
Gustilo and Anderson Grade I
• Energy – low
• Wound size - ≤ 1 cm
• Soft tissue damage: Minimal
• Contamination: Clean
• Fracture pattern: simple with
minimal comminution
• Periosteal stripping: No
• Skin coverage: Local coverage
• No vascular injury (Source: www.orthobullets.com)

26. Cont.
Gustilo and Anderson Grade II
• Energy – Moderate
• Wound size – 1-10cm
• Soft tissue damage: Moderate
• Contamination: Moderate
• Fracture pattern: Moderate
comminution
• Periosteal stripping: No
• Skin coverage: Local coverage
• No vascular injury
(Source: www.orthobullets.com)

27. Cont.
Gustilo and Anderson Grade IIIA
• Energy – High
• Wound size – usually >10cm
• Soft tissue damage: Extensive
• Contamination: Extensive
• Fracture pattern: Severe
comminution or segmental
• Periosteal stripping: Yes
• Skin coverage: Local coverage
• No vascular injury
(Source: www.orthobullets.com)

28. Cont.
Gustilo and Anderson Grade IIIB
• Energy – High
• Wound size – usually >10cm
• Soft tissue damage: Extensive
• Contamination: Extensive
• Fracture pattern: Severe
comminution or segmental
• Periosteal stripping: Yes
• Skin coverage: Require flap coverage
• No vascular injury
(Source: www.orthobullets.com)

29. Cont.
Gustilo and Anderson Grade IIIC
• Energy – High
• Wound size – usually >10cm
• Soft tissue damage: Extensive
• Contamination: Extensive
• Fracture pattern: Severe
comminution or segmental
• Periosteal stripping: Yes
• Skin coverage: Require flap coverage
• Vascular injury that require repair
(Source: www.orthobullets.com)

30. Cont.
(Source: Rockwood and Green’s Fractures in Adults 8th ed)

31. Cont.
• The following injury severity scores have been proposed to overcome
the disadvantages of GA classification:
• Mangled Extremity Severity Score (MESS)
• Limb salvage index
• Predictive salvage index
• Nerve injury, ischemia, soft tissue injury, skeletal injury, shock and age patient
(NISSSA) score
• Hannover fracture scale

32. Cont.
• But even these scores are not suitable for evaluating GA IIIb injuries
• To overcome the issue of salvage and reconstruction pathways in Type
IIIb injuries, The GHOIS (Ganga Hospital Open Injury Score) was
described in 2005 by Rajasekaran et al.
• In this score 3 component of the limb:
• covering tissues (skin)
• structural tissues (bone)
• functional tissues (muscles, tendons, and nerves)
• are graded separately form 1 to 5 based on severity.

33. Cont.
• Seven comorbidities that are known to influence the outcomes are
given two points for each.
• Total score: need for amputation
• Individual scores: provide guidelines for management such as the
need for a flap or the requirement for bone transport.

34. (Source: Rockwood and Green’s Fractures in Adults 8th ed)

35. (Source: Rockwood and Green’s Fractures in Adults 8th ed)

36. (Source: Rockwood and Green’s Fractures in Adults 8th ed)

37. Cont.
Comorbid conditions: 2 points for each
• Injury to debridement interval >12 hrs
• Sewage / organic contamination or farmyard injuries
• Age > 65 years
• DM / cardiorespiratory disease -> raised anesthetic risk
• Polytrauma involving chest or abdomen with ISS >25 or FE
• Hypotension with SBP <90 at presentation
• Another major injury to same limb / compartment syndrome

38. Cont.
INTERPRETATION
1. ≤ 14 : Salvage
2. ≥ 17 : Amputation
3. 15/16 : Grey zone, decision is made on patient to patient basis

39. (Source: Rockwood and Green’s Fractures in Adults 8th ed)

40. TREATMENT
Stabilization of patient
Debridement and Lavage
Skeletal Stabilization
Wound Cover

41. Stabilization of patient
• Maintain
• Airway
• Breathing
• Circulation

42. Debridement and Lavage
Lavage:
• Adequate quantity of fluid, at least 9L for Type IIIb
• No advantage of adding antiseptic solution and antibiotics
• Low pressure pulsatile lavage (14 psi @ 550 pulse/min) > High
pressure pulsatile lavage ( 70 psi @ 1,050 pulse/min)

43. Principles of Debridement
• Performed by experienced team as early as possible (6 to 24 hr)
STEPS
• Take pre-debridement photographs
• Use tourniquet -> clear, bloodless field

44. SKIN AND FASCIA
• Adequate longitudinal extension of wound
• Create clean wound edge
• Gentle handling of skin to prevent degloving
• Remove all avascular fascia
Cont.

45. Cont.
MUSCLE AND BONE
• Evaluate all compartment muscles for “4C”- color, consistency,
contractility, capacity to bleed
• Carefully examine bone ends and medullary cavity
• Excise all bone fragments without soft tissue attachment

46. Cont.
COMPLETION
• Deflate tourniquet -> evaluate viability of retained structures
• Photographic documentation for future reference and planning
• Plan for: wound closure or coverage and bone stabilization
• If very severe tissue loss -> VAC

47. A severe open fracture around the ankle in a 20 year old woman (A & B). After the debridement of necrotized
tissue (C), NPWT was applied (D).
(Source: Hyun-Joo Lee at. Al. “Negative pressure wound therapy for soft tissue injuries around the foot and ankle”

48. SKELETAL STABILIZATION
Skeletal stabilization
External skeletal fixation Primary internal fixation
Half pin unilateral
frames
Ring fixators Plate fixation IM nail

49. WOUND COVER
(Source: Rockwood and Green’s Fractures in Adults 8th ed)

50. (Source: Rockwood and Green’s Fractures in Adults 8th ed)

51. (Source: Rockwood and Green’s Fractures in Adults 8th ed)

52. Reference:
• Rockwood and Green’s Fractures in Adults 8th ed.
• Lee HJ, Kim JW, Oh CW, et al. Negative pressure wound therapy for
soft tissue injuries around the foot and ankle. J Orthop Surg Res.
2009;4:14. Published 2009 May 9. doi:10.1186/1749-799X-4-14
• www.orthobullets.com