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Open fracture
- 1. Orthopedic conference Ext. TorpathomPreukprasert
- 2. Case A 12 yearold boy No underlying disease CC.Motorcycle accident 3 hr PTA P.I. ผู้ป่วยโดนรถจักรยานยนต์เฉี่ยวขณะซ้อนมอเตอไซค์ ผู้ป่วยล้มลงขา กระแทกพื้น ผู้ป่วยยังมีสติแต่ไม่สามารถยืนและทรงตัวได้ มีอาการเจ็บ บริเวณขาซ้ายและมีแผลเปิดขนาดประมาณ 1cm ที่หน้าแข้งข้างซ้าย
- 3. Primary Survey A. Cantalk, No neck pain, can move neck, not tender along c-spine B. No wound, no dyspnea, clear breath sound, no adventitious sound, trachea in midline C. BP 114/72mmHg, HR 84/min cap. Refill <2 sec, no active bleeding wound ,pelvic compression negative D. E4V5M6, pupil 3mm RTLBE E. Deep wound ~1 cm at left shaft tibial
- 4. Secondary survey • Allergy: no history • Medication : no current medication • Past history : no underlying disease • Last meal : 4 hr PTA
- 6. Physical exam • GA:Thai boy, good conciousness • VS : BP 114/72mmHg HR 84/min RR18/min • HEENT : normal conjunctivae, anicteric scerlae • Heart : normal S1S2, no murmur • Lungs : clear both lung • Abdomen : soft, not tender • Neurological : grossly intact
- 7. • Left tibia: lacerated deep wound, minimal bleeding, marked tenderness at shaft left tibia, limit ROM of knee joint due to pain, full ROM at ankle and thumb, cap refill <2 sec, dorsalis pedis and posterior tibial pulse 2+ , intact pin prick sensation Physical exam
- 8. • Thoracolumbar spine: no tenderness along T-L spine, no pain on flexion and extension Physical exam
- 9. Investigation : FilmX-rayleg Ap, Lateral
- 10. Diagnosis • Open fractureshaft left tibia
- 11. Gustilo and Andersonclassification • Type I :wound < 1 cm • Type II: wound size 1-10cm • Type III A :wound size > 10 cm, high energy, adequate tissue for coverage includes segmental / comminuted fractures even if wound <10cm farm injuries are automatically Gustillo III • Type IIIB :extensive periosteal stripping and requires free soft tissue transfer • Type IIIC :vascular injury requiring vascular repair
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- 15. Grade IIIB GradeIIIC
- 16. Evaluation of openfracture 1.Characteristic of wound : cut wound lacerated, burn 2.Size , Depth, location 3.Contamination 4.Degree of soft tissue injury 5.Neurovascular status ประกอบการประเมิณโดยใช้ Gustilo and Anderson classification
- 17. Management of openfracture • Initial in the emergency room 1. ATB and Tetanus prophylaxis 2. Control bleeding 3. Assessment neurovascular and soft tissue injury 4. Dressing : remove gross debris and soak sterlie NSS on the wound
- 18. Antibiotic Indications forOpen Fractures 1. Gustillo I and II :1st generation cephalosporin 2. Gustillo III :1st generation cephalosporin + aminoglycoside 3. With farm injury :1st generation cephalosporin + aminoglycoside + PCN , add PCN for clostridia 4. Duration :initiate as soon as possible • increased infection rate when delayed > 3 hours from time of injury • continue for 72 hours after I&D
- 19. Management in OR 1.Aggressive debridement and irrigation :Type I: 3, Type II: 6L, Type III: 9L • surgical debridement 6-8 hours after time of injury • grossly contaminated wounds are irrigated in emergency 2. bony fragments without soft tissue attachment can be removed 3. Fracture stabilisation: internal or external fixation 4. Can place antibiotic bead-pouch in open dirty wounds
- 20. Open reduction internalfixation with plate and screw
- 21. Wound closure • 1.Primary closure : clean and no necrotic tissue or foreign material • 2. Secondary closure : flap and graft • 3. Delayed primary closure : high infected rate (Class III)
- 22. Rehabilitation • Elevation การยกExtremities ให้สูงหลังผ่าตัดสามารถลดอาการบวมได้ แต่ไม่ควรยกสูงเกิน 10cm • Benefit 1. ป้องกัน Muscle atrophy 2. ป้องกัน joint stiffness 3. เพิ่ม circulation, venous, lymphatic return
- 23. Thank you foryour attention