3. Open Tibia Fracture
• Because the tibia is a
subcutaneous bone, so
tibial fractures are
frequently open
fractures
4. Etiology
• Most open fractures are caused by some type
of high-energy.
• Motor vehicle accidents are the common
causes of open tibial fractures
• Other cause:
sport injury
Gun shot
Fall down
5. Etiology
• The severity of an open fracture depends
upon several factors, including:
1.The size and number of the fracture
fragments
2.The damage to surrounding soft tissues
3.The location of the wound and whether
the soft tissues in the area have good blood
supply
6. Classification of Open fracture
Cauchoix (1961)
Tscherne và Ocstern (1982)
Gustilo and Anderson(1984) Base on :
• Wound size
• Soft tissue damage
• Associated Vascular injury?
• Degree of contamination
13. Antibiotic
• Initiate early IV antibiotics as soon as possible
studies show increased infection rate when
antibiotics are delayed for more than 3 hours from
time of injury
• continue for 24 hours after initial injury if wound is
able to be closed primarily
• continue until 24 hours after final closure if wound is
not closed during initial surgical debridement
14. Gustilo Type Antibiotic recommendation
I 1st generation cephalosporin for gram +ve
coverage
- Cefazolin 1-2 g
- Clindamycin or Vancomycin in Penicillin
allergy
II
III A 1st generation cephalosporin plus
aminoglycoside for gram –ve coverage
- Cefazolin plus Gentamicin
- If Farm injuries exposed, anaerobic
coverage should be considered
III B
III C
16. Control Bleeding and Assessment
• Direct pressure will
control active bleeding
• do not blindly clamp or
place tourniquets on
damaged extremities
• Assessment soft-tissue
damage
• neurovascular exam
19. Open Fracture Management in the
Operating Room
• Debridement
Six hour golden period is controversy
Sequential debridement
• Skin Muscle viability 4 C’s
•Subcutaneous Contractility
• Fascia Capacity to bleed
• Muscle Color
• Bone Consistency
23. Irrigation & Lavage
• Adequacy of debridement come first
• • Additions in irrigation are proven useless –
Saline only
• • Amount of irrigation in guideline
• • Type I : 3L
• • Type II : 6L
• • Type III : 10 L
25. Fracture stabilization
• Temporary vs definitive
• External vs internal fixation vs combination
Anatomical site of injury
Contamination ?
Status of soft tissues
Associated injuries
Implant availability
Experience of surgeon
27. Internal fixation
• Nail or Plate
• Not a contraindication in
open fracture
• Meticulous debridement
• Need a good judgment
• Infection rate correlate
with type of open fracture
28. Fracture stabilization
If it not safe, external fixation is
preferred until soft tissue recover
and infection is absent
29. Initial wound coverage
Goal
• Protect nerve, vessel, tendon and bone
• Prevent from environment
Option
• Primary closure – tensionless
• Antibiotic bead pouch
• Vacuum dressing
30. Antibiotic bead pouch
• Deliver high
concentration antibiotic
• Keep moist to tissue
• Prevent from
environment exposure
33. Definitive wound coverage
• Primary clousere
• Delay/secondary Closure
• Skin grafting
• Flap : Local Flap or Free Flap
• Golden period of coverage < 5–7 days
