This document discusses the principles of operative fracture management for open fractures. It defines open fracture classifications according to the Gustilo system and outlines approaches for emergency assessment, wound excision and debridement, antibiotic therapy, wound management, soft tissue coverage, fracture stabilization, and rehabilitation. The key goals are to prevent infection, promote soft tissue and bone healing without complications, and restore function of the injured extremity.

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

2. Open Fractures Prof. Muhammad Shahiduzzaman Head, Department of Orthopaedics & Traumatology Dhaka Medical College

4. Patient evaluation

5. Surgical management

6. In the emergency department

7. First visit to the OT

8. Definitive management

9. Soft tissue

11. Classification

13. Minimal soft tissue injury

14. Minimal contamination

15. Fracture usually simple transverse, short oblique fracture

17. Moderate soft tissue injury

18. Slight or moderate crush

19. No extensive soft tissue damage, flaps or avulsions

22. Massive contamination

23. Severe comminution with high energy injury

25. Soft tissue and bone healing without complications

26. Restoration of function

27. Infection

28. Delayed and Non union

30. ATLS guidelines

31. Manage life threatening injuries first.

32. Examination of the injury

33. Wound (photos)

34. Neurological status

35. Vascular status

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

39. Reduce bone or joint

40. Splint limb

42. Evaluate the patient to diagnose other life threatening injury.

43. Institute appropriate and adequate antibiotic.

44. Adequate wound excision.

45. Stabilize the fracture.

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

47. Decide on early amputation.

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

51. Tetanus prophylaxis is indicated.

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

54. Wound excision Wound excision to be under taken under strict aseptic condition, must be systematic and complete. Lavage is done with normal saline or distilled water. For final irrigation mixture of bacitracin and polymyxin solution is preferable. Wound incision must be large enough to facilitate exposure and inspection. The following structures are debrided : skin, fascia and tendons,muscles, and bones.

56. Requires extension of the wound

57. Longitudinal

58. Systematic fashion

59. Skin

60. Subcutaneous fat

61. Fascia

62. Muscle

64. Requires extension of the wound

65. Longitudinal

66. Systematic fashion

67. Skin

68. Subcutaneous fat

69. Fascia

70. Muscle

72. Remove muscle that is dead or necrotic

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

75. Keep large articular fragments

77. Options:

78. Low pressure versus high pressure (pulse lavage)

81. Reduces oedema and bacterial counts

82. Enhances granulation tissue

83. Carefully does not prevent primary wound closure

84. Not a substitute for early definitive coverage

86. Fill dead space

87. High local antibiotic concentration

88. Seal wound from further contamination

90. Remember that this does interfere with fracture healing to some degree

91. High grade injury

92. Severe contamination

93. Questionable tissue viability

95. 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.Early soft tissue converge is key to minimize woundsepsis.

97. Delayed primary closure

98. Skin graft

99. Local flaps

100. Fasciocutaneous flaps

101. Muscle pedicle

102. Free flaps

103. Standard (eg lat dorsi)

105. Skeletal traction

106. Internal fixation with implant

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

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

111. Aids in wound care

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

117. A well-organized rehabilitation program initiated early will help return the patient to a functional status.