power point

1. PRINCIPLES OF MANAGEMENT OF OPEN
FRACTURE
SANUSI A.A
SUPERVISOR- DR OGUCHE
DEPT OF ORTHOPAEDICS AND TRAUMA
UATH

2. OUTLINE
• Introduction
– Definitions
– Epidemiology
• Aetiology
• Classification
• Management
– General principles
– Emergency care
– Definitive management
• Diagnosis
– History
– Physical exam
– Investigation
– Definitive treatment
– Rehabilitation
• Complications
• Prognosis
• Peculiarity in our environment
• Conclusions
• References

3. INTRODUCTION
• Definitions
– A fracture is a break or disruption in the
structural continuity of a living bone with
associated injury to the overlying tissue
– An open fracture is one in which the
fracture haematoma communicates with
the external environment

4. INTRODUCTION
• Epidemiology
– Annual incidence for open fracture of long bones: 11.5% (UK)
– About 40% involve the lower limbs
– Tibia is more commonly affected
– Age group: commonly 3rd and 4th decades
– Male > Female

5. AETIOLOGY
• Majority of open fractures (up to 60%) are caused by road traffic crash
• Other aetiological factors
• Fall from height
• Pedestrian/automobile collisions
• Motor to bike collisions
• Gunshot injury
• Bike to bike collisions
• Communal clashes
• Terrorist attacks
• Sports injury

6. CLASSIFICATION OF OPEN FRACTURE
• The most widely used is that of Gustilo and Anderson
• Other classification systems include;
– Tscherne and Oestern
– AO-ASIF
– Orthopaedic Trauma Association

7. GUSTILO AND ANDERSON OPEN FRACTURE
CLASSIFICATION
Open
fracture
Mechanism of
injury
Degree of soft
tissue damage
Fracture
configuration
Level of
contamination

8. GUSTILO AND ANDERSON OPEN FRACTURE
CLASSIFICATION
• Gustilo & Anderson type I
– Wound less than 1cm
– Minimal soft tissue injury
– Minimal contamination
– Fracture usually simple transverse,
short oblique fracture
– Low energy injury

9. GUSTILO AND ANDERSON OPEN FRACTURE
CLASSIFICATION
• Gustilo & Anderson type II
– Wound greater than 1 cm but <10cm
– Moderate soft tissue injury
– Slight or moderate crush
– Moderate contamination
– Simple transverse short oblique fracture with
moderate comminution
– Low-moderate energy

10. GUSTILO AND ANDERSON OPEN FRACTURE
CLASSIFICATION
• Gustilo & Anderson type III
– An open segmental # or a single # with extensive soft-tissue injury
– Highly contaminated
– Usually comminuted
– Severe energy injury
– IIIA, IIIB, IIIC
• Depends on soft tissue injury

11. GUSTILO AND ANDERSON OPEN FRACTURE
CLASSIFICATION
• Gustilo & Anderson type IIIA
– Adequate soft tissue coverage of
the bone

12. GUSTILO AND ANDERSON OPEN FRACTURE
CLASSIFICATION
• Gustilo & Anderson type IIIB
– Extensive periosteal stripping and
bone exposure
– Requires free or local flap for bone
coverage

13. GUSTILO AND ANDERSON OPEN FRACTURE
CLASSIFICATION
• Gustilo & Anderson type IIIC
– Any open fracture that is associated with
an arterial injury that must be repaired
regardless of the degree of soft tissue
injury

14. MANAGEMENT
• General principles
– Rescue
– Resuscitate
– Reduce
– Retain reduction
– Rehabilitate

15. MANAGEMENT
• Emergency care
– Open fracture is an orthopaedic emergency
– Treatment of open fracture is second only to life threatening and arterial injury
– It is imperative to immediately treat open fracture in order to reduce or prevent
wound sepsis
– Treat the patient, not only the fracture
– ATLS principles
– Take clinical photo
– Neurological status
– Vascular status

16. MANAGEMENT
• Emergency care (cont.)
– Remove gross debris, gentle pressure irrigation, sterile dressing
– Reduce fractures or dislocations
– Splint limb
– Analgesia
– Tetanus prophylaxis
– Antibiotics
– Basic investigations
• X-ray of the affected limb
• Trauma x-ray series if indicated
• Haemoglobin or packed cell volume
• Grouping and cross matching
– Pre operative planning

17. MANAGEMENT
• Definitive management
– Diagnosis
• History
– History of trauma
» Pain
» Bruising
» Loss of function
» Deformity
– Limitations and debilitation attributed to the problem
– Good surgical history, especially with regards to orthopaedic surgeries and
prior anesthesia
– Co-morbid conditions

18. MANAGEMENT
• Definitive management
• Physical examination
– General signs
– Local signs
» Look, feel and move principle
» Start with normal structures and move to abnormal
» Look
• Swelling
• bruises
• The posture of the distal extremity and
• The colour of the skin

19. MANAGEMENT
• Definitive management
• Physical examination (cont.)
– Local signs
» Feel
• localized tenderness
• Neurologic exam
• Vascular exam
» Move
• Abnormal movement
• While move when there are x-rays

20. MANAGEMENT
• Definitive management
– Investigation
• Radiological
– X-rays
» Rule of twos
– CT scan
– MRI
» Esp. soft tissue and ligamental injuries
• Others

21. MANAGEMENT
• Definitive treatment
• Goals of treatment
– Preservation of viable soft tissues
– Prevent infection
– Achieve fracture union
– Restore function

22. MANAGEMENT
• Definitive treatment
• Principles of treatment of open fracture
– Antibiotic prophylaxis
– Urgent wound and fracture debridement
– Stabilization of the fracture
– Early definitive wound cover

23. MANAGEMENT
• Definitive treatment
• Antibiotic prophylaxis
– Broad spectrum
– Continued until risk of infection is over

24. MANAGEMENT
• Definitive treatment
• Debridement
– To render the wound free of foreign materials and devitalized tissues,
leaving a clean surgical field and tissue with good blood supply
– Serial debridement
– Done under anaesthesia
– Principles
» Wound extension and exploration
» Removal of devitalized tissue
» Wound irrigation
» Nerves and tendons

25. MANAGEMENT
• Definitive treatment
• Stabilization of the fracture
– Method depends on
» Degree of contamination
» Duration of injury
» Degree of soft tissue damage
» Nature of fracture
» Other associated injuries and
treatment
» Experience of surgeon and
surgical team
» Implant availability
– No contamination, wound cover
achievable- internal fixation
– Contamination, wound cover not
achievable- external fixation

26. MANAGEMENT
• Definitive treatment
• Definitive wound care
– Criteria for primary closure
» All necrotic material
should be removed
» Circulation should be
normal
» Nerve supply should be
intact
» The patient’s general
condition should be
stable
» Wound should be closed
without tension
» No dead space should be
left after closure
– Otherwise, debridement is
done and fracture stabilized
with external fixator
– Second look surgery may be
needed usually within 48-
72hrs but not later than
5days

27. MANAGEMENT
• Rehabilitation
– Immediate objectives of rehabilitation are to prevent muscle atrophy, prevent joint
stiffness and improve circulation in the extremity
– The ultimate objective is to restore the extremity to the greatest degree of function
– A well-organized rehabilitation program initiated early will help return the patient to
a functional status
– This involves
• Physiotherapy
• Occupational therapy

28. COMPLICATIONS OF FRACTURE
• Early complications
– Haemorrhage
– Vascular injury
– Nerve injury
– Compartment syndrome
– Infection
– Haemarthrosis
– Thromboembolic phenomenon

29. COMPLICATIONS OF FRACTURE
• Late complications
– Delayed union
– Non union
– Malunion
– Avascular necrosis
– Growth disturbance
– Bed sores
– Dysuse atrophy
– Joint stiffness
– osteoarthritis

30. PROGNOSIS
• Type of injury
– High-energy vs low-energy
• Location and extent of injury(s)
– To the soft tissues
– To the bone
• Degree of contamination
• Health status of the patient
• Initial treatment

31. PECULIARITY IN OUR ENVIRONMENT
• TBS patronage and its attendant complications is still a big challenge

32. CONCLUSIONS
• Fractures occur daily and may b associated with other life threatening injuries.
Therefore, management of patients should be given a holistic approach
• Management is directed at getting the patient back to functional capacity as early as
possible
• Advocacy/public education is needed to curb the menace of patronizing the TBS

33. REFERENCES
• Selvadurai Nayagam; Principles of fractures, in Apley’s System of Orthopaedics and
Fractures, 9th ed. 2010; 23: 687-732
• Perminder Singh; Extremity Trauma, in Bailey and Love’s Short Practice of Surgery,
26th ed. 2013; 29: 364-384
• P.V. Giannoudis et al; A Review of the Management of Open Fractures of the Tibia
and Femur, in The Journal of Bone and Joint vol. 88-B, No.3, March 2006: 281-289
• U.E. Anyaehie et al; Pattern of Femoral Fractures and associated Injuries in a
Nigerian Tertiary Trauma Centre, in The Nigerian Journal of Clinical Practice vol. 18,
issue 4, Jul-Aug 2015: 462-466

34. REFERENCES
• John Ebenezer; General principles of fractures and dislocations, in Textbook of
Orthopaedics, 5th ed. 2010; 3:15-29
• John Ebenezer; Complications of fractures, in Textbook of Orthopaedics, 5th ed.
2010; 4:30-49
• I.C. Ikem et al; Open Fractures of the Lower Limbs in Nigeria, in The Journal of
International Orthopaedics (August 2001)25: 386-388
• David J. Dandy and Dennis J. Edwards; Principles of managing trauma, in Essential
orthopaedics and trauma, 5th ed. 2009; 7: 93-122