Open fracture

1. AO Foundation
Education
Management of Open Fracture
Dr. Zaw Min Htet
Assistant Lecturer
Orthopaedic Department
University of Medicine (2)

2. Definition & Cardinal Signs of Fracture
Fracture is a break in the structural continuity
of the bone. ( complete or incomplete break in the
cortex, with or without displacement )
Five cardinal signs of fracture
1. Deformity
2. Local bony tenderness,
3. Crepitus,
4. Abnormal movement,
5. Loss of function
2

3. Definition of open fracture
An open fracture is one in which a break in the
skin and underlying soft tissues leads directly into
or communicates with the fracture and its
haematoma to the external environment
3

4. Diagnosis of an open fracture can be difficult
because the wound may be a considerable distance
from the fracture site.
When a wound occurs in the same limb segment as a
fracture, the fracture must be considered open until
proved otherwise.
4

5. Open fracture is an
orthopaedic emergency
5

6. 6
An open fracture is a soft-tissue injury
which also involves the bone

7. Management
( A ) At the scene of accident
( B ) At the A & E Department
( C ) At the Orthopaedic Department
7

8. ( A ) At the Scene of Accident
• Irrigate the wound with large amount of
available water
• Cover and bandage the wound with clean cloth
• Splint the effected limb
• Elevate the effected limb if there is active or
profuse bleeding
• Transfer the patient to the nearest trauma
center
8

9. ( B ) At the A & E Department
(1) Follow ATLS protocol
(a) Primary survey
- Airway with cervical spine control
- Breathing and ventilation
- Circulation with haemorrhage control
- Disability ( neurological exam. ) ; ( AVPU )
Alert, response to Voice, response to Pain,
Unresponsiveness
- Exposure with awareness of the patient’s
body temperature
9

10. (b) rapid h/o taking ( AMPLE )
Allergies, Medications currently used, Past
illness / Pregnancy, Last meal, Events /
Environment
(c) Secondary survey
(i) detailed h/o
about mechanism of injury, time & place
of injury, pre-hospital care received,
occupation, handedness & personal h/o,
family status, socio-economic status
10

11. ( ii )Detailed physical examination
General examination – GCS, vital signs ( BP,
PR, RR, U.O, pain ), nutritional status
Local examination - contamination,
- condition of soft t/s & bone,
- articular involvement
- distal neurovascular status
11

12. • Photograph of the wound
• Bacteriological swab
• Saline soaked dressing
• Provisionally splint the fracture
• Tetanus prophylaxis
• Broad spectrum antibiotics

13. 13
Choice of Antibiotics
• Extent of wound and degree of contamination
• Injury environment
• Practice protocols
• Coamoiclav or cephalosporin (cefuroxime)
• Aminoglycoside(gentamycin)
• Penicillin (farm/soil)
• Clindamycin for penicillin allergy

14. (iii) Imaging
(X-ray )
- including proximal one joint & distal one joint,
- anteroposterior, lateral or oblique or other
special view
- two limbs if needed
Computerized tomography
- especially if fracture pattern is complex or
intra-articular involvement
14

15. 15

16. Gustillo-Anderson classification of open
fractures (1984)

18. 18

19. 19

20. ( C) At Orthopaedic Department
- wound debridement
- stabilization of fracture
- early wound cover
- Secondary/tertiary reconstruction
- Rehabilitation
20

21. Wound Debridement
• Aim
- to get rid of foreign material and dead tissue
- leaving a good blood supply throughout
• Under appropriate anesthesia

22. Steps
1. Wound excision—
• The wound margin excised
• Only enough to leave healthy skin edge
2. Wound extension—
• Adequate exposure for thorough cleaning
• Plan not to disturb further definite operation
3. Wound cleansing—
• Carefully remove all foreign materials and
tissue debris

26. Removal of devitalized tissues–
• Dead muscles - lack of 4 C’s
• Color
• Consistency
• Contractility
• Capacity to bleed
• Detached bone- removed
Tendons and nerves—
• Sutured if available necessary expertise
• Otherwise, tagged to the nearby structure

27. Blood vessels—
• Immediate ligations or coagulation for small
vessels and arterial bleeders
• Vascular repair for major vessel
Bone—
• Remove small detached bone
• Preserve large bone fragment with muscle
attachment
Joints—
• Arthrotomy and joint debridement
• Synovium closed back

28. Wound closure
• All open wounds- left open
• Until the danger of tension and infection
passed
• Wound- lightly packed with sterile gauze
• Inspected after 2 days
• Suture or skin graft if cleaned
• Type III wounds- may need further
debridement, plastic surgery, and muscle flap
operation

29. 29
Antibiotic bead pouch
• Antibiotic-PMMA beads
• Occlusive dressing
• Useful in large wounds
• Dead space control
• High local antibiotic
concentration
• Seal wound from
external contamination

30. 30
VAC Dressing
• Closed system
• Ongoing debridement
• Wound size
• Tissue edema
• Excellent for
staged coverage

31. VAC / NPWT Dressing
31

32. Sural fasciocutaneous flap
open distal Tibia # fixed with IMNail
32

33. Stabilization of fracture
• The methods of fixation depends on-
- degree of contamination
- the length of time from injury to operation
- the amount of soft tissues damage
• Methods- POP slabs, POP casts
- external fixation
- intramedullary nailing
• Depending on characteristics of fracture and
the wound

34. 34
Initial fracture stabilization
• Temporary vs definitive
• External vs internal fixation vs combination
• Anatomical site of injury
• Degree of contamination
• Status of the wound and soft tissues
• Other associated injuries and treatment
• Experience of surgeon and surgical team
• Implant availability

35. 35

36. 36

37. 37

38.  After initial debridement, separate prep and
drape is generally performed before fixation.
 After separate prep and drape, the bone is
stabilized.
 In this case, the initial stabilization is with a
spanning external fixator, with the plan of
definitive fixation at a later date.

40. 40
External fixation
• Soft-tissue management
• Severe contamination
• Extensive bone loss
• Vascular injury
• Unstable
• Dislocation or fracture dislocation
• Complex periarticular fracture
• Polytrauma

41. After care
• Elevate and carefully watch the limb
• Shock- may still required treatment
• Continue antibiotic injection
• Culture – if the wound open
• A different antibiotic is substituted if necessary

42. 42
Rehabilitation
• Of the limb
• Of the injury
• Of the patient
• Of the family

43. Complications of open fracture
Skin—
• Skin loss or contracture
Bone–
• Sequestrum & sinuses (chronic
om)
• Delayed union and non-union
Joints—
Ankylosed joints

44. Compartment Syndrome
“Compartment pressure rises to a level that
decreases perfusion”
•Diagnosis;
• High index of suspicion in trauma patients
• Pain out of proportion to that expected (5
Ps)
•Treatment;
• Emergency fasciotomy

45. 45
Take home message
• Assess soft tissue injuries well
• Management-consider bones and soft tissues
• Vigilant for compartment $/manage
aggressively
• Open fractures-expert multidisciplianry care
• Think of the patient