3. Primary Survey at MNRH
• A : Can speak, Full ROM of neck, No C-spine tenderness
• B : Trachea in midline, Equal breath sound, RR 20/min,
Chest compression test negative
• C : BP 125/89 mmHg, PR 82 bpm, Pelvic compression test negative
• D : E4V5M6, Pupil 2 mm RTLBE
• E : Laceration wound 3 x 1 cm at dorsum of right foot, No deformity,
No active bleeding
4.
5.
6. Secondary Survey
• A : No history of food and drug allergy
• M : No current medication
• P : No underlying disease
• L : Last meal 1 hour before go to hospital
• E : As present illness
9. Physical Examination
• V/S : Temp 36 c, BP 125/89 mmHg, HR 82 bpm, RR 14 /min
• GA : A Thai man, Good consciousness
• HEENT : No pale conjunctivae, Anicteric sclerae
• Neck : Active movement
• Heart : Normal S1 S2 no murmur
• Respiratory : Normal breath sound, Equal both lung
• Abdomen : Soft, not tender, Normoactive bowel sound
10. Physical Examination
• Extremities : Rt. Foot - Laceration wound size 3 x 1 cm. at lateral side
in dorsum of foot, No active bleeding,
no fat globule seen, no deformity
- Motor : Limit due to pain but can
dorsi/plantar flexion, eversion and
inversion
- Sensory : intact
- Capillary refill : 2+
: Others - WNL
13. Warning sign
Open fracture
Deformity
Bone penetrate fracture site
Fat globule
Unstoppable bleeding
Wound near fracture site
a fracture with direct
communication to the
external environment
17. Antibiotics
• Type I & II - 1st generation cephalosporin
- Clindamycin or Vancomycin can also be used if allergies
• Type III - 1st generation cephalosporin + Aminoglycoside
Duration - Initiate as soon as possible
- Continue 24 hours after initial injury
if wound is able to close primarily
- Continue until 24 hours after final closure
if wound is not closed during initial surgical debridement
21. Stabilization
• Splint fracture for temporary stabilization
• Assess soft tissue damage and neurovascular injury
decreases pain,
further injury from bone ends,
and disruption of clots
22. Basic Principles of Open Fracture
Management in the Operating Room
• When ?
- as soon as possible ( emergency )
• How ?
- Debridement
- Irrigation
- Fracture stabilization
- Wound closure
23. Basic Principles of Open Fracture
Management in the Operating Room
• Aggressive debridement and irrigation
- Thorough debridement is critical to prevention of deep infection
- Low and high pressure lavage are equally effective in reducing
bacterial counts
- Saline shown to be most effective irrigating agent
- Bony fragments without soft tissue attachment can be removed
Type I – 3 L Type II – 6 L Type III – 9 L
24. Basic Principles of Open Fracture
Management in the Operating Room
• Fracture stabilization
- can be with internal or external fixation, as indicated
• Staged debridement and irrigation
- performed every 24 or 48 hours as needed
• Early soft tissue coverage or wound closure is ideal
- increased risk of infection beyond 7 days
25. Basic Principles of Open Fracture
Management in the Operating Room
Type Recommendation fixation
Grade I Any device suitable for the fracture
Grade II Intramedullary nail
Grade IIIA Intramedullary nail
Grade IIIB External fixator
Grade IIIC External fixator
