4. Primary survey
• A : Can talk, not tender along c-spine
• B : Spontaneous breathing, equal breath sound, CCT -ve
• C : BP 78/48 mmHg, PR 92 bpm,
active bleeding from LW at Rt elbow
• D : E4V5M6 , pupil 2 mm RTLBE
• E : large LW 20cm deep to bone at Rt elbow
5. Adjunct Primary survey
• on O2 mask c bag
• NSS 1000 ml V load in 15 min (ได้ NSS จากรพช.มาแล้ว 3000 ml)
BP หลัง load 103/68
• Hct stat = 11
• G/M group O low titer 2 u v free flow
• Retain Foley, NG
• FAST –ve at 16.20
• Pressure dressing wound, on splint Rt arm&forarm
6. Secondary survey - History
• A : ปฏิเสธประวัติแพ้ยาแพ้อาหาร
• M : ปฏิเสธประวัติยาใช้ประจา
• P : ปฏิเสธประวัติโรคประจาตัว
• L : NPO 10.00
• E : ถูกมีดตัดฟืนฟันที่แขนขวา
7. Secondary survey – Examination(1)
• Head & Maxillofacial:
No wound, No facial deformities, no ecchymosis
• C-spine & Neck:
no wound, can move neck, C-spine not tender
• Chest:
Equal breath sounds, CCT -ve
• Abdomen & Pelvis:
no wound, bowel sound positive, soft, not tender
8. Secondary survey - Examination(2)
• Musculoskeletal:
Deformities of Rt arm&forarm ,
large laceration wound 20 cm deep to bone at Rt elbow(dorsum) with bone fracture,
Radial pulses 2+ both, capillary refill < 2 sec, sensory cannot evaluate due to pain
Rt wrist can flex but cannot extend, All finger can flex and extend
• Neurologic:
GCS: E4V5M6
CN: pupils 3 mm RTLBE, full EOM, no facial palsy
Motor: grade V all except Rt arm cannot evaluate
• Perineum/Rectum: no ecchymosis
15. Diagnosis
• Open comminuted fracture at Rt distal humerus
• Open fracture both bone Rt forarm
Gustilo and Anderson classification IIIA
16. Management
• Resuscitation
• Pre-operative lab
• Set OR for Debridement + EF span elbow
• Antibiotic: cefazolin 1 g iv q6 hr c stat
• Consult trauma: R/o vascular injury
17. Post-operative
• Routine post operative care
• Pain control
• Serial Hct
• Antibiotic: Cefazolin 1 g iv q 6 hr
Gentamycin 240 mg iv OD x3 days
PGS 3million unit iv q 6 hr
20. Definition
• Open fracture is defined as one in which the fracture
fragments communicate with the environment through
a break in the skin
21. History in open fractures
• Mechanism of injury
– Date, time, type, method of impact, …
• Consciousness
• Size of wound
• Amount of bleeding
• Other injuries: often missed
• Anti-Tetanus status
22. Classification
“Gustilo and Anderson classification”
• Based on
1) Size of wound
2) Amount of soft tissue injury
3) Presence/absence of NV injury
4) Degree of contamination
25. Gustilo Grade I
• Low energy
• Simple fracture
• Skin open by fragment pressure
• Wound < 1 cm
• No / little contamination
www.orthopaedicsone.com/
26. Gustilo Grade II
• Higher energy
• Laceration > 1 cm
• No flap / No contusion
• Minimal contamination
30. Higher infection rate
Increased contamination
– Exposure to soil
– Exposure to water
– Exposure to fecal material
– Exposure to oral material
– Gross contamination
– Delay > 12 hours
31. Principal of treatment
• Antibiotic prophylaxis
• Urgent and proper wound and fracture debridement
• Stabilization of the fracture – External Fixation
• Early definitive wound cover
32. Management
• Gustilo I, II - Can treat by primary internal fixation
• Gustilo IIIA - Usually defer internal fixation until soft tissue condition allows
• Gustilo IIIB - External fixation
- Later, internal fixation
• Gustilo IIIC - Vascular repair is a priority
- External fixator
Grade I
Low-energy, minimal soft-tissue damage
wound < 1cm
Grade II
Higher energy, no flaps needed / no crushing
Moderate contamination
wound > 1cm
Grade III
High-energy, flaps needed / crushing
Significant contamination
Type IIIA : Adequate soft-tissue cover
Can cover skin primarily
Type IIIB: Inadequate cover
Can not cover skin primarily
May need skin graft or flap
Type IIIC: Vascular injury
Requires vascular repair
