Management of Open fracture

2. ▪

4. ▪ These are the fractures in
which there is break in the
soft tissue envelope over or
near the fracture, such that
fracture haematoma
communicates with external
environment.

5. Review Historical Basis for Management of
Open Fractures
▪ Pierre Desault (1731-1795)
▪ Promoted deepening of
incisions to explore wounds,
remove nonviable tissue,
allow a path for drainage
▪ Coined the term
“debridement”
▪ Stated the sooner
debridement performed, the
less likely an infection would
develop

6. Review Historical Basis for
Management of Open Fractures
Joseph Trueta (1897-1977
The Principles and Practice of War Surgery
1.) Enlargement of the wound to permit
adequate visualization
2.) Assessment of injured tissue for
viability
3.) Excision of all contaminants and all
nonviable tissue
4.) Stabilization of fracture
5.) Establishment of appropriate Drainage

7. Review Historical Basis for
Management of Open Fractures
▪ WorldWar II
▪ Penicillin becomes
readily available by the
end of the war
▪ Widespread use in the
treatment of wounds
from open fractures
with good results

8. Etiology
▪ Direct mechanisms
Motor Vehicle Collisions (MVCs)
firearms
fall from height
▪ Indirect mechanisms
 torsional injuries (sports)
Fall from height
 Extent of trauma directly related to amount
of energy.

9. Epidemiology
▪ Most common causes:
 Crush injuries
 Fall from standing height
 Road traffic accidents
 M:F = 7:3
 Most common bone:
 finger phalanges
 tibia
 Distal radius
• Polytrauma
• 30% of open fractures are in polytrauma patients.

10. Physical Examination
Detailed Patient assessment and
resuscitation
Limb assessment:
• vascular injury
• Motor and sensory function
• Compartment syndrome
• Size of wound
• Degree of soft tissue damage
• Fracture stability
Hard signs forVascular injury
• Diminished or no distal pulses
•Active hemorrhage
• Expanding or pulsatile hematoma
• Bruit or thrill
• Distal ischemia
Soft signs for Vascular injury
• small, stable hematoma
•Anatomically related nerve injury
• Unexplained hypotension
• History of hemorrhage
• Injury proximal to major vessel

11. Methods of Classification
▪ Grading System- Focus on severity of limb injury only.
Ex: Gustilo Anderson,
Tscherne and Gotzen, Bryd and Spicer etc.
▪ Scoring System-Focus on limb injury and general health; also
gives Amputation
Score. Ex: MESS, NISSA, LSI, PSI etc.
▪ Comprehensive System- Combines the above two systems. Ex:
AO System,
Ganga hospital score

12. Gustilo-Anderson Classification: describes open
fractures and their risk of infection according to degree of soft
tissue injury and contamination

13. Gustilo-Anderson Grade I
▪ clean skin opening of
<1cm, usually “poke
hole” from inside to
outside, minimal muscle
contusion, often
associated with low
energy simple spiral or
short oblique fractures
(0-2% infection risk)

14. Gustilo-Anderson Grade II
• Laceration >1cm, more
extensive soft tissue damage
• minimal to moderate
crushing component
• associated with simple
transverse or short oblique
fractures with minimal
comminution (2-5%
infection risk)

15. Gustilo-Anderson Grade III: extensive soft tissue damage
including muscles, skin, and neurovascular structures, any high
energy injury with severe crushing component
Grade IIIA
• extensive soft tissue
laceration, adequate bone
coverage
• segmental fractures, minimal
periosteal stripping, high
energy traumas regardless of
size of wound (crush
component, GSW, farm
injuries, amputations) (5-10%
infection risk)

16. Grade IIIB
• extensive soft tissue
injury with periosteal
stripping and bone
exposure requiring soft
tissue flap closure;
• usually associated with
massive contamination
(10-50% infection risk)

17. Grade IIIC
• >10cm long
• highly contaminated
• Very severe soft tissue
injury with vascular injury
requiring repair; usually
requires reconstructive surgery
for coverage
• May be severely
comminuted (infection risk
25-50%)

19. AO classification

20. Imaging
▪ Obtain X-rays with at least 2 views at 90 degrees to
one another
▪ X-ray the joints above and below the injury
▪ Visible tracking of air from the wound to the
fracture may be visible on X-ray in cases where
open fractures are not obvious
▪ CT of the extremity if intra-articular involvement is
suspected to evaluate for air in the intra-articular
space
▪ CTA in cases of suspected vascular injury on exam

21. Basic Principles of Open Fracture
Management in the Emergency Room
▪ Fracture management begins after initial trauma survey and resuscitation
is complete
▪ Antibiotics
– initiate early IV antibiotics and update tetanus prophylaxis as indicated
▪ Control bleeding
– direct pressure will control active bleeding
– do not blindly clamp or place tourniquets on damaged extremities
▪ Assessment
– soft-tissue damage
– neurovascular exam
▪ Dressing
– remove gross debris from wound
– place sterile saline-soaked dressing on the wound
▪ Stabilize
– splint fracture for temporary stabilization
▪ decreases pain, further injury from bone ends, and disruption of clots

22. Antibiotics
▪ Extent of wound and degree of contamination
▪ Injury environment

23. Basic Principles of Open Fracture
Management in the Operating Room
▪ Gross decontamination
▪ Irrigation and debridement
▪ Stabilization of fracture
▪ Final inspection wound culture
▪ Initial wound coverage

24. 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
on average, 3L of saline are used for each
successive Gustilo type
Type I: 3L
Type II: 6L
Type III: 9L
– bony fragments without soft tissue attachment can
be removed

25. 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

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

27. Goal of external fixation
▪ Definitive fracture treatment
▪ Temporary spanning external fixator
- Until soft-tissue stabilization
- Then change to another fixation
method
▪ Early fracture healing
- Then change to another fixation
method

28. Intramedullary fixation
▪ Literature
• Supports use in open
shaft fractures
• IM better than external
fixator
for definitive treatment
• Timing
• Reamed vs unreamed

29. Plate fixation
▪ Intraarticular and
metaphyseal fractures
▪ Upper extremity
(forearm and humerus)
▪ Femur in ARDS
▪ Plate techniques
- Standard
- MIPO
- LISS
- Locked
- Periarticular

30. Initial wound management
▪ Goal: Cover nerves, vessels, tendons, bone
▪ Avoid: Dead tissues and space, wound tension
▪ Loose re-approximation of skin flaps
▪ Antibiotic bead pouch
▪ VAC dressing
▪ Biological dressing

31. Biological dressings
▪ Semipermeable films
▪ Epigard
▪ Allograft and enografts

32. Second stage management
▪ Antibiotics 24–48 hrs
▪ Repeat debridement 48–72 hrs as needed
▪ Repeat antibiotics 24–48 hrs with repeat
surgery
Soft-tissue coverage
• Condition of the wound
• Location
• Size of the defect
• Tissue available
• Other reconstruction
- Bone
- Joints
- Soft-tissues
• Patient factors
- Age and general health
- Smoking
- Associated vascular
disease
• Expertise of surgical team

33. Staged reconstruction
▪ • Definitive fixation
• Secondary bone procedures
- Bone grafting
- Exchange nailing/fixation
- Bone defect reconstruction
- Joint reconstruction/salvage
• Secondary soft-tissue
reconstruction
- Tendon
- Nerve

34. Rehabilitation
▪ • Of the limb
• Of the injury
• Of the patient
• Of the family

35. Complications
▪ EARLY-Shock
– Compartment syndrome
– Crush syndrome
– Infection and sepsis
– DVT and embolism
– ARF
▪ Late-
– Osteomyelitis
– Non union

36. Summary: open fractures
▪ Evaluation of patient and injury
▪ Initial debridement
▪ Soft-tissue management
▪ Fracture stabilization
▪ Early soft-tissue closure/coverage
▪ Bone and soft-tissue reconstruction
PRN
▪ Rehabilitation

37. References
▪ Adams, J et. al. Rosen’s Emergency Medicine: Concepts and Clinical
Practice. Philadelphia: Saunders/Elsevier; 2014: 511-533.
▪ Egol, KA, et. al. Handbook of Fractures. Philadelphia: Wolter Kluwer; 2015.
▪ Gustilo, RB, Anderson, JT. Prevention of infection in the treatment of one thousand and
twenty-five open fractures of long bones: retrospective and prospective. J Bone Joint
Surg Am. 1976; 58A: 453-458. PMID: 773941
▪ Jedlicka, N, et. al. Overview of concepts and treatments in open fractures. Clin. Podiatr
Med Surg. 2012: 29(2). PMID: 22424488
▪ Kanakaris, NK, Giannoudis, PV. “Open Fractures.” Trauma and Orthopaedic
Classifications: A Comprehensive Overview, 2014: 487-493.
▪ Konda SR, Davidovitch RI, Egol, KA. Open knee joint injuries: an evidence-based
approach to management. Bull Hosp Jt Dis. 2014;72(1):61-9. PMID: 25150238
▪ Mauffrey, C, et.al. Acute Management of open fractures: proposal of a new
multidisciplinary algorithm. Orthopedics. 2012; 35:10. PMID: 23027477
▪ by Alexandra Ortego, MD