EVALUATION AND MANAGEMENT OF OPEN FRACTURE
- 1. Evaluation and management of open fractures Dr. Bipul Borthakur Professor And Head Department of orthopaedics Assam Medical College Dibrugarh, Assam
- 2. Definition • An open fracture is a fracture in which there is a break in the skin and underlying soft tissues which leads to direct communication of the fracture and its hematoma with the outside environment • When the wound occurs in the same limb segment as that of the fracture , then it must be considered as an open fracture until proven otherwise
- 3. Classification for open fractures 1. Gustilo and Anderson classification 2. AO classification 3. Ganga Hospital open injury score
- 4. Gustilo and Anderson Classification
- 5. • Gustilo and Anderson classification used for most open fractures • The wound classification should be done in the OT • Advantages of classifying the wound in the OT 1. The complete extent of soft tissues injury and viability can be noted 2. Size of the skin injury can be adequately assessed 3. Periosteal stripping can be noticed
- 6. • Limitations of Gustilo and Anderson Classification 1. Inter observer variation 2. Lack of uniformity 3. Doesn’t address the question of salvaging the limb 4. Includes wide spectrum of injuries in Type IIIB 5. Depends on size of the skin wounds
- 7. AO classification • Grade 1 - skin breakage from inside out • Grade 2 – skin breakage from outside in , < 5 cm size with contused edges
- 8. • Grade 3 – skin breakage from outside in , > 5 cm , skin contusion with devitalised edges • Grade 4 – full thickness contusion , abrasion , skin loss
- 9. • Grade 5 – Extensive degloving of the limb
- 10. Ganga Hospital open injury severity score (GHOISS) More commonly used for open tibia fractures
- 11. Aim of the initial treatment 1. Convert an open fracture to a closed fracture as soon as possible 2. Create an environment suitable for fracture union 3. Not hinder secondary procedures 4. Avoid complications 5. Regain function 6. Get good cosmetic outcome as far as possible
- 12. Concept of Early Total Care • Mostly reserved for patients who are hemodynamically stable • The idea is to definitively fix the bone as soon as possible • The concept of ETC has taken a back foot now due to complications . • Newer concept of a staged treatment of patients is followed now which is called Damage Control Orthopaedics
- 13. Damage control orthopaedics • Basic strategies of DCO 1. Immediate and rapid stabilization of long bone fractures 2. Control hemorrhage 3. Release of tight soft tissue compartments 4. Reduction of dislocations 5. Surgical debridement of open wounds 6. Amputation in case of unsalvageable injuries
- 14. • Damage control orthopaedics employs staged treatment 1. Stage 1 – early temporary external fixation and stabilization 2. Stage 2 – resuscitation of the patient in the ICU 3. Stage 3 – delayed definitive management of the fracture • DCO is mainly reserved for patients with severe injuries who cannot tolerate long operations, blood loss , and medullary canal manipulation without deterioration of pulmonary function and hemostasis
- 15. Assessment of the patient • On arrival , patient are assessed and ressucitated according to ATLS protocols • The injured limb is assessed for neurovascular injuries and compartment syndromes • Photographic documentation of wounds undertaken whenever possible
- 16. • If immediate operative intervention planned then vigorous debridement is discouraged • On surgical delay of > 24 hours , irrigation with normal saline done • Gross contamination should be removed • Wound is covered with saline soaked dressings
- 17. • Splintage • Any skeletal trauma to be splinted with the best option available at that moment . • After temporary splintage , stabilization with external fixator or definitive internal fixation is done
- 18. • Prevention of infection • All open fracture wound should be considered as contaminated • Infection is enhanced by – 1. Bacterial contamination 2. Colonization of the wound 3. Presence of dead space with devitalised tissues 4. Foreign materials within the wound • Practice of routine cultures from wound from pre or post debridement is no longer advocated
- 19. • Antibiotic coverage for open fractures 1. Type I and II – first generation cephalosporin 2. Type III – first generation cephalosporin + aminoglycoside 3. Farm yard injuries – penicillins + aminoglycosides • Antibiotics should be started as soon as possible • Recent Studies shown no clear consensus about the type of antibiotics to be used . • Emphasis given on early start of systemic antibiotics with Gram + and Gram - coverage
- 20. • Guidelines for tetanus prophylaxis • Tetanus prophylaxis to be given in the emergency • Current dose of toxoid is 0.5 ml regardless of the age • Toxoid and immunoglobulins given intramuscularly with two different syringes in two different locations • Dose of immunoglobulins < 5 years of age – 75 IU 5 – 10 years of age – 125 IU > 10 years of age – 250 IU
- 21. • The guidelines for prophylaxis depend on 3 factors complete or incomplete vaccination history ( 3 doses ) Date of most recent vaccination Severity of the wound
- 22. Wound management • Assessment of the wound 1. What is the nature of the wound ? 2. What is the state of the skin around the wound ? 3. Is the circulation satisfactory ? 4. Are the nerves intact ?
- 23. • Irrigation and debridement Adequate irrigation and debridement most important steps in open fracture management The most commonly used irrigant is normal saline High pressure irrigation removes more bacteria and necrotic tissues but might reduce bone healing
- 24. The current consensus leans more towards high volume , low pressure lavage repeated adequate number of times in pulsatile manner for better healing and prevention of infection
- 25. • Technique of debridement Wash and drape the wound as for normal surgical procedures Remove devitalized and contaminated tissues until fresh bleeding occurs Remove devitalized fats beneath the flaps Look for 4 C’s – contraction of the muscle, consistency of the muscle, capillary flow, colour of the muscle
- 26. Open the fascia to allow exposure of the muscles , tendons Remove all devitalised muscles and tendons Enlarge the wound for proper debridement and exposure of the fracture
- 27. Retained avascular bone and small devitalised fragments which are to be removed Irrigate the wound with Normal Saline after removal of dead tissues Close the surgically created wound first Loosely close the other wound with a corrugated rubber drain insitu if needed
- 28. • Volume of fluid required for irrigation For type I open fractures – 3 litres For type II open fractures – 6 litres For type III open fractures – 9 litres
- 29. • Serial debridement if needed , planned after 24 to 48 hours from first debridement • Debridement is an urgent procedure • Adequacy of the debridement is more important • • Timing of debridement depends on heamodynamic stability of the patient
- 30. • Fracture stabilization For type I fractures , any technique that is suitable for closed fracture management is satisfactory Upto type IIIA closed internal fixation can be done The method of reduction and stabilization of the fracture depends on 1. Bone that is involved 2. Type of fracture 3. The efficacy of the debridement 4. Patient’s general condition 5. Surgeons choice
- 31. External skeletal fixators • Types Tubular external fixators and dynamic external devices (LRS) Ring external fixators ( Ilizarov , Taylor’s spatial frame ) Hybrid external fixators
- 32. • External fixators are mainly used as temporary stabilizers • Used as definitive treatment when stable fracture configuration with good reduction is achieved • Pin tract infection is the most common complication with external fixators • External fixators are preferred for metaphyseal and diaphyseal fractures
- 33. • Advantages of external fixators 1. Reasonable stability is obtained 2. Reasonable anatomical reduction is possible in most cases 3. Minimal additional soft tissue trauma 4. Chances of infection are minimised 5. Can easily be converted to internal fixation at the appropriate time 6. Proper wound care is possible
- 34. Plate fixation • Indications 1. Most open upper limb fractures 2. Femoral fractures involving periarticular and articular regions 3. All intra articular and juxta articular fractures • Disadvantage • Needs increased soft tissue exposure and stripping of the periosteum
- 35. Intra medullary nailing • Often first choice for lower limb diaphyseal fractures • Suited for type I and type II injuries and some type III injuries with minimal contamination • Role of unreamed nails Advantages 1. Cause less devascularization 2. Shorter operating time 3. Lower incidence of fat embolism and thermal necrosis Disadvantages 1. Increased rate of implant failure 2. Fracture disruption during surgery 3. Higher rate of non union and malunion
- 36. Wound closure • Primary wound closure is controversial but in some cases it has shown good results • Indications 1. Type I , II and III A injuries of the limb 2. Wounds without primary skin loss or secondary skin loss after debridement 3. Injury to debridement interval less than 12 hrs 4. Presence of bleeding wound margins which can be apposed without tension 5. Stable fixation achieved with internal or external fixation
- 37. • Contraindications of primary closure 1. Delayed presentation >12 hours 2. Delayed administration of antibiotics >12 hours 3. Deep seated contamination 4. Immunocompromised patients 5. Nerve injuries 6. Inability to achieve tension free closure 7. High risk of anerobic contamination
- 38. • Concept of reconstruction ladder • The traditional reconstruction ladder concept proposed the reconstruction of tissues in a step wise pattern with increasing complexity as we go up the ladder
- 39. • The older concept of reconstruction ladder was shown to have drawbacks so a new concept has been developed in the recent years which is called Reconstruction Elevator
- 40. • Skin grafting principles 1. Harvest skin from doner site to cover the defect 2. Split thickness skin graft – when the graft includes only portion of the dermis 3. Full thickness skin graft - when a graft contains entire dermis • Split thickness skin grafts can survive in conditions with less vascularity but can develop contracture
- 41. • Flap coverage • Unlike grafts , flaps maintain its own blood supply • Used for large wounds or to cover underlying bone and tendons that may not be managed by graft alone
- 42. • Negative pressure wound therapy • It is beneficial in the treatment of all injuries where soft tissue coverage is not immediately possible and can be done with Vacuum Assisted wound closure ( VAC )
- 43. • Advantages of VAC therapy 1. Promotes wound contracture and increases the chances of delayed primary closure 2. Removes excess edematous fluid 3. Causes reactive increase in blood flow and promotes wound healing 4. Decreases bacterial burden 5. Removes protein and electrolytes that are harmful for healing
- 44. Limb salvage and Amputation • Limb is not viable as evidenced by 1. Irrepairable vascular injury 2. Warm ischemia time > 8 hours 3. Severe crush injury with minimal viable soft tissues remaining 4. Severely damaged limb may constitute a threat to patient’s life 5. The severity of the injury would demand multiple operative procedures and prolonged reconstruction time 6. ISS score > 20
- 45. • A Mangled extremity score ( MESS ) of > 7 accurately predicts the need for amputation • MESS Developed to identify patients who will be benifited by primary amputation The outcome of the limb is either salvage or amputation A score of >/= to 7 is predictive of amputation
- 46. Mangled extremity score ( MESS )
- 47. Summary • Assessment and classification of open fractures should be done intra operatively based on the degree of bacterial contamination , soft tissue damage and fracture charcteristics • To avoid complications the wound should be thoroughly irrigated and debrided • Tetanus toxoid and immunoglobulins should be given in emergency department • Early systemic , wide spectrum antibiotic therapy is to be used to cover both gram positive and gram negative organisms
- 48. • In the presence of extensive soft tissue loss and exposed bone , coverage is accomplished with early transfer of free or local muscle flaps • Stable fracture fixation is important , the method chosen depends on the bone and soft tissue characteristics • Early bone grafting is indicated for bone defects , unstable fractures treated with external fixation , and delayed union
- 49. Thank you