KIRU OPEN FRACTURES from Bapras guideline
- 1. Comprehensive Approaches to Managing Open Fractures” Dr. S Kirushanth (Registrar – Surgery)
- 2. Definition • A fracture, where the fracture hematoma communicates with the external environment via a traumatic violation of the soft tissue and skin Open fractures are associated, • High-energy trauma • Thus, associated systemic injuries • Significant soft tissue injury • High risk of infection due to contamination
- 5. • According to ATLS principles C (Overt bleeding) ABDE • Identify limb-threatening injuries • Vascular injuries to limb • Compartment syndrome (10% open fracture can have compartment Xn) • If there is doubt about an open fracture, it is safer to proceed as though open until proven otherwise ALWAYS!!!!! 1. Life 2. Limb 3. Function
- 6. 1. Gross contamination is removed manually (no washing) 2. Photographed 3. The limb is re-aligned 4. Covered with a sterile saline-soaked dressing 5. Splinted
- 7. A ‘mini debridement’ of the open fracture in the emergency room does not aid treatment. (Lavage through the open wound serves to drive particulate debris further in !!!!) Antiseptics in the dressing should not be used !!
- 8. Assessment of the limb Distal neurovascular status should be assessed & documented (and repeated after each intervention – e.g. – splinting) IF ABSENT - REALIGNMENT Look for features of compartment syndrome Analgesics
- 9. Antibiotic (first most important intervention in reduction of future wound infection) • Majority of deep infections were caused by nosocomial organisms, most being resistant to the initial antibiotic prophylaxis aimed at environmental flora Two-phase antibiotic protocol • co-amoxiclav (1.2 g) 8-hourly intravenously (iv) or • an intravenous cephalosporin, e.g. ceftriaxone 2 g daily • Penicillin allergy – IV Clindamycin 900mg 8-hourly (+ Gentamicin 3mg/kg single dose for presumed Gustilo grade III fractures) • Known or high risk of MRSA – IV Teicoplanin 800mg daily (Extra loading dose after 12h) Phase 1 – within 1 hour of injury
- 10. • Singe dose of IV Gentamicin 3mg/kg should be added to the above (Unless the patient has already received gentamicin within the past 16h) • Further dose of co-amoxiclav intraoperatively if, • Major blood loss (>10% of blood volume) • If the procedure lasts for more than 3 hours • Do not give additional doses of once-daily antibiotics unless it has been more than 16h from the last dose • Following wound excision phase 1 should be continued for 24h At first wound excision on induction of anaesthesia
- 11. • Phase 2 • At the time of definitive skeletal stabilization and soft tissue coverage • Teicoplanin 800mg (if not been given within the past 12h) PLUS • Gentamicin 3mg/kg (If not been given within the last 16h) (This will provide cover for organisms selected out from initial prophylaxis & Nosocomical pathogens) • No further post-operative antibiotics are required
- 12. Thromboprophylaxis 58% of patients with major trauma develop venous thromboembolism Risk population • Advanced age • obesity All patients must be considered for thromboprophylaxis. • Low molecular weight heparin (i.e. enoxaparin) is preferred Although caution is needed where patients are coagulopathic or there may be bleeding from associated vascular, intracranial, or visceral injuries
- 13. Imaging • X Rays- • Two views obtained should be orthogonal to each other • Include joints above and below the injured segment. • Angiography – • Should not delay emergency revascularization of an ischemic limb • Immediate surgical exploration and shunting is indicated if hard signs of vascular injury persist after any necessary restoration of limb alignment and joint reduction.
- 14. Tetanus Prophylaxis If given with 5 year No further immunization needed Given 5 – 10 years Booster dose is given Not given within 10 years 1. Vaccine + 2. Immunoglobulin
- 16. Multiple scoring systems……!!!!! The most widely used scoring systems are •Mangled Extremity Severity Score (MESS) •Mangled Extremity Syndrome Index (MESI) •Predictive Salvage Index (PSI) •Limb Salvage Index (LSI) •Ganga Hospital Open Injury Severity Scoring (GHOISS)
- 17. Most commonly used scoring system worldwide <6 – Salvagable >7 – Amputation The disadvantage is that it gives more emphasis on limb ischaemia but less importance to soft tissue injury.
- 19. Do not base the decision on whether to perform limb salvage or amputation on an injury severity tool score. Ideally, decisions regarding salvage or primary amputation of a severely injured limb should be made jointly by an orthopedic and plastic surgeon with appropriate experience of limb salvage surgery and with careful counselling of the patient their family members about likely outcome with the two treatment option.
- 21. Gustilo’s classification of open fractures into three types is widely used for this purpose (Gustilo et al., 1984) If the limb can be salvaged, subsequent treatment is determined by the Type of fracture, Nature of the soft-tissue injury (including the wound size) Degree of contamination.
- 30. Timing of wound debridement If any limb threatening condition(GA IIIc) Highly contaminated open fractures (Marine, agricultural and sewage contamination) High-energy open fractures (likely Gustilo–Anderson classification type IIIA or type IIIB) that are not highly contaminated All other open fractures (Type I & II) Immediate WD Immediate WD within 12 hours of injury Within 24H WD
- 31. Who should do wound Debridement? • Wound debridement should be done by the most experienced senior plastic and orthopedic surgeons working together
- 32. Principles of WD • Dressings applied in the emergency room should only be removed when the patient is in the operating theatre. • After induction à a ‘prewash’ of the limb is performed with a soapy chlorhexidine solution • After the prewash à the patient is then transferred to the operating table and limb prepped & draped for surgery in the standard manner (No betadine on wound) • Tourniquet use is determined by surgical preference • Gentamycin single dose of 3mg/kg is given at the time of WD (not on admission)
- 33. Debridement should be from systematically in turn from superficial to deep, layer by layer, peripheral to central. Non-viable skin à excised to leave edges that bleed from the dermis Subcutaneous fat à needs wider excision compared to skin Wound extension? à always along fasciotomy lines. This incision does not disturb skin perforators (important for flap cover later). Subcutaneous Tissue Deep Fascia Muscle Bone
- 34. • Muscle à viability four ‘C’s; • Color (pink not blue), • Contraction • Consistency (devitalized muscle tears in the forceps during retraction) • Capacity to bleed. Devitalized muscles need to be excised. • Bone - Gently deliver the bone ends through the wound - Clean edges. Then nibble the bone ends until capillary bleeding (punctate bleeding) from exposed cortical surfaces (paprika sign) - Loose fragments of bone which fail the ‘tug test’ are removed - Bone fragments that do not dislodge with viable soft tissue attachments are left • Low- pressure lavage with a high volume of 0.9% saline completes the wound excision.. (3L – 12L)
- 35. Management / Reconstruction of bone and Soft tissues
- 37. • So, ideally, open fractures should be managed in a single sitting, with cleaning of the wound, wound debridement, fracture fixation and soft tissue closure • This immediate definitive treatment has been termed ‘fix and flap’ • However, immediate stabilization and cover is only possible if surgeons with orthopedic and plastic surgical expertise are both present at the time of initial surgery. “This should result in the lowest free flap failure and deep infection rates (No time for wounds to become colonized)”
- 38. Management of Soft tissues Soft tissue Management GA Type I GA Type II GA Type III immediate fracture stabilization and primary soft tissue cover Local/Distal flap SSG (Primarily sutured (after debridement), provided this can be done without tension) Both orthopedic and plastic surgeons are satisfied with a clean, viable wound achieved after debridement
- 39. • The definitive soft tissue coverage cannot be achieved at the time of initial debridement in the following instances, • Unable to achieve a clean, viable wound after debridement (e.g. – severe contamination) • No plastic surgical expertise is available • Patients is not physiologically well enough to tolerate prolonged surgery and will require temporization of their injuries (Damage Control Orthopaedic)
- 40. Definitive soft tissue coverage cannot be achieved Fracture is temporarily stabilized externally and dress with a temporary impervious dressing Second look procedure for definitive coverage or closure should be performed within 72 hours and not later than 5 days Gentamicin 3 mg/kg dose is combined with either vancomycin 1 g or teicoplanin 800 mg on induction of anesthesia
- 41. Management of bone If there is 1. No obvious contamination 2. Minimal contamination 3. Definitive wound cover can be achieved at the time of debridement open fractures of all types can be treated as for a closed injury.
- 42. Bone Fixation GA Type I GA Type II GA Type III If your happy with your wound debridement and tissue cover can be achieved Internal fixation (Primarily Internal fixation) “This is because open fractures are only contaminated and not infected”
- 43. Definitive soft tissue coverage cannot be achieved External fixation can be used as a temporary measure The external fixator may be exchanged for internal fixation at the time of definitive wound cover as long as: (1) The delay to wound cover is less than 7 days (2) Wound contamination is not visible.
- 44. After care
- 45. In the ward, the limb is elevated and its circulation carefully watched. Antibiotics are continued accordingly Optimize general condition of patient (Hb, Nutrition, etc.) Start rehabilitation
- 47. SOURCES • The Standards for the Management of Open Fractures of the Lower Limb – BAPRAS, BOA 2020 • Classification and management of acute wounds and open fractures- Surgery International Article • Apley and Solomon’s System of Orthopedics and trauma(10th edition) • https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/further- reading/principles-of-management-of-open-fractures
- 48. Thank you