Management of open fracture true ppt
- 3. ▪ 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.
- 4. 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
- 5. 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
- 6. 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
- 7. 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.
- 8. 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.
- 9. 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
- 10. 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
- 11. Gustilo-Anderson Classification: describes open fractures and their risk of infection according to degree of soft tissue injury and contamination
- 12. 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)
- 13. 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)
- 14. 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)
- 15. 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)
- 16. 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. 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
- 20. 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
- 21. Antibiotics ▪ Extent of wound and degree of contamination ▪ Injury environment
- 22. 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
- 23. Aggressive debridement and irrigation – thorough debridement is critical to the prevention of deep infection – low and high-pressure lavage are equally effective in reducing bacterial counts – saline showed to be a most effective irrigating agent on average, 3L of saline is used for each successive Gustilo type Type I: 3L Type II: 6L Type III: 9L – bony fragments without soft tissue attachment can be removed
- 24. 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
- 25. External fixation ▪ Soft-tissue management ▪ Severe contamination ▪ Extensive bone loss ▪ Vascular injury ▪ Unstable - Dislocation or fracture dislocation ▪ Complex periarticular fracture ▪ Poly-trauma
- 26. 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
- 27. Intramedullary fixation ▪ Literature • Supports use in open shaft fractures • Intramedullary better than external fixator for definitive treatment • Timing • Reamed vs unreamed
- 28. Plate fixation ▪ Intra-articular and metaphyseal fractures ▪ Upper extremity (forearm and humerus) ▪ Femur in ARDS ▪ Plate techniques - Standard - The minimally invasive plate osteosynthesis (MIPO) - Less invasive stabilization system (LISS) - Locked - Periarticular
- 29. 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
- 30. Biological dressings ▪ Semipermeable films ▪ Epigard ▪ Allograft and enografts
- 31. 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
- 32. Staged reconstruction ▪ • Definitive fixation • Secondary bone procedures - Bone grafting - Exchange nailing/fixation - Bone defect reconstruction - Joint reconstruction/salvage • Secondary soft-tissue reconstruction - Tendon - Nerve
- 33. Rehabilitation ▪ • Of the limb • Of the injury • Of the patient • Of the family
- 34. Complications ▪ EARLY-Shock – Compartment syndrome – Crush syndrome – Infection and sepsis – DVT and embolism – Acute kidney failuer (ARF) ▪ Late- – Osteomyelitis – Non union
- 35. 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 ▪ Rehabilitation
- 36. 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