Management of open fractures final
- 1. MANAGEMENT OF OPEN FRACTURES Dr Abhishek Pathak Asso Prof Orthopaedics GMC Bhopal
- 2. OPEN FRACTURES • Fracture- Discontinuity of bone • An open fracture is one in which break in the skin and underlying soft tissue leads to communication of fracture hematoma to external environment. • Open fractures are also known as compound fracture
- 3. ETIOLOGY
- 4. HIGH ENERGY TRAUMA • Caused by high energy trauma most commonly from direct blow by road traffic accident or fall from hieght. • These fractures can be caused by high energy twisting injuries.
- 5. CRUSH INJURY • a force is applied to an immobilized portion of the body. • Causes Muscle ischaemia due to occlusion of blood vessels by pressure • When blood flow is restored causes reperfusion injury – due to circulation of myoglobin –can damage kidney, brain & lung function • CRUSH Syndrome
- 6. Gun Shot injury • Effectiveness depends on dissipation of energy to local soft tiisue • Most of time extent of soft tissue damage more than size of wound
- 7. Blast Injury • Supersonic shock wave causing extensive damage • Higher severity score • Shear forces ripping muscle tendon nerves vessels apart
- 8. Epidemiology • Usually diaphyseal • Tibia commonest
- 9. Etiology • High energy trauma so – Severe bony and soft tissue involvement – Decreased blood supply – Contamination – Degloving
- 10. Open Fractures Treatment = amputation Mortality 75% Function in “survivors” poor
- 11. Prognosis • Outcome is improved – Intensive care management – Availablity of powerful antibiotics – Radical debridement – Immidiate bony stablisation – Early soft tissue involvement
- 12. CLASSIFICATION The classification of open fractures is most reliably done in the operating room at the completion of primary wound care and debridement.
- 13. Gustilo and Anderson classification • relatively simple • It has been validated with regard to time to union, incidence of nonunion, and the need for bone grafting. major disadvantage • not accurate • Subjective nature of injury description resulting in high interobserver variability
- 14. Gustilo and Anderson classification Grade 1 < 1 cm clean wound, with a simple fracture pattern. Grade 2. > 1 cm wound and a low energy fracture pattern Grade 3 high-energy or crush injuries with extensive muscle damage.
- 15. Gustilo and Anderson classification Grade 3A . has adequate bone coverage by local soft tissues. Grade 3B has soft-tissue loss over the bone with some contamination or periosteal stripping, which requires a local or free tissue transfer. Grade 3C is an arterial injury, requiring repair, associated with any fracture pattern
- 16. Goals in the treatment of open fractures • The treatment of high-energy injuries aims at preserving life, limb, and function, in that order of priority. • The intermediate objectives are: • Prevention of infection • Fracture stabilization • Soft-tissue coverage
- 17. • Evaluation entire patient – injury protocols (ATLS) • Evaluation limb – complete evaluation (as possible) – wound covered & limb splinted- “one look” – antibiotics – tetanus “prophylaxis” ANALGESIA • Preoperative planning
- 18. Stages of care
- 19. Initial assessment • Important components in assessing traumatized extremity 1. History and mechanism of injury 2. Neurovascular status 3. Size of skin wound 4. Muscle crush or loss 5. Periosteal stripping or bone loss 6. Fracture pattern, fragmentation 7. Contamination 8. Compartment syndrome
- 20. Primary surgery
- 22. Irrigation • Supplements systemic debridement in removing foreign material and decreasing bacterial load. Fracture type Vol of fluid used for irrigation Type I 3 L Type 2 6L Type 3 9L
- 23. Irrigation 2 adages…. • If a little does some good, a lot will do a great deal more • solution to pollution is dilution
- 24. Irrigation • NS normally used for irrigation. • Antibiotic solution is no better than soap for open fracture irrigation • Antiseptic solutions have been not shown to decrease infection rates. • Surfactant(non sterile soap) same effectiveness, less tissue damage n more economical.
- 28. Timing of debridement and irrigation • Most guidelines recommend debridement within 6 hrs. • Scientific evidence for 6 hour rule is lacking and a little delay for better team coordination improves results • Serial debridement may be necessary every 24-48hrs until the wound viability is ensured
- 31. extent of wound & degree of contamination injury environment practice protocols cephalosporin + aminoglycoside (or alternative gram (-) coverage for gross soft tissue damage + metronidazole (farm/soil/ischemia) Antibiotics
- 32. Antibiotics • Early administration of antibiotics is associated with improved outcome (<3 Hrs) • Antibiotics should be continued for atleast 24 hours after primary wound closure in type I and II fracture and 72 hours in type III fractures.
- 33. Tetanus prophylaxis • Tetanus Toxoid(TT), dose is 0.5ml i.m. regardless of age • Immunoglobulin • 75IU <5yrs of age • 125IU 5-10yrs • 250IU >10yrs
- 34. RE-prep & drape between 1, 2, 3 Stages of surgical treatment—the plan • gross decontamination • irrigation & debridement • stabilization of fracture • final inspection wound culture ?? • initial wound coverage
- 35. Operative treatment: “extend the wound" • zone of injury • may need atypical incisions • consider – fracture treatment options – soft tissue coverage & reconstruction options • REMEMBER— I & D is 1st priority
- 36. Zone of injury • Wound is merely a window through which a wound communicates with exterior • Zone of injury may be much larger
- 37. Systematic wound debridement • remove debris • remove non-viable soft tissues • layer by layer • tourniquet used only if major bleeding • Experienced surgeon! • inexperience under-debridement
- 38. • The initial surgical management should be performed by an experienced surgeon: inadequate initial debridement has been shown to contribute to poor outcomes following open fractures.
- 39. Bone debridement • Remove avascular, contaminated fragments • Protect soft tissue attachments • Retain key bone fragments ? – articular surface • Re-evaluate “crucial tissues” at 2nd debridement
- 40. Gravity Irrigation Minimum six liters Choice of fluid is probably irrelevant The solution to pollution is dilution Operative treatment: irrigation
- 41. Initial fracture stabilization • Choice of stabilization technique depends on many factors – anatomic site of injury – degree of contamination – status of the wound and soft tissue(s) – other associated injuries & treatment – experience of surgeon & surgical team – implant availability
- 42. Fracture stabilization—external fixation Allows easy access to soft tissues but may interfere with subsequent flap placement Safest option in cases with severe contamination or when there is a delay in presentation Fast application allows speedy vascular injury repair Speed of application is advantageous in cases of poly-trauma
- 43. Goal of external fixation • definitive fracture treatment ? • temporary? – until soft-tissue stabilization – then change to another fixation method
- 44. Fracture stabilization - Intramedullary fixation • Literature – supports use in open shaft fractures – IM “better” than ex fix for definitive treatment – timing – reamed vs unreamed—no clear evidence – Do NOT treat with immediate ORIF unless you are sure of adequate debridement and you are SURE of getting definitive soft tissue cover with 72 hours
- 45. antibiotic bead pouch VAC dressing Initial wound management • Goal: cover nerves, vessels, tendons, bone • Avoid: dead tissues & space, wound tension
- 46. Antibiotic bead pouch • Antibiotic-PMMA beads • Occlusive dressing • Useful in large wounds – dead space control – high local antibiotic concentration – seal wound from external contamination
- 47. Closed system Ongoing debridement wound size tissue edema Excellent for staged coverage VAC Dressing
- 50. Second stage management • antibiotics 24–48 hrs • repeat debridement 48–72 hrs as needed
- 51. Open fracture with arterial injury • The factors that are important in the decision making include: • General condition of the patient (the presence of shock) • Warm ischemia time (more than 6 hours) • Age of the patient (older than 30 years) • Cut to crush ratio (blunt injuries have a large zone of crush)
- 52. Open fracture with arterial injury • Fasciotomy is usually mandatory following an arterial repair, as reperfusion will result in swelling and can cause a compartment syndrome. Fasciotomy early in the procedure is recommended as this facilitates surgical exposure of vessels and bone.
- 53. Summary: open fractures • Evaluation of patient and injury • Initial debridement! • Soft tissue management! • Fracture stabilization • Early soft-tissue closure/coverage • Bone & soft tissue reconstruction PRN • Rehabilitation
- 54. THANKS