Management of open fractures
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This document discusses the management of open fractures. It defines an open fracture as one where the skin and soft tissue is broken, communicating with the fracture site. Initial management involves assessing injuries, covering wounds, antibiotics, and debridement to remove dead tissue. Fractures are then stabilized, either externally or internally. Wounds are closed primarily if possible or allowed to heal secondarily. Complications can include early issues like infection or late problems like nonunion. Grading and scoring systems help determine prognosis and need for amputation. The goal is always limb salvage when possible.
Management of open fractures
- 1. Management ofManagement of Open FracturesOpen Fractures
- 2. IntroductionIntroduction An open fracture is one in which a break inAn open fracture is one in which a break in the skin and underlying soft tissue leadsthe skin and underlying soft tissue leads directly into or communicates with thedirectly into or communicates with the fracture and its hematoma.fracture and its hematoma. When wound occurs in the same limbWhen wound occurs in the same limb segment as a fracture, the fracture mustsegment as a fracture, the fracture must be considered open until provenbe considered open until proven otherwise.otherwise.
- 4. Methods of ClassificationMethods of Classification Grading System- Focus on severity of limbGrading System- Focus on severity of limb injury only. Ex: Gustilo Anderson,injury only. Ex: Gustilo Anderson, Tscherne and Gotzen, Bryd and Spicer etc.Tscherne and Gotzen, Bryd and Spicer etc. Scoring System-Focus on limb injury andScoring System-Focus on limb injury and general health; also gives Amputationgeneral health; also gives Amputation Score. Ex: MESS, NISSA, LSI, PSI etc.Score. Ex: MESS, NISSA, LSI, PSI etc. Comprehensive System- Combines theComprehensive System- Combines the above two systems. Ex: AO System,above two systems. Ex: AO System, Ganga hospital score.Ganga hospital score.
- 5. GradeGrade WoundWound Level ofLevel of ContaminationContamination Soft TissueSoft Tissue InjuryInjury Bone InjuryBone Injury 11 < 1 cm long< 1 cm long CleanClean MinimalMinimal Simple #Simple # MinimalMinimal comminutioncomminution 22 > 1 cm long> 1 cm long ModerateModerate No extensiveNo extensive soft tissuesoft tissue damage.damage. ModerateModerate crushing injurycrushing injury ModerateModerate comminutioncomminution 3 A3 A Severe withSevere with crushingcrushing Segmental orSegmental or severelyseverely comminuted.comminuted. Soft tissueSoft tissue coverage ofcoverage of bone possiblebone possible BB Usually > 10Usually > 10 cmscms HighHigh Very severe lossVery severe loss of coverage.of coverage. Usually requiresUsually requires soft tissuesoft tissue reconstructivereconstructive surgery.surgery. PeriostealPeriosteal stripping. Maystripping. May be moderate tobe moderate to severesevere comminution.comminution. CC Very severe lossVery severe loss of coverage +of coverage + vascular injuryvascular injury requiring repairrequiring repair Bone coverageBone coverage poor. May bepoor. May be moderate tomoderate to severesevere comminution.comminution.
- 6. Tscherne system- this systemTscherne system- this system includes compartment syndromeincludes compartment syndrome which is not included in the otherwhich is not included in the other grading systems.grading systems. Byrd and Spicer- lacks sophisticationByrd and Spicer- lacks sophistication and hence not widely used.and hence not widely used.
- 7. Scoring systemScoring system MESS( Mangled Extremity SeverityMESS( Mangled Extremity Severity Score) for prediction of amputationScore) for prediction of amputation Developed to identify patients whoDeveloped to identify patients who will be benefited by primarywill be benefited by primary amputation in retrospective analysis.amputation in retrospective analysis. The outcome of injured limb is eitherThe outcome of injured limb is either salvage or amputation.salvage or amputation. A score of > or equal to 7 isA score of > or equal to 7 is predicative of amputation.predicative of amputation.
- 8. NISSA-Nerve injury, ischemia, soft tissue injury, skeletalNISSA-Nerve injury, ischemia, soft tissue injury, skeletal injury, shock, age; more sensitive and specific than MESS.injury, shock, age; more sensitive and specific than MESS. LSI- limb salvage indexLSI- limb salvage index Applied to limbs with arterial injury.Applied to limbs with arterial injury. Warm ischemia time together with scores for injuredWarm ischemia time together with scores for injured skin, muscle, bone, NV are added to give a total score.skin, muscle, bone, NV are added to give a total score. LSI>6 AND Grade IIIC Gustillo with major nerve injuryLSI>6 AND Grade IIIC Gustillo with major nerve injury are amputated.are amputated.
- 9. Comprehensive systemsComprehensive systems AO SystemAO System Skin lesions, muscle tendons, NV, bone injuries areSkin lesions, muscle tendons, NV, bone injuries are graded separately. AO system allows better prediction ofgraded separately. AO system allows better prediction of outcome when compared to Gustilo. Due to its complexity,outcome when compared to Gustilo. Due to its complexity, not widely accepted.not widely accepted. Ganga hospital scoreGanga hospital score Includes additional criteria like age>65, DM,Includes additional criteria like age>65, DM, cardiorespiratory disease, trauma chest/abdomen,cardiorespiratory disease, trauma chest/abdomen, farmyard/sewage contaminations, delay in debridementfarmyard/sewage contaminations, delay in debridement >12h.>12h.
- 10. Initial managementInitial management Patient assessment: ABCPatient assessment: ABC Address life threatening injuries.Address life threatening injuries. Rule out cervical injuries, chest, abdominal injuries, head injuries inRule out cervical injuries, chest, abdominal injuries, head injuries in polytrauma patients.polytrauma patients. Identify all injuries to extremities and assess neurovascular status ofIdentify all injuries to extremities and assess neurovascular status of injured limb.injured limb. Assess skin and soft tissue damage.Assess skin and soft tissue damage. Obvious foreign bodies that are easily accessible may be removed- don’tObvious foreign bodies that are easily accessible may be removed- don’t do digital exploration.do digital exploration. The open wound should be covered with a sterile saline soaked gauze pad.The open wound should be covered with a sterile saline soaked gauze pad. Identify skeletal injuries and obtain necessary radiographs.Identify skeletal injuries and obtain necessary radiographs. IV TetanusIV Tetanus IV AntibioticsIV Antibiotics
- 11. Principles of TreatmentPrinciples of Treatment Antibiotic prophylaxisAntibiotic prophylaxis Wound debridementWound debridement Fracture stabilizationFracture stabilization
- 12. DebridementDebridement Most important step.Most important step. Aim-Removal of dead tissue andAim-Removal of dead tissue and foreign material to ensure goodforeign material to ensure good blood supply.blood supply. Debridement done as soon asDebridement done as soon as possible.possible.
- 13. Superficial DebridementSuperficial Debridement Wound margins are excised to identify and explore the entire zoneWound margins are excised to identify and explore the entire zone of injury and to access ends of bone fragments. Extensileof injury and to access ends of bone fragments. Extensile longitudinal incision to visualize deep tissue and can be extendedlongitudinal incision to visualize deep tissue and can be extended till normal tissue encountered clearly.till normal tissue encountered clearly. Nonviable skin and subcutaneous tissue excised but of marginalNonviable skin and subcutaneous tissue excised but of marginal viability may be left for later debridement.viability may be left for later debridement. Do not detach skin and subcutaneous tissue from the fascia. AnyDo not detach skin and subcutaneous tissue from the fascia. Any nonviable shredded fascia and even the marginally viable onesnonviable shredded fascia and even the marginally viable ones excised.excised.
- 14. Deep DebridementDeep Debridement Muscle because of water content are subject to hydraulic damageMuscle because of water content are subject to hydraulic damage by fluid waves during injury. In muscle debridement, the conceptby fluid waves during injury. In muscle debridement, the concept is when in doubt take it out.is when in doubt take it out. In type I, II, and IIIa open # all non-vital and in doubt muscleIn type I, II, and IIIa open # all non-vital and in doubt muscle can be debrided.can be debrided. IIIb and IIIc fractures- removal of entire muscle compartmentIIIb and IIIc fractures- removal of entire muscle compartment may be needed.may be needed. Viability of muscle is checked by its color, capacity to bleed,Viability of muscle is checked by its color, capacity to bleed, contractility, and consistency(4c’s-last 2 more reliable).contractility, and consistency(4c’s-last 2 more reliable).
- 15. IrrigationIrrigation Usual irrigation fluid used is NSUsual irrigation fluid used is NS High volume low pressure repeated lavage isHigh volume low pressure repeated lavage is performed.performed. Volume of fluid used varies- usually about 3 L isVolume of fluid used varies- usually about 3 L is used for grade 1 #; 6-10 L is used for grade 2 orused for grade 1 #; 6-10 L is used for grade 2 or 3 #.3 #.
- 16. Tendons, unless injured beyond repair should beTendons, unless injured beyond repair should be preserved.preserved. In open wounds tendons are subject toIn open wounds tendons are subject to desiccation and hence it should be covered withdesiccation and hence it should be covered with soft tissues if not with moist dressings.soft tissues if not with moist dressings. In general bone devoid of soft tissue attachmentIn general bone devoid of soft tissue attachment are removed and large fragments with soft tissueare removed and large fragments with soft tissue attachments are preserved.attachments are preserved. One exception to strict removal of bone withoutOne exception to strict removal of bone without soft tissue attachment, is significant portion ofsoft tissue attachment, is significant portion of articular surface attached to bone fragment.articular surface attached to bone fragment.
- 17. Limb Salvage vs. AmputationLimb Salvage vs. Amputation Limb is nonviable as evidenced by irreparableLimb is nonviable as evidenced by irreparable vascular injury, warm ischemia time >8 hrs,vascular injury, warm ischemia time >8 hrs, severe crush injury with minimal remaining viablesevere crush injury with minimal remaining viable tissue.tissue. Severely damaged limb may constitute a threatSeverely damaged limb may constitute a threat to patients life especially in patients with severeto patients life especially in patients with severe debilitating c/c illness. The severity of injurydebilitating c/c illness. The severity of injury would demand multiple operative procedures andwould demand multiple operative procedures and prolonged reconstruction time.prolonged reconstruction time. Mangled extremity severity score of >7Mangled extremity severity score of >7 accurately predicts amputation.accurately predicts amputation. Score doubles for ischemia>6 hrs.Score doubles for ischemia>6 hrs.
- 18. Skeletal StabilizationSkeletal Stabilization Done once vascular repair is completed and limbDone once vascular repair is completed and limb salvaged or once irrigation and debridement issalvaged or once irrigation and debridement is done.done. Restoring the length, rotational, and angularRestoring the length, rotational, and angular alignment has many benefits for healing of softalignment has many benefits for healing of soft tissues.tissues. Fracture reduction unkinks NV conduits and helpsFracture reduction unkinks NV conduits and helps in soft tissue healing.in soft tissue healing. Minimizing motion of fragments also decreasesMinimizing motion of fragments also decreases further damage, pain and permits mobilization offurther damage, pain and permits mobilization of joints.joints.
- 19. Skeletal Stabilization-TypesSkeletal Stabilization-Types Extra osseous- In low grade open fracturesExtra osseous- In low grade open fractures splints, plasters, wt bearing casts, etc.splints, plasters, wt bearing casts, etc. Internal fixation- usually appropriate if wound clean, andInternal fixation- usually appropriate if wound clean, and soft tissue coverage available.soft tissue coverage available. External fixation- in high grade open fracturesExternal fixation- in high grade open fractures in dirty wounds, or extensive soft tissuein dirty wounds, or extensive soft tissue injuries.injuries.
- 20. External fixationExternal fixation Excellent stability obtained.Excellent stability obtained. Reasonable anatomic reductionReasonable anatomic reduction possible.possible. Minimal additional soft tissue traumaMinimal additional soft tissue trauma Risk of infection-minimized.Risk of infection-minimized. Ability to convert to internal fixation.Ability to convert to internal fixation.
- 21. Internal fixationInternal fixation Plates and screws- to minimize complications IVPlates and screws- to minimize complications IV anti staph antibiotics should be started as soon asanti staph antibiotics should be started as soon as possible, sterile dressing, meticulouspossible, sterile dressing, meticulous debridement, copious irrigation and minimaldebridement, copious irrigation and minimal stripping and accurate anatomical reduction is tostripping and accurate anatomical reduction is to be done.be done. IM nail- currently the treatment of choice forIM nail- currently the treatment of choice for grade I,II,IIIa, and IIIb fractures as ex-fixgrade I,II,IIIa, and IIIb fractures as ex-fix devices leads to more malalignment, nonunion,devices leads to more malalignment, nonunion, and delayed return to function.and delayed return to function.
- 22. Wound closure and coverageWound closure and coverage Wounds without skin loss: tension free primary closureWounds without skin loss: tension free primary closure after thorough debridement.after thorough debridement. Contraindications for primary closureContraindications for primary closure Delayed presentation >12 hrs.Delayed presentation >12 hrs. Delayed administration of antibiotics>12 hrs.Delayed administration of antibiotics>12 hrs. Deep seated contaminationDeep seated contamination ImmunocompromisedImmunocompromised NV injuryNV injury Inability to achieve tension free sutureInability to achieve tension free suture High risk of anaerobic contamination like farm yardHigh risk of anaerobic contamination like farm yard injuries.injuries. Wounds with skin loss: healing by secondary intention.Wounds with skin loss: healing by secondary intention. Delayed primary closure, SSG, free flaps.Delayed primary closure, SSG, free flaps.
- 23. ComplicationsComplications EARLY-ShockEARLY-Shock Compartment syndromeCompartment syndrome Crush syndromeCrush syndrome Infection and sepsisInfection and sepsis DVT and embolismDVT and embolism ARFARF Late- OsteomyelitisLate- Osteomyelitis Non unionNon union