Managment of open fractures
- 1. Standards for the Management of open fractures of the lower limb Dr Nikki Walsh 18.2.2013
- 2. BOA/BAPRAS 2009 last update – 20 principal recommendations Open fractures of lower limb – below knee Few randomized trials Evidence based plus data from associated areas and experience of the working party Specialist centres Orthopaedic surgeons and plastic surgeons British Infection Society and Association of Medical Microbiologists reviewed guidelines on antibiotic prophylaxis
- 3. Recommendation 1:Specialist Centres MDT approach Characteristics of open injuries requiring referral to specialist centre Fracture pattern Transverse or short oblique with similar level fibular fracture Tibial fracture comminution with similar level fibular fracture Segmental tibial fractures Fractures with bone loss Soft tissue Injury pattern Skin loss Degloving Injury requiring excision of devitalised muscle via wound extension Arterial injury
- 4. 2. ED Management ATLS Careful assessment Photograph Minimal handling – no ‘provisional cleaning’ Control haemorrhage with pressure Sterile dressing IVAB’s Anti-tetanus prophylaxis Splintage – No provisional external fixators Radiographic assessment to include 2 orthogonal views of tibia plus knee and ankle joint
- 5. 3. Antibiotic prophylaxis ASAP, ideally within 3 hours of injury Cephalosporin 1.5g TDS until 1st debridement At time of debridement Cephalosporin Gentamicin 1.5mg/Kg Continued until soft tissue closure or 72 hours On induction of anaesthesia for skeletal stabilization– above and Vancomycin 1g or teicoplanin 800mg Clindamycin if allergic to penicillin/cephalosporin
- 6. 4. Timing of wound excision Immediate Gross contamination Compartment syndrome Devascularized limb Multiple – injured patient Marine/agricultural or sewage contamination Senior orthopaedic and plastic surgeons working together on a scheduled trauma operating list, within normal working hours and within 24 hours of injury
- 7. 5. Wound debridement Excision of all devitalised tissue (except neurovascular bundles) Wash with soapy solution and tourniquet applied Prep with alcoholic chlorhexidine solution avoiding contact with open wound Systematic debridement and assessment from superficial to deep and from the periphery to the centre of the wound Classify wound and plan definitive reconstruction If definitive skeletal stabilisation and soft tissue coverage is not undertaken in a single setting – apply VAC +/- antibiotic bead pouch
- 8. 6. Debridement of bone Extend traumatic wounds along nearest fasciotomy incision Deflate tourniquet before bone debridement to assess viability Careful surgical delivery of bone ends through the wound Remove fragments which fail to ‘tug test’ Major articular fragments preserved as long as they can be reduced and fixed with absolute stability Lavage – high pressure pulsatile lavage Not recommended
- 9. 7. degloving Thrombosis of subcutaneous veins usually indicates the need to excise the overlying skin Circumferential degloving often indicates that the involved skin is not viable Severe injuries – multi-planar degloving – second stage debridement may be needed
- 10. 8. Classification of open fractures Accurate, simple and reproducible system Gustillo and Anderson best applied after wound excision
- 11. 9. Temporary Wound dressings VAC Antibiotic impregnated beads under a semi-permeable membrane combination
- 12. 10. Skeletal stabilisation Spanning Ex-fix Change from ex-fix to definitive fixation as early as possible Internal fixation safe if minimal contamination and soft tissue coverage at same time. Multiplanar/circular fixators if significant contamination, bone loss and multilevel fractures of the tibia
- 13. 11. Timing of soft tissue reconstruction Local flaps same time as fixation Free flaps on scheduled trauma lists Dedicated specialist team after CT scan, angiography as needed Little evidence for 5 day rule Microsurgery best performed in first week Recommend definitive soft tissue reconstruction within first 7 days
- 14. 12. Types of soft tissue reconstruction All open fractures covered with vascularised soft tissue Low energy injuries can be covered by local fasciocutaneous flaps Diaphyseal tibial fractures with periosteal stripping best covered by muscle flaps rather than fasciocutaneous flaps Metaphyseal fractures – fasciocutaneous flaps including free flaps
- 15. 13. Compartment syndrome Diagnose and treat early Clinical picture may be distorted by nerve injury Loss of pulses usually due to vascular injury Measure intracompartment pressures Inappropriate fasciotomy can be associated with significant morbidity 2 incision, 4 compartment decompression Late diagnosis may result in amputation
- 16. 14. Vascular injuries Immediate management Aim to restore vascularity within 3-4 hours of the injury Maximum acceptable delay is 6 hours warm ischaemic time Shunting reduces ischaemic time Stabilise skeleton, then replace shunts Assess if limb is salvagable
- 17. 15. Open fractures of foot and ankle Challenging as limited soft tissue flap options Consider amputation vs final functional outcome Initial fixation with spanning ex-fix, no fibular plate at initial stage Difficulties with distal anchor points for ex-fix Definitive fixation at same time as soft tissue coverage Consider amputation with open hind foot, open mid-foot injuries. Ist Metatarsal injuries treated aggressively. Ray amputation for lesser MT’s.
- 18. 16. Things go wrong with soft tissues Revision to healthy tissue Leeches for limited tip congestion Revascularization if needed Some local fasciocutaneous flaps may be more prone to develop complications in patients with comorbidities.
- 19. 17. Bone complications Wound leakage Sepsis Loss of alignment Common causes include Inadequate debridement Haematoma formation Inapproriate or delayed soft tissue cover Unstable fixation Each cause is sought and remedied promptly
- 20. 18 Primary amputation Damage control – uncontrollable haemorrhage, crush injuries with warm ischaemic time > 6 hours Incomplete traumatic amputations