Mx of Open fracture ( FP 2 teaching ).ppt
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An open fracture involves a break in the bone with an associated break in the skin. It is an orthopedic emergency. Management involves thorough irrigation and debridement of the wound at the scene and in the emergency department. Antibiotics are given and the fracture is provisionally stabilized. In the orthopedic department, further debridement removes devitalized tissue followed by stabilization of the fracture, often with external fixation initially. Wounds are left open and monitored for closure. Rehabilitation addresses both the bone and soft tissue injury.
Mx of Open fracture ( FP 2 teaching ).ppt
- 1. AO Foundation Education Management of Open Fracture Dr. Zaw Min Htet Assistant Lecturer Orthopaedic Department University of Medicine (2)
- 2. Definition & Cardinal Signs of Fracture Fracture is a break in the structural continuity of the bone. ( complete or incomplete break in the cortex, with or without displacement ) Five cardinal signs of fracture 1. Deformity 2. Local bony tenderness, 3. Crepitus, 4. Abnormal movement, 5. Loss of function 2
- 3. Definition of open fracture An open fracture is one in which a break in the skin and underlying soft tissues leads directly into or communicates with the fracture and its haematoma to the external environment 3
- 4. Diagnosis of an open fracture can be difficult because the wound may be a considerable distance from the fracture site. When a wound occurs in the same limb segment as a fracture, the fracture must be considered open until proved otherwise. 4
- 5. Open fracture is an orthopaedic emergency 5
- 6. 6 An open fracture is a soft-tissue injury which also involves the bone
- 7. Management ( A ) At the scene of accident ( B ) At the A & E Department ( C ) At the Orthopaedic Department 7
- 8. ( A ) At the Scene of Accident • Irrigate the wound with large amount of available water • Cover and bandage the wound with clean cloth • Splint the effected limb • Elevate the effected limb if there is active or profuse bleeding • Transfer the patient to the nearest trauma center 8
- 9. ( B ) At the A & E Department (1) Follow ATLS protocol (a) Primary survey - Airway with cervical spine control - Breathing and ventilation - Circulation with haemorrhage control - Disability ( neurological exam. ) ; ( AVPU ) Alert, response to Voice, response to Pain, Unresponsiveness - Exposure with awareness of the patient’s body temperature 9
- 10. (b) rapid h/o taking ( AMPLE ) Allergies, Medications currently used, Past illness / Pregnancy, Last meal, Events / Environment (c) Secondary survey (i) detailed h/o about mechanism of injury, time & place of injury, pre-hospital care received, occupation, handedness & personal h/o, family status, socio-economic status 10
- 11. ( ii )Detailed physical examination General examination – GCS, vital signs ( BP, PR, RR, U.O, pain ), nutritional status Local examination - contamination, - condition of soft t/s & bone, - articular involvement - distal neurovascular status 11
- 12. • Photograph of the wound • Bacteriological swab • Saline soaked dressing • Provisionally splint the fracture • Tetanus prophylaxis • Broad spectrum antibiotics
- 13. 13 Choice of Antibiotics • Extent of wound and degree of contamination • Injury environment • Practice protocols • Coamoiclav or cephalosporin (cefuroxime) • Aminoglycoside(gentamycin) • Penicillin (farm/soil) • Clindamycin for penicillin allergy
- 14. (iii) Imaging (X-ray ) - including proximal one joint & distal one joint, - anteroposterior, lateral or oblique or other special view - two limbs if needed Computerized tomography - especially if fracture pattern is complex or intra-articular involvement 14
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- 16. Gustillo-Anderson classification of open fractures (1984)
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- 20. ( C) At Orthopaedic Department - wound debridement - stabilization of fracture - early wound cover - Secondary/tertiary reconstruction - Rehabilitation 20
- 21. Wound Debridement • Aim - to get rid of foreign material and dead tissue - leaving a good blood supply throughout • Under appropriate anesthesia
- 22. Steps 1. Wound excision— • The wound margin excised • Only enough to leave healthy skin edge 2. Wound extension— • Adequate exposure for thorough cleaning • Plan not to disturb further definite operation 3. Wound cleansing— • Carefully remove all foreign materials and tissue debris
- 26. Removal of devitalized tissues– • Dead muscles - lack of 4 C’s • Color • Consistency • Contractility • Capacity to bleed • Detached bone- removed Tendons and nerves— • Sutured if available necessary expertise • Otherwise, tagged to the nearby structure
- 27. Blood vessels— • Immediate ligations or coagulation for small vessels and arterial bleeders • Vascular repair for major vessel Bone— • Remove small detached bone • Preserve large bone fragment with muscle attachment Joints— • Arthrotomy and joint debridement • Synovium closed back
- 28. Wound closure • All open wounds- left open • Until the danger of tension and infection passed • Wound- lightly packed with sterile gauze • Inspected after 2 days • Suture or skin graft if cleaned • Type III wounds- may need further debridement, plastic surgery, and muscle flap operation
- 29. 29 Antibiotic bead pouch • Antibiotic-PMMA beads • Occlusive dressing • Useful in large wounds • Dead space control • High local antibiotic concentration • Seal wound from external contamination
- 30. 30 VAC Dressing • Closed system • Ongoing debridement • Wound size • Tissue edema • Excellent for staged coverage
- 31. VAC / NPWT Dressing 31
- 32. Sural fasciocutaneous flap open distal Tibia # fixed with IMNail 32
- 33. Stabilization of fracture • The methods of fixation depends on- - degree of contamination - the length of time from injury to operation - the amount of soft tissues damage • Methods- POP slabs, POP casts - external fixation - intramedullary nailing • Depending on characteristics of fracture and the wound
- 34. 34 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
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- 38. After initial debridement, separate prep and drape is generally performed before fixation. After separate prep and drape, the bone is stabilized. In this case, the initial stabilization is with a spanning external fixator, with the plan of definitive fixation at a later date.
- 40. 40 External fixation • Soft-tissue management • Severe contamination • Extensive bone loss • Vascular injury • Unstable • Dislocation or fracture dislocation • Complex periarticular fracture • Polytrauma
- 41. After care • Elevate and carefully watch the limb • Shock- may still required treatment • Continue antibiotic injection • Culture – if the wound open • A different antibiotic is substituted if necessary
- 42. 42 Rehabilitation • Of the limb • Of the injury • Of the patient • Of the family
- 43. Complications of open fracture Skin— • Skin loss or contracture Bone– • Sequestrum & sinuses (chronic om) • Delayed union and non-union Joints— Ankylosed joints
- 44. Compartment Syndrome “Compartment pressure rises to a level that decreases perfusion” •Diagnosis; • High index of suspicion in trauma patients • Pain out of proportion to that expected (5 Ps) •Treatment; • Emergency fasciotomy
- 45. 45 Take home message • Assess soft tissue injuries well • Management-consider bones and soft tissues • Vigilant for compartment $/manage aggressively • Open fractures-expert multidisciplianry care • Think of the patient