the management of open fracture - aado

Wound Management Workshop

Dr. WH Yip Department of O&T

Queen Elizabeth Hospital Sept 2013

Open Fracture Fracture communicates through a traumatic wound to

surrounding environment

Resulting in contamination, devascularization & disruption of soft tissue envelope

Open Fracture High energy

Outcome depends on the extent of soft tissue injury

Treatment of

Soft tissue trauma with contamination

Skeletal injury

Classification: Gustilo & Anderson

Grade Size (cm) Energy of trauma Infection rate (%)

I <1 Low energy 0-2

II >1 Moderate energy 2-5

III >10 High energy

5-50

Principles of Management

ATLS: Save life first, then save limb

Prevent infection: Wound debridement & lavage,

IV / local antibiotics, Tetanus prophylaxis

Fracture stabilization: Temporarily & Definitive

Early soft tissue coverage: Initial flap preservation, delayed 1°

suture, secondary intention, skin graft, flap

Mx of bone defect: Shortening, bone graft / transport

Rehabilitation: To minimize disability & optimize functional

recovery

Initial Wound Management Wound assessment & documentation, take clinical photo

Initial cleansing ( 1 L NS at bedside) if possible

Sterile cover - do not open until in the OT Multiple inspections before debridement increase infection

Realign the limb with well-padded splint Immediate systemic antibiotics

OT as soon as fasted enough for GA or regional anesthesia - It is an Emergency!

Analyze needs, prioritize aims, and plan for the worst Non-salvageable limb Amputation

Wound Assessment

Aseptic techniques

Wound condition

Neurovascular injuries

Associated fracture open fracture ?

Look out for compartment syndrome

Control the bleeding

Direct pressure, wound packing, elevation, tourniquet, direct clamping

Any major vascular injury requires emergency repair

No pulse & Pallor !!

Vascular Injury

Gustilo-Anderson Classification of Open Fractures

Grade Size of wound

I </= 1cm Minimal soft tissue stripping, minimal # comminutions

II >1cm Moderate soft tissue damage, moderate # comminutions

III >10cm Extensive soft tissue damage

IIIa: adequate soft tissue coverage, # comminuted

IIIb: extensive soft tissue injury with periosteal stripping, massive contamination, # comminuted

IIIc: with an arterial injury, poor soft tissue coverage

First Operation “EOT” Detail assessment and document wound location, size,

contamination - photos

Debridement and copious lavage (6 - 10 L.), discard loose bony fragments

Initial wound swab x C/ST: limited value not suggested

Preserve flaps

Stabilize fracture – Ext. Fix. or Nail

Do NOT close the wound

Great demand on appropriate decision making and surgical proficiency

Experienced surgical team makes a difference!

Prevent Infection: Wound Debridement & Lavage

Remove all devitalized tissue (esp. muscle), debris, loose fragments & foreign body

NS / antiseptic irrigation

Copious pulsatile lavage (6 - 10 L)

Wound left open

+/- 2nd look debridement every 24 - 72 hrs until completely clean

1st debridement 2nd debridement

Handling of Tissues

Skin: preserve if viability is uncertain

Fascia: excise if viability is uncertain

Tendon: preserve paratenon

Muscle: excise if viability is uncertain

Nerve: preserve

Periosteum: preserve whenever possible

Bone: preserve with intact periosteum

Viability of Muscle Circulation

Color

Contraction

Consistency

Lavage Wound irrigation is the key to prevent infection

Decrease bacterial load and remove foreign body

“Copious”: up to 10 L. “The best solution to pollution is dilution”

Pulsatile seems to be better - enhance dislodgement of particulate matter

Pressure High pressure (>8psi): cause bone damage & spread bacteria into

intramedullary cavity

Low pressure: equally effective

Controversy: sterile NS, antiseptic, antibiotic, soap, tap water

Drainage

Prevent potentially harmful collection of body fluid, blood

By 1) elevation, 2) tissue drain, or 3) Suction drain

Prevent Infection: IV Antibiotics

Broad spectrum cephalosporin (Gm +ve & -ve)

adequate for Grade I & II Zinacef / Cefazolin

Aminoglycoside (Gm -ve) additional for Grade III

Gentamicin

Metronidazole (anaerobes) additional for farm injury Flagyl / Penicillin

Duration: No optimal regimen!

Depends on the

wound condition !!

Prevent Infection: Local Antibiotics

Antibiotic loaded beads

1. High local concentration

2. Temporary spacer

Prevent Infection: Tetanus Prophylaxis Previously immunized

toxoid booster

Not immunized

toxoid + immune globulin

Wound Care Reconstruction Ladder

Early Soft Tissue Coverage: Initial Flap Preservation

Esp. where local flaps are not readily available

Distal 1/3 of tibia and beyond

Don’t jeopardise blood supply by insertion of pins, drains etc. thro’ the flap

No tension

Minimise soft tissue motion - to enhance regeneration of microvasculature - skeletal immobilisation

Early Soft Tissue Coverage “Very early fix and flap” protocol

Usually within 3 days to 1 week

Prevent nosocomial infection (main source of infection in open #) and improve outcome

Balanced by soft tissue tension & infection

Methods:

- Delayed 1° closure (Sutures, adhesives, strips, surgical staples )

- Skin graft (PTSG, full thickness)

- Flap (local, free) bring in blood supply

Soleal flap

Vacuum Assisted Closure (VAC) Sub-atmospheric pressure therapy

Negative pressure assists with removal of interstitial fluid, decreasing localised oedema and increasing blood flow → Decreases tissue bacterial levels

Accelerates wound healing by promoting the formation of granulation tissue, collagen, fibroblasts, and inflammatory cells

Vacuum Assisted Closure (VAC)

Piece of foam with an open-cell structure is introduced into the wound

Wound drain with lateral perforations is laid on top of it

Entire area is covered with a transparent adhesive membrane

Connection to a vacuum source

Foam

Ensures that the entire surface area of the wound is uniformly exposed to the negative pressure effect

Prevents occlusion of the perforations in the drain

Eliminates the theoretical possibility of localised areas of high pressure and resultant tissue necrosis

Plastic membrane

Prevents ingress of air

Allow a partial vacuum to form within the wound, reducing its volume and facilitating the removal of fluid

Vacuum Assisted Closure (VAC) Intermittent or continuous pressure

Pressure: 125mm Hg (50 - 200mmHg)

Infected wound: change every 24 hours

Clean wound: change every 2 days

Indications and Contraindications

Fracture Stabilization: Optimize Fracture Healing

Fracture reduction

Stable fixation

Dynamize and weight bear at appropriate time

Bone graft: bring in blood supply

Fracture Stabilization: Temporarily

Standard: External Fixation

Quick & easy

Minimal invasive

Good stability

Prevent infection

Temporarily stabilization

Fracture Stabilization: Definitive Usually done after wound conditions (infection

& coverage) stabilized

Timing & method depends on fracture pattern & wound conditions

Choices of Definitive Fixation

1. Primary Internal Fixation (Nailing / MIPO)

2. Conversion from External Fixation to Internal Fixation

Nailing/ MIS implants/ Percutaneous screw/ K-wire

3. Keep External Fixation (Simple / Hybrid)

4. Conversion from External Fixation to Casting

Case 1: Nailing

Case 2: Nailing

Case 3: MIPO

Case 1: Type I Open Fracture M/53

Wound debridement + Primary Nailing

Case 2: Type I Open Fracture

M/24

Case 3: F/53

Type I wounds on medial aspect

CT done, fracture extended very distally. Too distal for Distal Nailing.

Distal Tibial LCP

Day 1

Case 1: Conversion to Nailing

Case 2: Conversion to Plate & Screw

Conversion of Ext. Fix. to Reamed Nailing Tibia - generally not later than one week For I, II and IIIa #’s One stage (<3 wks) or “cooling” period (>3 wks) Better access for flap surgery Less prone to delayed or mal-union Generally more acceptable to patients Shorter hospital stay Only if fracture location and type amenable to

nailing

Open wounds at left leg Case 1: M/23

Initial debridement

and Hoffmann II

External Fixation

Before and after initial external fixation

Day 3, fixation revised

Injured limb supported

and raised on the fixator

frame to facilitate

drainage, nursing care

and surgery.

Skin graft

4 weeks

Fixation removed (already the 9th operation).

Pin holes “rested” for 4 weeks.

8 weeks after injury

IC Tibial nail

inserted.

1 year after injury

2 years after injury

Case 2: F/68

Emergency Treatment

Wound Lavage +

Debridement +

External Fixation

Day 5 Debridement + PTSG + ORIF

Ext. Fix. kept for soft tissue injury

2 Months

Case 1: Comminuted Fracture

Case 2: Infection

Case 3: Severe Soft Tissue Injury

Case 4: Polytrauma with complex management

Pin Fixators

AO Orthofix

Stryker: Hoffmann II

Ring & Hybrid Fixators

AO Orthofix

Half pin

Tensioned wire

Stryker: Tenxor

Case 1: Comminuted Open Fracture

M/40

Emergency Treatment Wound Lavage + Debridement + External Fixation

Definitive Treatment

PTSG + Conversion to Hybrid

External Fixation

16 Weeks

Case 2: Infected Open Fracture

M/50

Type IIIA

Conversion from Ext. Fix. to IM nail on Day 2

ORIF for calcaneal

& navicular fracture

on Day 11

MRSA Infection: repeated debridement from 3 to 8 weeks

10 weeks Loosening of distal

fixation detected, fracture went into valgus & recurvatum

Subsequent Management

(11 weeks) Wound debridement

Removal of nail

Conversion to hybrid external fixation

14 weeks

14 weeks

Then Ext.

Fix removed

on 17 weeks

43 weeks from

hybrid

fixation

13 months

after injury

Stick walking 30 min, unaided 10 min

Case 3: Severe Soft Tissue Injury

F/75

Emergency Treatment Wound Lavage +

External fixation

2 Weeks

Debridement + PTSG +

Limited Percutaneous

Internal Fixation

4 Weeks

Fracture Healed Up

Right Forearm

Case 4: M/57

Polytrauma

Right Femur

Right Knee

Right Tibia

Requires

Bone Grafting

Left Side

Stellate wound at the front of knee

Shattered patella

Shattered distal femur – intercondylar and lower shaft

Left Knee – after 1st Debridement

Left Knee – after 2nd Debridement Followed by MRSA infection and

multiple debridement

Left Knee

(12 weeks)

What to do?

Intercondylar screw fixation with limb shortening at 13 Week

Gastrocnemius Flap with BG & PTSG 3 days later

Post-Flap 2 week

9 Months

Case 1: Minor Open Wound with osteosporosis, poor pre-morbid

F/74

Limited Internal Fixation + Pin & Cast

Case 1: Delayed Amputation

Case 2: Primary Amputation

Amputation: Guideline

Non-viable limb

Non-functional limb

Life-threatening limb

Too extensive & prolonged reconstruction

MESS >7

Amputation: MESS

MESS for limb salvage

<4 good prognosis

>7 poor prognosis (100% predictive value for amputation)

Case 1: M/54 Knocked down by a car

MESS=7

Day 1, 2nd Debridement

MESS Very high energy : 4

Age 54 : 2

Transient shock : 1

Limb ischaemia : 0

Total: 7 / 14

Amputation recommended for score of >= 7.

What next ?

Keep fixator, skin graft, wait for bone healing; Or

BKA

Change to Ring Fixation to buy more time

Day 3

Hybrid Fixator

with tensioned wire

Soft tissue defect anticipated!

Local antibiotics:

Gentamicin beads

Bone defect also anticipated!

Day 10: Complicated with Infection despite Repeated Debridement

Agreed to BKA

Salvaged limb Functional limb

Never forget prosthesis

Case 2: Jump Railway

Primary Amputation

Summary Outcome depends extent of soft tissue injury

Treatment of

Soft tissue trauma with contamination Primarily important

Skeletal injury Secondary

Management Protocol

Adequate debridement

is the single most

important factor in

minimizing infection

with open fracture !

The End