COMPOUND FRACTURES OF LOWER LIMB- PRINCIPLES OF MANAGEMENT

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DefinitionDefinition

A FRACTURE IN WHICH FRACTURE HAEMATOMA A FRACTURE IN WHICH FRACTURE HAEMATOMA COMMUNICATES WITH EXTERIORCOMMUNICATES WITH EXTERIOR

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Gustillo Classification

•Grade I:        - wound less than 1 cm w/ minimal soft tissue injury;   - wound bed is clean

 

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Gustillo Classification

• Grade I:        - wound less than 1 cm w/ minimal soft tissue injury;   wound bed is clean

 

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Type IIType II : : greater than 1cm in length greater than 1cm in length moderate amount of soft tissue damagemoderate amount of soft tissue damage higher energy trauma.higher energy trauma.

(Usually confined to one compartment (Usually confined to one compartment

and amount of debridement required is minimal)and amount of debridement required is minimal)

ClassificationClassification[Gustillo & Anderson][Gustillo & Anderson]

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¤ Type III¤ Type III :: Wound longer than 10cm Wound longer than 10cm with extensive muscle devitalisationwith extensive muscle devitalisation

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Type IIIaType IIIa : :

Limited stripping of periosteum and soft Limited stripping of periosteum and soft tissues from bone.tissues from bone.

adequate soft tissue coverage for bone,adequate soft tissue coverage for bone,

tendons and neurovascular bundle.tendons and neurovascular bundle.

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¤ ¤ Type IIIbType IIIb : Extensive stripping of soft : Extensive stripping of soft tissue and periosteum from bone. tissue and periosteum from bone.

Requires a local flap or free tissue transfer Requires a local flap or free tissue transfer

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¤ ¤ Type IIIcType IIIc : A major vascular : A major vascular injury requiring repairinjury requiring repair

((A A tibia # with disruption of ant. tibial tibia # with disruption of ant. tibial arteryartery

but preservation of post. tibial artey is but preservation of post. tibial artey is not Type IIIc)not Type IIIc)

ClassificationClassification[Gustillo & Anderson[Gustillo & Anderson

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Depending on mechanism

a. Compounding from with in

b. Compounding from with out

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MANAGEMENT

EMERGENCY

GOLDEN HOUR CONCEPT

AIM:-

To convert contaminated wound into clean wound To convert contaminated wound into clean wound

To convert the open # into a closed one.To convert the open # into a closed one.

To establish a union in a good positionTo establish a union in a good position

To prevent pyogenic and clostridial infection.To prevent pyogenic and clostridial infection.

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MANAGEMENT

ORDER OF PRIORITY

1. PATIENT

2. LIMB

3. WOUND

4. FRACTURE

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PATIENT

POLYTRAUMA

RESUSCITATION

LIMB

VASCULAR STATUS

NEUROLOGICAL STATUS

COMPARTMENT SYNDROME

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WOUND

CLEAN

STERILE DRESSING

CULTURE SWAB?

FRACTURE

DONOT REDUCE

POSITION AND SPLINT

ANTIBIOTICS

BROAD SPECTURM

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PRINCIPLES OF MANAGEMENT

SURGICAL TECHNIQUE

TOURNIQUET

UsesUses

DisadvantagesDisadvantages

Never use as a routineNever use as a routine

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SKIN AND S/C TISSUESKIN AND S/C TISSUE

Expose entire zone of injuryExpose entire zone of injuryMeticulous hemostasisMeticulous hemostasisElliptical wound preferred Elliptical wound preferred Wound extensionsWound extensionsBe conservativeBe conservative

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FASCIAFASCIA

Excise contaminated fasciaExcise contaminated fascia

Enlarge small rents in fasciaEnlarge small rents in fascia

Prophylactic fasciotomyProphylactic fasciotomy

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MUSCLEMUSCLEMechanism of injuryMechanism of injury

Necrotic muscle : pabulum of infectionNecrotic muscle : pabulum of infection

““When in doubt,take it out” is approachWhen in doubt,take it out” is approach

10 % muscle belly is enough10 % muscle belly is enough

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Vascular anatomyVascular anatomy

Viability of muscle :4 C’sViability of muscle :4 C’s

Look beyond superficial layerLook beyond superficial layer

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FACTORS OF VIABILITY

1. COLOUR

2. CONSISTENCY

3. CONTACTILITY

4. CAPACITY TO BLEED

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TENDONSTENDONS

Not a pabulum of infectionNot a pabulum of infection

Adequate coverageAdequate coverage

RepairRepair

Usually preservedUsually preserved

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BONEBONE

Retain bones with soft tissue Retain bones with soft tissue attachmentattachmentDebridementDebridementViabilityViabilityAdequate coverageAdequate coverage

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JOINTSJOINTS

ArthrotomyArthrotomy

Irrigation and debridementIrrigation and debridement

Loose fragmentsLoose fragments

Tight closure of capsuleTight closure of capsule

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NERVES AND VESSELSNERVES AND VESSELS

Layer by layer hemostasisLayer by layer hemostasisDelayed repair if contaminatedDelayed repair if contaminatedTotal loss of blood supply-more Total loss of blood supply-more than 8 hrs:AMPUTATIONthan 8 hrs:AMPUTATIONEmergency repairEmergency repair

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Wound coverWound cover

TypesTypes

1)Split thickness free skin graft1)Split thickness free skin graft

2)full thickness free skin graft2)full thickness free skin graft

3)Local flap graft3)Local flap graft

4)fasciocutaneous flaps4)fasciocutaneous flaps

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5)Myo-cutaneous flaps5)Myo-cutaneous flaps

6)Pedicle flaps6)Pedicle flaps

7)Free micro vascularised muscle flap7)Free micro vascularised muscle flap

Biological dressingsBiological dressings

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STABILIATION OF OPEN FRACTURESTABILIATION OF OPEN FRACTURE

METHODSMETHODS

1.1. PLASTER IMMOBILISATIONPLASTER IMMOBILISATION

2.2. PINS &PLASTERPINS &PLASTER

3.3. SKELETAL TRACTIONSKELETAL TRACTION

4.4. EXTERNAL FIXATIONEXTERNAL FIXATION

5.5. INTERNAL FIXATIONINTERNAL FIXATION

6.6. HYBRID FIXATIONHYBRID FIXATION

trade-off between bony stability and foreign body response

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External fixatorsExternal fixators

Method of choice in most open fracturesMethod of choice in most open fractures

ADVATAGESADVATAGES•Easily applied Easily applied •Good skeletal & soft tissue stabilityGood skeletal & soft tissue stability• Anatomical reduction.Anatomical reduction.• No additional traumaNo additional trauma

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ADVATAGES of EX.FIXADVATAGES of EX.FIX

•Risk of infection is comparatively less.Risk of infection is comparatively less.•Allows wound inspection & wound dressing.Allows wound inspection & wound dressing.•Temporarizing frame ,restoring the limb to length Temporarizing frame ,restoring the limb to length until definitive fixation.until definitive fixation.•Allows transportationAllows transportation•Better nursing careBetter nursing care

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INTERNAL FIXATIONINTERNAL FIXATION

CONTROVERSIALCONTROVERSIAL

IndicationIndication

1.1. Type- I # Type- I #

2.2. Type-II # - 5-8% infectionType-II # - 5-8% infection

3.3. Type III # - 26-43 % infectionType III # - 26-43 % infection

4.4. Intra articular #Intra articular #

5.5. Reimplantation surgeryReimplantation surgery

6.6. Vascular repairsVascular repairs

7.7. Old patientsOld patients

8.8. Polytrauma patientsPolytrauma patients

BONE GRAFTINGBONE GRAFTING

INDICATIONSINDICATIONS

1.1. Bone lossBone loss

2.2. High velocity traumaHigh velocity trauma

3.3. Severe comminutionSevere comminution

TimingTiming

type-I immediatetype-I immediate

type II &III 6-12 weekstype II &III 6-12 weeks

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AMPUTATIONAMPUTATION

IndicationsIndications

1.1.vascular injury – norepair possiblevascular injury – norepair possible

2.functional outcome better with prosthesis2.functional outcome better with prosthesis

3. Life saving to arrest bleeding3. Life saving to arrest bleeding

4. Associated diseases OVD- DM etc.4. Associated diseases OVD- DM etc.

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COMPLICATIONSCOMPLICATIONS

EARLYEARLY

                                1. Gas gangrene 1. Gas gangrene                 2. Tetanus                 2. Tetanus                 3. Crush                 3. Crush syndrome syndrome    

1.1.Chronic osteomyelitis Chronic osteomyelitis

2.Delayed union & Non union 2.Delayed union & Non union

3.Joint stiffness3.Joint stiffness

LATELATE

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OPEN FRACTURES IN CHILDRENOPEN FRACTURES IN CHILDREN

differ from those in adultsdiffer from those in adults

1.1. healing capacity of the soft tissues & bone healing capacity of the soft tissues & bone excellentexcellent

2.2. No bone grafting neededNo bone grafting needed

3.3. Infection rare Infection rare

4.4. External fixation left in place until union External fixation left in place until union

5.5. social and psychological impact social and psychological impact

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