Download - Debridement in Open Fracture Aditya
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OPEN FRACTURES DEBRIDEMENT
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Open fracture
osseous disruption in which a break in the
skin and underlying soft tissue communicates
directly with the fracture and its hematoma Surgical Emergencies
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ClassificationGustilloGustillo Anderson (1976)Anderson (1976)
Type 1
The wound is < 1 cm long.
It is usually a moderately clean puncture throughwhich a spike of bone pierces the skin.
There is little soft tissue damage and no sign ofcrushing injury.
The fracture is usually simple, transverse, or shortoblique with minimal comminution.
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ClassificationGustilloGustillo Anderson (1976)Anderson (1976)
Type 3
It is characterized by extensive soft-tissue
damage to the muscles, skin, and neurovascularstructures.
There is high degree of contamination.
It is often the result of high velocity injury;
considerable comminution and instability arecommonly seen.
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ClassificationGustilloGustillo MendozaMendoza Williams (1984)Williams (1984)
Type 3A
There is adequate soft tissue coverage of the fractured bonedespite extensive laceration, flaps, or other trauma.
It includes segmental or severely comminuted fractures from
high-energy trauma, regardless of the size of the wound. Type 3B
There are extensive soft tissue injury or loss with periostealstripping and bone exposure, massive contamination, andsevere fracture comminution from high-velocity injury.
Since there is exposed bone segment, it usually requires localflaps or free flaps for coverage.
Type 3C
It is associated with arterial injury requiring repair, regardless
of the degree of soft tissue injury.
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Classification
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EVALUATION
Mechanism of injury
Open fractures result from the application of aviolent force.The applied kinetic energy (0.5 mv2)is dissipated by the soft tissue and osseous
structures Contamination of the wound and fracture by
exposure to the external environment
Time of injury
The patient's tetanus immun status
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Treatment
Pre-hospital
Pressure over the wound
Splinting of fractures Placement of sterile dressings
Rapid transport to appropriate medical center
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TREATMENT
Emergency DepartmentManagement After initial trauma survey and resuscitation for life-
threatening injuries : Foreign bodies or obvious debris, such as leaves, stones, or
grass, found in open wounds that can be easily removedshould be manually removed with sterile forceps.
irrigate the wound with 1 to 2 L of saline fluid (*)
Wound hemorrhage should be addressed with directpressure rather than limb tourniquets or blind clamping
Cover the wound with a sterile bandage
Perform provisional reduction of fracture and place a splint
X ray or other exam.
Parenteral Antibiotics
Tetanus Prophylaxis
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Treatment Debridement and Irrigation
The objectives of debridement (andirrigation) are as follows: Extension of the traumatized wound to allow
identification of the zone of injury.
Detection and removal of foreign material,especially organic foreign material.
Detection and removal of nonviable tissues.
Reduction of bacterial contamination.
Creation of a wound that can tolerate the residualbacterial contamination and heal withoutinfection.
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technique
Adequate personal protection splash guards,goggles, boots, gloves
Prepare the patient and the skin
Apply a sterile torniquet, but do not inflate Wash and drape the wound, allow a wide exposure
of the involved area
The wound should be extended proximally anddistally to examine the zone of injury
Debridement of tissue begin at the skin and proceedin an orderly fashion
Remove devitalized skin until bleeding is visible inthe skin edge
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An elliptical excision ofthe fracture woundpermits properinspection of the areaof injury as well asbetter closure if thewound is sutured
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M
ethods for extending atraumatic transverse oroblique wound.
A.The Z-plasty techniqueproduces two large flaps, andrisks necrosis of the tips of
the flaps. B,C. Both of these methods
also produce large skin flapsthat risk necrosis of the distalportion of the flap.
D. Incision bisecting the
wound results in the smallestflaps.This reduces the risk offlap necrosis and is thepreferred incision in mostinstances
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technique
Remove the subcutaneous tissue, including
all contaminated tissue
Remove devitalized fat beneath the flapsdown to clean, bleeding, subcutaneous tissue
Open the fascia to allow exposure of the
muscle tendon
Removal of all devitalized muscle,
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technique
Trim completely severed tendons back to
viable tendon
Intact tendons cleaned and not excised Remove devascularized bone
Remove contamination in the medullary
canal by progressively removing bone with asaw or rongeur
Avoid curettage of the medullary canal
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Technique
Irrigate with normal saline
A number of irrigation additives have been examinedconcurrent to the focus on method of irrigationdelivery. Antisep tics investigated include hydrogenperoxide, povidone-iodine, chlorhexidine, and variousalcohol solutions . These agents inhibit pathogens bydamaging cell walls. Host toxicity through this samemechanism, to include impaired osteoblast function,has been demonstrated as well
The benefit of adding antibiotics to irrigation solutions hasnot been fully demonstrated either. Rosenstein et al (79)noted a decrease in positive cultures following instillationof bacitracin P.405
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Irrigation variables
Variable Effect Recommendation
Volume Increasing volume removes more particulatematter and bacteria, but the effect plateaus at
a level dependent of the system
Grade 1, 3 LGrade 2, 6 L
Grade 3, 9 L
P
ressureI
ncreased pressure removes more debris andbacteria; the highest pressure settings damage
bone, delay fracture healing, and may increaserisk of infection by damaging soft tissues
Use a power irrigationsystem that provides a
variety of settings, select alow or middle range setting
Pulsation In theory, improves removal of surface debrisby means of tissue elasticity
Not established
Anglen JO. Wound irrigation in musculoskeletal injury.
J Am Acad Orthop Surg 9:219, 2001
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Suture the surgically created wound first
Loosely close the remaining wound over adrain ifnecessary
If closure is not possible, leave open Keep structures such as bone, nerve, and tendon
moist
Prepare and drape again, discard all instruments,change operating gowns and gloves before applying
internal or external fixation Serial debridement(s) should be performed every 24
to 48 hours as necessary until there is no evidence ofnecrotic soft tissue or bone.
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Complication
Infection: Open fractures may result in cellulitisor osteomyelitis, despite aggressive, serial
debridements, copious lavage, appropriateantibiosis, and meticulous wound care.
Compartment syndrome:This devastating
complication results in severe loss of function,
especially in tight fascial compartments
including the forearm and leg. It may be avoidedby a high index of suspicion with serial
neurovascular examinations
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Thank you
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Case
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Mr. Ade Rizky M/ 21 Y.O
Chief complaint : pain on his left leg HOI : 9 hour before admission, the patient was
riding a motorcycle. When he was going to stop,suddenly a car right behind him crashed him.
Patient fell out from motorcycle with unknownmechanism, unconscious (-), Helmet (+). Afterthe accident patient felt pain on his left thighand leg and couldnt move it. Patient also feltpain on his right upper arm. active bleeding(+)
on left leg.Vomiting (-). Patient got transferedto a nearby clinic, then was transfered to CMHospital.
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Primary Survey
A: Clear
B: spontaneous, RR 18x/mnt,
C: Warm, PR 100x/mnt BP130/70
D: GCS 15
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GeneralCondition
Head : normal
Neck: swelling (-), deformity (-), pain (-)
Eyes: pale conjunctiva -/-,
Lungs: symetrical, vesicular, rhales -/-, wheezing -/- Heart: normal hearts sounds, murmurs (-), gallop (-)
Abdomen: no bulging at the lower abdomen, tender,
normal bowel sound
Pelvis: no deformity
Extremity: local state
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Local StateCruris Sinistra
Look:Deformity: Angulation (-),shortening -
Swelling (-); open wound (+),
in poplitea 10x 3 x3 cm ,base subcuticular. And inmid cruris anterior 5x 3x3,base subcuticular.
Feel:
tenderness (+), a dorsalispedis -, a tibialis post -, apoplitea -.
Move:
not performed
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Laboratorium
Laboratorium (5 Januari 2010) :
CBC: HB: 9,9; Ht : 30,9; Lekosit : 10.150;Trombosit:403.000
SGOT/SGPT : 71/46
Ur/Cr : 17/0,40
Na/K/Cl : 131/4,04/92,6
GDS: 123 PT: 12,0/12,3
APTT: 38,6/31,6
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DIAGNOSIS
MultipleTrauma Closed Fracture Right Humerus + Post U-Slab + Suspect
Right Radialis Nerve Injury
Closed Fracture Left Femur
Open Fracture LeftTibia-Fibula Gr. IIIC Rupture Left A.V. Femoralis + Post Repair
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