open (compound) fractures prof. m. ngcelwane 2013
DESCRIPTION
OPEN (compound) FRACTURES Prof. M. Ngcelwane 2013. 1. MUST BE ABLE TO DIAGNOSE OPEN FRACTURES RECOGNIZE THAT THERE MAY BE ASSOCIATED INJURIES BE ABLE TO CLASSIFY OPEN FRACTURE PRINCIPLES OF EARLY MANAGEMENT DEFINITIVE MANAGEMENT COMPLICATIONS. OBJECTIVES. 2. WHAT IS A FRACTURE. 3. - PowerPoint PPT PresentationTRANSCRIPT
OPEN (compound) FRACTURES
Prof. M. Ngcelwane2013
1
OBJECTIVES
MUST BE ABLE TO DIAGNOSE OPEN FRACTURES
RECOGNIZE THAT THERE MAY BE ASSOCIATED INJURIES
BE ABLE TO CLASSIFY OPEN FRACTURE
PRINCIPLES OF EARLY MANAGEMENT
DEFINITIVE MANAGEMENTCOMPLICATIONS
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WHAT IS A FRACTURE
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OPEN (COMPOUND) FRACTURE
FRACTURE
XR: A break in the continuity of boneClinically: swollen, deformed, tender, loss of fx
COMPOUND FRACTURE
Fracture where there is a skin wound communicating with the fracture
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Examples of open fractures
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IMPORTANCE OF SOFT TISSUES
An open fracture is a severe soft tissue injury in which bone is also broken.
Extent of damage to soft tissue determine the prognosis
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Gustilo and Anderson classification of open
fractures
I < 1cm clean wound, simple fracture patternII > 1cm, no extensive soft tissue damage, no flaps/avulsion, simple fracture fractureIII (A) Extensive wound, bone adequately covered. (B) Bone exposed, usually contaminated. (C) Arterial injury.
NB 7
Causes
High energy traumaLook for other injuries
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Anatomic considerations
Commonest long bone open fracture is tibia
Most studied bonePoor soft tissue coverCf. femur
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CLINICAL APPROACH TO PATIENT WITH OPEN
FRACTURE1. Assess life threatening injuries
• ABC of resuscitation• Physical and neurologic exam• Emergency Surgery (decision)
2. Assess limb (a) Vasculature pulse doppler angiogram (b) Soft tissues Skin - site - bruising contamination muscles periosteum (c) Neurology Plantar skin sensation3. Fracture pattern XR
NB 10
Neurovascular assessment (tibia)
Vascular:- Dorsalis pedis- Posterior tibial
Motor:- all compartments of the leg: toe flexures, toe dorsiflexors, ankle evertors, plantar flexors
Sensory:- Tibial n: plantar surface of foot- Deep peroneal n: dorsal web space 1st and 2nd toe- Superficial peroneal n: dorsolateral- Saphenous n: medial
REMEMBER - NOT POSSIBLE IN ALL PATIENTS
11NB
Treatment
MAIN COMPLICATION OF OPEN FRACTURES IS INFECTION
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Open Tibial Fractures
A Open Fractures: Challenges1. Management of traumatic wound2. Achieving bony stability3. Decision making -limb salvage
vs. amputation4. Achieving soft tissue coverage5. Achieving fracture union
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PRINCIPLES OF
TREATMENT
B1. Wound debridement2. Antibiotic therapy3. Bony stabilization 4. Wound coverage5. Maintain vascularization
14NB
Emergency Room
Treatment
C1. Reduce and splint the limb2. Document neurologic and vascular
status3. (Lavage wound)4. Sterile compression dressing,
do not open again5. (photograph)6. Start I/V antibiotics7. Tetanus prophylaxis8. X-ray evaluation9. To surgery as soon as possible
< 6 hours
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I II IIIA IIIB IIIC * * * * *
* * *# # #
INTRAVENOUSANTIBIOTICS
Cefazolin AminoglycosidePenicillin
Type open fracture
# Soil contamination (clostridia)
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MANAGEMENT
Limb - specific treatment(a) debride/decontaminate• No tornique• Remove all dead tissue • Save bone
(b) Skeletal stabilization(c) Soft tissue cover(d) Bone reconstruction(e) Rehabilitation
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Sepsis cannot occur if good bleeding tissue
is present
“The solution to pollution is dilution”
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Principles of
DebridementD.
1. Classification determined at time of debridement of future surgeries
2. Extend wounda. Visualise entire zone of
injury and where hematomatraveled
3. Debride wound in a systematic waya. Skin edges subcutaneous
muscle bone 4. Remove foreign material
5. Debride necrotic skin, fat, muscle, bonea. Skin: conservativeb. Fat and fascia: radical
6. Prophylactic fasciotomy ofcompartment exposure
7. Muscle: debride non-viable tissuea. Colorb. Consistencyc. Contractilityd. Capacity to bleede. Response to hemostasis 19NB
MUSCLE DEBRIDEMENT
Colour: red/brownConsistency: feels like
muscle/softCapillary circulation: does it
bleed?Contractility: does it contract
with cautery or pinching
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COVER EXPOSED
9 a Neurovascular structuresb Tendonc Boned Articular surface
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BONE STABILIZATION
EXTERNAL FIXATORReason: be able to clean/dress
wound; difficult to eradicate infection with internal fixation/plate
22NB
COMPLICATIONS
NeurovascularCompartment syndromeINFECTION (prophylaxis NB!!)Loss of limb
23NB
Mangled Extremity Severity Score
“MESS”Skeleton Soft Tissue PointsLow energy, simple fx, low velocity GSW 1Medium, moderate comminution 2High energy (close range shot gun, etc) 3Massive crush 4
Shock
Normotensive (SBP>90) 0Transient hypotension 1Persistent hypotension 2IschemiaNone 0Decreased pulses 1*No pulse, slow cap refill, paresthias 2*Cool pulseless, insentiate 3*
Points double if ischemia > 6 hrsAge< 30 Yr 030-50 1>50 2
MESS > 6 Amputation24
Not for studying purposes
MANAGEMENT
1. General supportive measures (a) cover wounds (b) fluid resuscitation/blood (c) Antibiotics - Cephosporin (2nd generation) 2. Limb - specific treatment
(a) debride/decontaminate• No tornique• Remove all dead tissue • Save bone
(b) Skeletal stabilization(c) Soft tissue cover(d) Bone reconstruction(e) Rehabilitation
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EndThank you 26