open fracture
DESCRIPTION
opTRANSCRIPT
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OPEN FRACTURES
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OPEN FRACTURES -INTRODUCTION
OPEN FRACTURES ARE ALSO KNOWN AS COMPOUNDFRACTURES
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Defnition
Open racture implie communication!et"een e#ternal en$ironment an%t&e racture'
A ot tiue in(ur) complicate% !) a!ro*en !one'
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Component o open racture
Fracture
Sot+tiue %ama,e
Neuro$acular compromie
Contamination
E#tent o eac& component mut !e aee%
in%i$i%uall) in or%er to ac&ie$e acompre&eni$e un%ertan%in, o t&e in(ur)-upon "&ic& t&e treatment plan can !e !ae%'
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.itor)
A centur) a,o- t&e &i,& mortalit) opatient "it& open racture le% to earl)amputation to pre$ent %eat&'
Trueta recommen%e% open "oun%treatment an% u!e/uent encloure oe#tremit) in a cat
0n 1234- t&e ue o Penicillin re%uce% t&erate o "oun% epi
.ampton recommen%e% cloure !et"een3t&+5t&%a) ater in(ur)
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Mec&anim o in(ur)
Open racture occur a a reult o%irect &i,& ener,) trauma eit&errom Roa% tra6c colliion or all
rom &ei,&t'
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Epi%emiolo,)
Diap&)eal racture"ere more commont&an metap&)eal
racture' .i,&etrate o %iap&)ealracture "ere eenin ti!ia781'9:;ollo"e% !)emur718'1:;- ra%iuan% ulna72'4:;- an%&umeru7
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Micro!iolo,)
Poor tiue o#),enation an% %e$itali=ation o t&eurroun%in, tiue inclu%in, t&e !one pro$i%e aperect me%ium or inection an% !acterialmultiplication'
W&en let open >8"ee* ? prone to noocomialinection uc& a peu%omona pecie an% ,ramne,ati$e !acteria'
T&i p&enomenon o &opital ac/uire% inectionemp&ai=e t&e importance o a trict protocol or in+
&opital mana,ement an% earl) "oun% co$era,e'
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OPEN FRACTURES -COMPLICATIONS
W.@ OPEN FRACTURES CAN E DANBEROUS
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Earl) Complication
0nection
.)po$olemic &oc*
Compartment )n%rome Fat em!olim
Ar%
Neuro$acular in(urie
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.)po$olemic &oc*
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.)po$olemic &oc* +mana,ement
T"o lar,e+!ore 0 line &oul% !etarte%'
Once 0 acce i o!taine%- initialui% reucitation i perorme% "it&an iotonic cr)talloi%- uc& a Rin,erlactate olution or normal aline' An
initial !olu o 1+8 L i ,i$en in ana%ult 78 mLG*, in a pe%iatricpatient;- an% t&e patientH repone
i aee%'
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.)po$olemic &oc*
T)pe o ui%+
Colloi% ? al!umin- %e#tran- plama
Cr)talloi% ? NS- D
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Compartment )n%rome
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Compartment )n%rome
Claicall) < P aociate% "it&compartment )n%rome
Pain out o proportion to "&at ie#pecte%
Paret&eia
Pallor
Paral)i
Palpa!le pule
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Meaurement o compartment )n%rome+,au,in, preure !) intro%ucin, nee%le into
compartment
Str)*er 82< /uic*+preuremonitor et
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Compartment )n%rome
Treatment + Faciotom)
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Fat em!olim
Defnition + Occluion o mall $eel!) at ,lo!ule
T)pe+
1' cere!ral ? %ro")- retle an%%ioriente%
8'pulmonar) ? tac&)pnea-tac&)car%ia- petec&ial ra&7in ront onec*- ant a#illar) ol%- c&et an%con(ucti$a;
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Fat em!olim
Dia,noi ?
i,n o retinal arter) em!oli7triate&emorr&a,e an% e#u%ate; ma) !epreent'
Sputum an% urine ma) re$ealpreence o at ,lo!ule'
+ra) o c&et &o" patc&)pulmonar) inarct'
loo% Po8
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Fat em!olim
Treatment+
Repirator) upport
.eparini=ation 0ntra$enou lo"+molecular "ei,&t
%e#tran an% corticoterio%
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ARDS
0 caue% !) releae o inammator)me%iator "&ic& caue %iruption opulmonar) $aculature'
Si,n an% )mptom ? Tac&)pnea-lo" P- C)anoi
Treatment ? 1: o#),en
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0n(ur) to !loo% $eel
A!ent perip&eral pule in an in(ure%lim! &oul% !e coni%ere% to !e %ue to$acular %ama,e unle pro$e%
ot&er"ie' &ar% i,n o arterial in(ur)
7a; a!ent pule
7!; acti$e &emorr&a,e
7c; e#pan%in, &ematoma- an%
7%; !ruit or t&rill'
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acular in(ur)
0n$eti,ation+
Colour %oppler tu%)
Arterio,rap&)
Treatment+
Arterial recontruction
)pa ,rat
Timin,+ lo o total !loo%uppl) to t&e lim! or > &our nearl) al"a)reult in amputation'
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Ner$e in(ur)
Ner$e repair &oul% !e %one "it&in 4"ee* o in(ur) or !etter reult
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OPEN FRACTURES GRADING ANDCLASSIFICATION
TO ACCURATEL@ DESCR0E S0M0LAR 0NQUR0ES 0N ORDER TO
PRO0DE A AS0S FOR TREATMENT- TO EST0MATEPROBNOS0S AND TO ENALE COMPAR0SON ETWEENCENTERS'
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Butilo an% An%eron
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Butilo an% An%eron
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Tc&erne
Grade I? mall puncture "it&out aociate%contuion- ne,li,i!le contamination- lo"+ener,)mec&anim o racture'
Grade I0+ mall laceration- *in an% ot tiuecontuion- mo%erate !acterial contamination
Grade III+ lar,e laceration "it& &ea$) !acterialcontamination- e#teni$e ot tiue %ama,e
Grade IV+ incomplete or complete amputation"it& $aria!le
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.anno$er racture cale
Total score - T&i coni%er e$er) %etail ot&e in(ur) to t&e in$ol$e% e#tremit) an% i ma%eup a a c&ec*lit' T&e racture t)pe accor%in, tot&e AO claifcation- t&e *in laceration- t&eun%erl)in, ot tiue- t&e $acularit)- t&eneurolo,ical tatu- t&e le$el o contamination- acompartment )n%rome- t&e time inter$al!et"een in(ur) an% treatment- an% t&e o$erall
e$erit) o t&e in(ur) to t&e patient are a%%e% up
to pro$e t&e total core'
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.anno$er racture cale
0nterpretation
minimum core
ma#imum core 88
T&e &i,&er t&e core t&e "ore t&ein(ur)'
A core 11 in%icate i,nifcanttrauma- "it& amputationrecommen%e%'
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AO claifcation
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AO claifcation
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0o 1 ? *in !rea*a,e rom ini%e out
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0o 8+ *in !rea*a,e rom outi%e in
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0o4 ? *in !rea*a,e rom outi%e in >
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0O 3 ? Coni%era!le- ull t&ic*ne contuion-a!raion- e#teni$e open %e,lo$in,- *in lo
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0O< ? e#teni$e %e,lo$in,
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Neuro$acular in(ur) + AO
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MucleGten%on in(ur) ? AO
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Ban,a &opital core
0nterpretation
T&e total core "a ue% to a%%ret&e /uetion o al$a,e an% t&e
outcome "a meaure% !) %i$i%in,t&e in(urie into our ,roup 7Broup 0+
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Man,le% e#tremit) e$erit) in%e#
Man,le% e#tremit) e$erit)
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Man,le% e#tremit) e$erit)
core7MESS;
LS0+ lim! al$a,e in%e#
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LS0 lim! al$a,e in%e#
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Lim Sal!a"e I#de$ O%tcome
< lim! al$a,e ucceul 7
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Pre%icti$e al$a,e in%e#
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0nterpretation minimum core 4 7!ae% on t&e point
ai,nment i no $acular- !one or mucle in(ur)t&en t&e core coul% reac& 1- !ut t&en it "oul%not !e a erioul) in(ure% lim!;
ma#imum core 14
T&e &i,&er t&e core t&e "ore t&e c&ance or aucceul lim! al$a,e'PSI O%tcome
5 ,oo% 718 o13 lim!al$a,e%
poor 75 o 5amputate%;
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N0SSSA
Parameter
N V ner$e in(ur)
0 V ic&emia
S V ot tiue contamination
S V *eletal in(ur)
S V &oc* A V a,e o t&e patient
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N0SSSA
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N0SSSA
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N0SSSA
0nterpretation
minimum core
ma#imum core 12
T&e &i,&er t&e core- t&e more e$eret&e in(ur)'
A core 5 "a 1: eniti$e or
amputation- !ut "it& pecifcit) o 39:' A core 11 &a% a 1: pecifcit) an%
poiti$e pre%icti$e $alue or amputation'
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OPEN FRACTURES -MANAGEMENT
T.E TREATMENT OF .0B. ENERB@ 0NQUR0ES A0M TOPRESERE L0FE- L0M AND FUNCT0ON'
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Boal o treatment
T&e interme%iate o!(ecti$e are+
Pre$ention o inection
Fracture ta!ili=ation
Sot+tiue co$era,e
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Sta,e o care
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0nitial aement
0mportant component in aein,traumati=e% e#tremit)
1' .itor) an% mec&anim o in(ur)
8' Neuro$acular tatu4' Si=e o *in "oun%
3' Mucle cru& or lo
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Primar) ur,er)
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0rri,ation
Supplement )temic %e!ri%ementin remo$in, orei,n material an%%ecreain, !acterial loa%'
Fract%re t&'e Vol o( )%id %sed (orirri"atio#
T)pe 0 4 L
T)pe 8 9L
T)pe 4 2L
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0rri,ation
8 a%a,e'
0 a little %oe ome ,oo%- a lot "ill%o a ,reat %eal more
olution to pollution i %ilution
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0rri,ation
NS normall) ue% orirri,ation'
Anti!iotic olution i no!etter t&an oap or openracture irri,ation
Antieptic olution &a$e!een not &o"n to%ecreae inection rate'
Suractant7non terileoap; ame eXecti$ene-le tiue %ama,e n moreeconomical'
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Timin, o %e!ri%ement an%
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Timin, o %e!ri%ement an%
irri,ation
Mot ,ui%eline recommen%%e!ri%ement "it&in 9 &r'
Serial %e!ri%ement ma) !e
necear) e$er) 83+3&r until t&e"oun% $ia!ilit) i enure%
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Anti!iotic
S)temic a%minitration
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Anti!iotic
Local anti!iotic
0n ,utilo t)pe 000 racture a%%itionalue o local amino,l)coi%e
impre,nate%pol)met&)lmet&acr)late7PMMA;!ea% re%uce o$erall inection rate'
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P i
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Primar) ur,er)
Timin,
Sur,ical emer,enc)
Operatin, room "it& 9+&r o in(ur)? contaminate% "oun% not treate%"it&in t&i time "ill &a$e utaine%!acterial multiplication to reult in
earl) inection'
P i
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Primar) ur,er)
Fracture ta!ili=ation
A oon a primar) "oun% care icomplete%- treatment &oul%
procee% to racture re%uction an%f#ation'
Sur,eon &oul% recru!- re,o"n an%
re,lo"' DiXerent et o intrumentt&an t&oe ue% or %e!ri%ement inecear)'
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Relati$e 0n%ication or T)pe o
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Relati$e 0n%ication or T)pe oS*eletal Fi#ation in Open Fracture
E#ternal f#ation
Se$ere contamination an) ite
Periarticular racture
Defniti$e
Dital ra%iu
El!o" %ilocation
Selecte% ot&er ite
Tempori=in,
Knee
An*le
El!o"
Writ
Pel$i
Ditraction oteo,enei
0n com!ination "it& cre" f#ation or e$ere ot tiue in(ur)
Relati$e 0n%ication or T)pe o
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Relati$e 0n%ication or T)pe oS*eletal Fi#ation in Open Fracture
0nternal f#ation
Periarticular racture
DitalGpro#imal ti!ia
DitalGpro#imal emurDitalGpro#imal &umeru
Pro#imal ulnar ra%iu
Selecte% %ital ra%iuGulna
Aceta!ulumGpel$i
Diap&)eal racture
FemurTi!ia
.umeru
Ra%iuGulna
Pl t
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Plate
Open %iap&)eal racture o t&era%iu an% ulna a "ell a t&e&umeru are !et mana,e% "it&
plate f#ation' T&e plate f#ation o lo"er e#tremit)
%iap&)eal racture i ,enerall) not
recommen%e% %ue to &i,&er rate oinection'
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0ntrame%ullar nailin,
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0ntrame%ullar) nailin,
Loc*e% intrame%ullar) nailin, &a !eeneta!li&e% a t&e treatment o c&oice ormot %iap&)eal racture in lo"ere#tremit)'
T&e tec&ni/ue &a particular $alue oropen racture' 0ntrame%ullar) nail can !einerte% "it& no urt&er %iruption o t&e
alrea%) in(ure% ot+tiue en$elope an%preer$e t&e remainin, e#tra oeou!loo% uppl) to cortical !one'
0M nailin,
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0M nailin,
Data &o"in, t&at oli% intrame%ullar)nail inerte% "it&out reamin, &a$e alo"er ri* o inection'
On t&e ot&er &an% reame% intrame%ullar)nail can relia!l) maintain racturere%uction "it& re,ar% to an,ulation-rotation- %iplacement- an% len,t&'
Propecti$e ran%omie% trail t&atcompare% reame% "it& unreame%interloc*e% 0M nail %i% not &o" an)i,nifcant %iXerence concernin, outcome
an% ri* o com lication'
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E#ternal f#ation
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E#ternal f#ation
A%$anta,e o e#t Fi#ation+
Can !e applie% relati$el) eail) an%/uic*l)
0t pro$i%e relati$el) ta!le racturef#ation
T&ere i no urt&er %ama,e %one i
applie% correctl) 0t a$oi% implantation o &ar%"are in
open "oun%'
E#t f#ator
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E#t f#ator
Ma(or pro!lem "it& e#ternal f#ation arerelate% to pin tract inection- malali,nment -%ela)e% union- poor patient compliance'
E#ternal f#ator are particularl) ueul inracture "it& e$ere %ama,e an%contamination- "&ere metallic implant ?"it& ri* o !acterial a%&erence ? are !et
a$oi%e%' Rin, f#ator ma) !e an option in
%iap&)eal racture
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T)pe ?
Rin, f#ator
Qoint pannin, e#ternal f#ator
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Open "oun% co$era,e ater primar)
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p , p )
ur,er)
Primar) Cloure
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Primar) Cloure
0 it i to !e %one- t&e ollo"in, criteria mut !e met
1' T&e ori,inal "oun% mut &a$e !een airl) clean- an% not&a$e occurre% in a &i,&l) contaminate% en$ironment'
8' All necrotic tiue an% orei,n material &a$e !een %e!ri%e%'
4' Circulation to t&e lim! i eentiall) normal'
3' Ner$e uppl) to t&e lim! i intact'
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Dela)e% primar) cloure
cloure !eore t&e ft& %a) i terme% %ela)e%primar) cloure
A lon, a cloure i ac&ie$e% !eore t&e ft&%a)- "oun% tren,t& at 13 %a) are
compara!le "it& t&oe in "oun% cloe% on t&efrt %a)
lea$in, t&e "oun% open minimi=e t&e ri* oanaero!ic inection- an% t&e %ela) allo" t&e
&ot to mount local "oun% %eeni$emec&anim t&at permit aer cloure t&an ipoi!le on t&e frt %a)'
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Current tan%ar% o care or all openracture "oun% i to !e let openinitiall)'
Dela)e% cloure i accompli&e%"it&in 8+5%a)
AC aite% "oun% cloure i
preentl) recommen%e% ortemporar) mana,ement o openracture "oun%'
AC
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AC
T&e "oun% !e% i e#poe% to mec&anicall)in%uce% ne,ati$e preure in a cloe%)tem '
T&e )tem remo$e ui% rom e#tra$acular
pace- re%uce e%ema- impro$e microcirculation an% en&ance t&e prolieration opreparati$e ,ranulation tiue'
Pol)uret&ane oam %rein, i place% in"oun% an% enure an e$en %itri!ution one,ati$e preure'
AC
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AC
Anti!iotic !ea% pouc&
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tec&ni/ue
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Reerence
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Reerence
AO principle o racturemana,ement 8n%E%
Roc*"oo% an% ,reen ? racture in
a%ult 5t&E% Camp!ell + operati$e ort&ope%ic 11t&
E%'
Mana,ement o open racture !) Dr'TSE Lun, Fun,
ariou ource on 0nternet
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T*AN+ ,OU