open fracture raju3

8/6/2019 Open Fracture Raju3

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IntroductionIntroduction

An An openopen fracturefracture refersrefers toto osseousosseousdisruptiondisruption inin whichwhich aa breakbreak inin thetheskinskin andand underlyingunderlying softsoft tissuetissue or or bodybody cavitycavity communicatescommunicates directlydirectly

withwith thethe fracturefracture andand itsits haematomahaematoma. .O pen fractures often result fromO pen fractures often result fromhighhigh--energy trauma and areenergy trauma and arecharacterized bycharacterized by

variable degrees of soft tissue andvariable degrees of soft tissue andskeletal injury, both of which impair localskeletal injury, both of which impair localtissue vascularity.tissue vascularity.

In addition, bone, tendons, nerves,In addition, bone, tendons, nerves,and articular cartilage may beand articular cartilage may beexposed and subject to damage.exposed and subject to damage.


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IntroductionIntroduction

TheThe annualannual incidenceincidence of of openopen fracturesfractures of of longlong bonesbones hashasbeenbeen estimatedestimated toto bebe 1111..55 perper 100100 000000 personspersons 11 withwith 4040%%occurringoccurring inin thethe lowerlower limb,limb, commonlycommonly at at thethe tibialtibial diaphysisdiaphysis. .

OneOne--thirdthird of of patientspatients withwith openopen fracturesfractures areare multiplymultiplyinjuredinjured..


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IncidenceIncidence


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Significance of Open fractureSignificance of Open fracture(Why it is an emergency)(Why it is an emergency)

S ignificant increase in risk of infection (up to 25S ignificant increase in risk of infection (up to 25- -50%).50%).Risk of eventual amputation.Risk of eventual amputation.Degloving injuries and ischaemic necrosis of skinDegloving injuries and ischaemic necrosis of skin

MusclesMusclesCrush and compartment syndromesCrush and compartment syndromes

Blood vesselsBlood vessels Vasospasm and arterial laceration Vasospasm and arterial laceration

NervesNervesNeurapraxias, axonotmesis, neurotmesisNeurapraxias, axonotmesis, neurotmesis

LigamentsLigamentsJoint instability and dislocationJoint instability and dislocation


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Significance of Open fractureSignificance of Open fracture

S oft tissue injuries in an open fracture may have threeS oft tissue injuries in an open fracture may have threeimportant consequencesimportant consequences

Contamination of

the wound andfracture

Crushing,stripping &devascularization

Destruction or lossof the soft tissueenvelope

INFECTION

Affect methodofimmobilization

Fracture Healing

Results in lossof functionfromMuscleTendonNerve

VascularLigament orS kin damage


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Significance of Open fractureSignificance of Open fracture

IN SHORT

Op en fractures communicatewith the outside environment, andthe resulting contamination of the

wound with microorganisms, cou pl edwith the com promis ed va scular

supply t o the r eg ion, l e ads t o an incr e as e d

risk of inf e ction as we ll as tocomplications in he aling.


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Mechanism of Injury Mechanism of Injury

Usually high energyUsually high energytrauma.trauma.

Open fracture results fromOpen fracture results fromthe application of a violent the application of a violent force.force.

The amount of osseousThe amount of osseousdisplacement anddisplacement andcomminution is suggestivecomminution is suggestiveof the degree of soft tissueof the degree of soft tissueinjury and is proportionalinjury and is proportionalto the applied force.to the applied force.


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ManagementManagement

T heT he initialinitial evaluationevaluation of of aa patientpatient withwith anan openopen fracturefracture of of aalimblimb shouldshould alwaysalways followfollow thethe principlesprinciples andand guidelinesguidelines of of thethe Adv ance d Adv ance d T raumaT rauma LifeLife Support Support SystemSystem ..

P rimary Survey (ABCDE)P rimary Survey (ABCDE) & & ResuscitationResuscitation Adjuncts to P rimary Survey & Resuscitation Adjuncts to P rimary Survey & ResuscitationConsider need for P atient T ransfer Consider need for P atient T ransfer Secondary SurveySecondary Survey (with AM PL E History)(with AM PL E History)Continued P ostContinued P ost--Resuscitation Monitoring & ReResuscitation Monitoring & Re- -evaluationevaluationT ransfer to Definitive CareT ransfer to Definitive Care


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P RIMARY SURVEYP RIMARY SURVEY

AA -- AirwayAirway && Cervical Spine ControlCervical Spine Control

BB -- BreathingBreathing & & OxygenationOxygenation

CC -- CirculationCirculation & & Haemorrhage ControlHaemorrhage Control

DD -- DysfunctionDysfunction & & Disability of the CNSDisability of the CNS

EE -- ExposureExposure & & Environmental ControlEnvironmental Control


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P RIMARY SURVEY


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ImmediatelyImmediately L ifeL ife T hreateningT hreatening InjuriesInjuries or or ConditionsConditions whichwhichshouldshould bebe pickedpicked upup inin ABCDE ABCDE andand treatedtreated immediatelyimmediately : :

1.1. Inadequate Airway P rotectionInadequate Airway P rotection

2.2. Airway O bstruction Airway O bstruction3.3. T ension P neumothoraxT ension P neumothorax4.4. O pen P neumothoraxO pen P neumothorax5.5. Flail Chest with HypoxiaFlail Chest with Hypoxia6.6. Massive HaemothoraxMassive Haemothorax7.7. Cardiac T amponadeCardiac T amponade8.8. Severe HypothermiaSevere Hypothermia9.9. Severe Shock from Haemorrhage Unresponsive to FluidSevere Shock from Haemorrhage Unresponsive to Fluid

Resuscitation.Resuscitation.


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The 4 most common causes of shock in trauma patients:The 4 most common causes of shock in trauma patients:

HaemorrhageHaemorrhageBleedingBleedingExsanguinationExsanguinationHypovolaemiaHypovolaemia

HypovolaemiaHypovolaemia is is thethe mostmost commoncommon causecause of of shockshock inintraumatrauma. . T herefore,T herefore, inin thethe presencepresence of of hypotension,hypotension, it it isisreasonablyreasonably safesafe toto assumeassume haemorrhagehaemorrhage andand directdirect teamteameffortsefforts towardtoward stoppingstopping thethe bleedingbleeding. .


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All All obviousobvious externalexternal haemorrhagehaemorrhage shouldshould bebe identifiedidentified byby adequateadequatepatientpatient exposureexposure andand managedmanaged byby appliedapplied pressurepressure. . Appropriate Appropriate

splintingsplinting of of longlong bonebone fracturesfractures throughthrough alignmentalignment andand immobilisationimmobilisationisis alsoalso importantimportant. .


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DISABILITYDISABILITY

Disability,Disability, inin termsterms of of thethe primaryprimary survey,survey, isis assessedassessed byby thethe AV P U AV P U scalescale: :

A A -- alert, that is responds to voice appropriately, i.e. obeys commandsalert, that is responds to voice appropriately, i.e. obeys commandsVV -- vocalises, may be inappropriate or incomprehensible soundsvocalises, may be inappropriate or incomprehensible soundsP

P

-- responds to pain only (should be assessed in all 4 limbs if initialresponds to pain only (should be assessed in all 4 limbs if initiallimb fails to respond)limb fails to respond)UU -- unresponsive to pain.unresponsive to pain.


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EXP OSUREEXP OSURE

Expose the patient. Expose the patient. Log roll and examine the back. Log roll and examine the back. Attend to PR examination. This must be done prior to male Attend to PR examination. This must be done prior to male

catheterisation.catheterisation.

Expose the patient only for the duration of the external examination.Expose the patient only for the duration of the external examination.Once this has been completed, cover the patient with warm blanketsOnce this has been completed, cover the patient with warm blanketsand keep him / her covered unless reand keep him / her covered unless re- -examination is necessary.examination is necessary.


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LIMBS IN P RIMARY SURVEYLIMBS IN P RIMARY SURVEYQ uicklyQ uickly movemove ontoonto thethe limbs,limbs, cuttingcutting off off clothesclothes asas necessary,necessary,andand examiningexamining for for thethe presencepresence of of obviousobvious deformitydeformity or or softsofttissuetissue haematomahaematoma. .

Any Any sourcessources of of externalexternal haemorrhagehaemorrhage shouldshould immediatelyimmediately bebe

stemmedstemmed byby applyingapplying directdirect pressurepressure andand wrappingwrapping inin aabandagebandage. .If If therethere areare O penO pen (Compound)(Compound) FracturesFractures, ,

TheThe surgeonsurgeon sendsend aa swabswab forfor bacteriologicalbacteriological analysisanalysis..TheThe woundwound shouldshould bebe immediatelyimmediately coveredcovered withwith aa BetadineBetadine swabswab oror clingclingfilm,film, preferablypreferably afterafter takingtaking aa polaroidpolaroid photographphotograph. . TheThe woundwound shouldshould not not bebeuncovereduncovered againagain untiluntil thethe patient patient isis inin theatretheatre. .TheThe patient patient shouldshould bebe givengiven intravenousintravenous morphine,morphine, a a tetanustetanus injectioninjection andandintravenousintravenous antibioticsantibiotics (usually(usually cefuroximecefuroxime && metronidazole)metronidazole). .T heT he orthopaedicorthopaedic teamteam shouldshould bebe informedinformed andand askedasked toto attendattend thethe A&E A&Edepartmentdepartment. .


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Adjuncts to the primary Adjuncts to the primarysurvey include:survey include:

Radiology:Radiology: CXR first CXR first P XR second P XR second

C C--spine thirdspine third

ADJUNCTS TO THE P RIMARY SURVEY


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SECONDARY SURVEYSECONDARY SURVEYThe secondary survey covers (in this order):The secondary survey covers (in this order):

1. Head and scalp / maxillofacial.1. Head and scalp / maxillofacial.2. Cervical spine and neck.2. Cervical spine and neck.

3. Chest.3. Chest.4. Abdomen and pelvis.4. Abdomen and pelvis.5. Back and perineum.5. Back and perineum.6. Extremities.6. Extremities.7. Neurological.7. Neurological.

AMPL E AMPL E HistoryHistory A A -- Allergies AllergiesMM -- MedicinesMedicinesPP -- P ast Medical HistoryP ast Medical History / / P regnancyP regnancyLL -- Last MealLast MealEE -- EventsEvents / / Environment leading to the current traumaEnvironment leading to the current trauma


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T he principles that govern open fracture management includeT he principles that govern open fracture management include

Assessment of the patient and classification of the injury, Assessment of the patient and classification of the injury,prevention of infection,prevention of infection,wound management, andwound management, andfracture stabilization.fracture stabilization.

ManagementManagement of of openopen fracturesfractures cancan bebe challenging,challenging, andand multiplemultiple

surgicalsurgical proceduresprocedures frequentlyfrequently areare neededneeded toto achieveachieve softsoft--tissuetissuecoveragecoverage andand fracturefracture unionunion..


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A complete history and physical examination is essential, which include A complete history and physical examination is essential, which includecomplete assessment of open fracturecomplete assessment of open fracture

Complete assessment of the open fracture includesComplete assessment of the open fracture includes

reviewing the mechanism of injury,reviewing the mechanism of injury,condition of the soft tissues,condition of the soft tissues,degree of bacterial contamination, and characteristics of thedegree of bacterial contamination, and characteristics of thefracture.fracture.

T he evaluation of these factors will help toT he evaluation of these factors will help toclassify the fracture,classify the fracture,determine the treatment regimen, anddetermine the treatment regimen, andestablish the prognosis and potential clinical outcome. In particular,establish the prognosis and potential clinical outcome. In particular,the degree of bacterial contamination and softthe degree of bacterial contamination and soft- -tissue damage istissue damage isimportant in classifying an open fracture.important in classifying an open fracture.


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ASSESSMENT OF O P EN FRACTURE


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ASSESSMENT OF O P EN FRACTUREASSESSMENT OF O P EN FRACTUREHISTORYHISTORY

Knowledge of the mechanism of injury is essential. It will often give theKnowledge of the mechanism of injury is essential. It will often give theonly indication of the level of energy transfer to the tissues.only indication of the level of energy transfer to the tissues.

T he features that should alert the admitting doctors to the possibility of T he features that should alert the admitting doctors to the possibility of a high energy injury include:a high energy injury include:

Any road traffic accident. Drivers, passengers or pedestrian. Any road traffic accident. Drivers, passengers or pedestrian.Falls from a significant height.Falls from a significant height.

Any injury mechanism involving extensive or localised crushing. Any injury mechanism involving extensive or localised crushing.Missile wounds.Missile wounds.Contamination from the scene of the accident.Contamination from the scene of the accident.

A history of entrapment or lying immobile on the injured limb for a prolonged A history of entrapment or lying immobile on the injured limb for a prolongedperiod.period.

Any suggestion of possible limb ischaemia. Any suggestion of possible limb ischaemia.


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ASSESSMENT OF O P EN FRACTUREASSESSMENT OF O P EN FRACTURE

EXAMINATION OF WOUNDEXAMINATION OF WOUND

Assess skin and soft tissue damage: Assess skin and soft tissue damage:Exploration of the wound in the emergency setting is not indicatedExploration of the wound in the emergency setting is not indicatedbecause it risks further contamination.because it risks further contamination.

Location and extent of the woundLocation and extent of the woundLength of the woundLength of the wound

Number of skin woundNumber of skin woundDegree of wound and skin contaminationDegree of wound and skin contamination Apparently intact tissues of the limb Apparently intact tissues of the limbshould also be examined.should also be examined.Palpate the wound for foreign bodies.Palpate the wound for foreign bodies.

A small wound doesntalways necessarily carriesa good prognosis becausethere may be significantassociated contaminationand tissue damage.


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Systematic examination of the affected limb will reveal theSystematic examination of the affected limb will reveal thefollowing features of high energy injury:following features of high energy injury:

SKI NSKI N

Large or multiple wounds.Large or multiple wounds.I mprints or tattooing from dirt or tyres.I mprints or tattooing from dirt or tyres.Crush or burst wounds.Crush or burst wounds.ClosedClosed deglovingdegloving.. S kinS kin isis intact intact but but withwith nono bloodblood supplysupply duedue

toto shearingshearing betweenbetween thethe deepdeep fasciafascia andand subcutaneoussubcutaneoustissuestissues. . I t I t cancan bebe difficult difficult toto diagnosediagnose but but maymay bebe suspectedsuspectedfromfrom thethe boggyboggy feelfeel of of thethe skinskin oror thethe abnormalabnormal loosenesslooseness of of thethe skinskin whenwhen it it isis pinchedpinched. .


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Signs of Nerve InjurySigns of Nerve Injury Abnormal sensation is more Abnormal sensation is moreimportant than loss of motor important than loss of motor power as it occurs earlier.power as it occurs earlier.

Never merely ask Can youNever merely ask Can youfeel this?. Compare the twofeel this?. Compare the twosides.sides.Check all peripheral nerveCheck all peripheral nerveterritories, particularly that of territories, particularly that of the posterior tibial nerve, thethe posterior tibial nerve, the

plantar surface of the foot.plantar surface of the foot. Always examine several Always examine severalzones of each nerve territoryzones of each nerve territoryin case of a partial nervein case of a partial nervelesion.lesion.

Signs of Vascular InjurySigns of Vascular Injury

Absence of peripheral pulses Absence of peripheral pulsesor reduced capillary returnor reduced capillary return

after correction of after correction of hypovolaemia and reductionhypovolaemia and reductionof limb deformityof limb deformity ..


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ClassificationClassification

Although there are other classifications of open fractures, the Although there are other classifications of open fractures, theG ustilo classification G ustilo classification has now been adopted worldwide.has now been adopted worldwide.

I t is based on theI t is based on the

size of the wound,size of the wound,the amount of soft tissue damage or contamination,the amount of soft tissue damage or contamination,and the type of fracture.and the type of fracture.

There are three fracture types, with the Gustilo type III fracturesThere are three fracture types, with the Gustilo type III fracturesdivided into three subtypes based ondivided into three subtypes based on

the extent of the periosteal damage,the extent of the periosteal damage,the presence of contamination,the presence of contamination,and the extent of arterial injury.and the extent of arterial injury.


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Gustilo classification used for prognosisGustilo classification used for prognosis

Fracture healing, infection and amputation rate correlateFracture healing, infection and amputation rate correlatewith the degree of soft tissue injury by Gustilowith the degree of soft tissue injury by Gustilo

Fractures should be classified in the operating room at theFractures should be classified in the operating room at thetime of initial debridement time of initial debridement

Evaluate periosteal strippingEvaluate periosteal strippingConsider soft tissue injuryConsider soft tissue injury


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T ype I Open Fractures T ype I Open Fractures

InsideInside--out injuryout injury

Clean wound,Clean wound,


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T ype II Open Fractures T ype II Open Fractures

Moderate soft tissueModerate soft tissuedamagedamage

Clean, >Clean, > 1cm1cm

UsuallyUsually S imple FractureS imple Fracture

OutsideOutside--in mechanismin mechanism

Higher energy injuryHigher energy injury

S ome necrotic muscle,S ome necrotic muscle,some periosteal strippingsome periosteal stripping


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T ype IIIA Open Fractures T ype IIIA Open Fractures

High energyHigh energy

O utsideO utside--in injuryin injury

Extensive muscleExtensive muscledevitalizationdevitalization

Bone coverage withBone coverage withexisting soft tissue notexisting soft tissue notproblematicproblematic


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T ype IIIC Open Fractures T ype IIIC Open Fractures

High energyHigh energy

Increased risk of Increased risk of amputation and infectionamputation and infection

Major vascular injuryMajor vascular injuryrequiring repair requiring repair


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T ype III Open Fractures T ype III Open Fractures

BewareBeware

High velocity gunshot injuriesHigh velocity gunshot injuries

Farm injuriesFarm injuries

Severe contamination more than 8 hoursSevere contamination more than 8 hours

T raumatic amputationT raumatic amputation


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ASSESSMENT OF O P EN FRACTUREASSESSMENT OF O P EN FRACTURE

Signs of Compartment SyndromeSigns of Compartment Syndrome

MoreMore painpain thanthan expected,expected, eveneven whenwhen thethe fracturedfractured legleg isisimmobilisedimmobilised.. Never Never assumeassume thatthat severesevere painpain isis fromfrom thethe bonebone. .RelentlessRelentless painpain unrelievedunrelieved byby opiatesopiates isis moremore likelylikely toto bebe producedproducedbyby ischaemicischaemic musclemuscle. .P ain on passive stretching of the muscles in the affectedP ain on passive stretching of the muscles in the affectedcompartment.compartment.

A tense, swollen limb. A tense, swollen limb.Sensory disturbance of the foot.Sensory disturbance of the foot.T ender or indurated muscle compartment ( Late sign).T ender or indurated muscle compartment ( Late sign).


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ASSESSMENT OF O P EN FRACTUREASSESSMENT OF O P EN FRACTURERadiological ExaminationRadiological Examination

Usually, only anteroposterior and lateral radiographs are requiredUsually, only anteroposterior and lateral radiographs are requiredT hey should include adjacent joints and any associated injuries.T hey should include adjacent joints and any associated injuries.


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The fracture pattern can often give clues to the degree of energyThe fracture pattern can often give clues to the degree of energytransfer through the bone. Important features include:transfer through the bone. Important features include:

MRI and C T scans are rarely required in the acute situation but may be helpfulin open pelvic, intra-articular, carpal, and tarsal fractures.

Angiography may be required in Gustilo IIIb or IIIc fractures. In thepolytraumatized patient, the surgeon must decide if a delay for further imagingis appropriate.

Multiple bone fragments.Wide displacement of fracture

fragments. Any segmental injury. Air in the tissues.More than one fracture in the

same limb .


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T he goals in the treatment of open fractures are toT he goals in the treatment of open fractures are to

prevent infection,prevent infection,

achieve bone union,achieve bone union,avoid malunion, andavoid malunion, andrestore the limb and patient to full function as early asrestore the limb and patient to full function as early aspossible.possible.

O f these, it is most important to avoid infection, as infectionO f these, it is most important to avoid infection, as infectionis the most common complication leading to nonunion andis the most common complication leading to nonunion andloss of function.loss of function.


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TREATMENT OF O P EN FRACTURETREATMENT OF O P EN FRACTURETreatment in the ERTreatment in the ER

Haemorrhage should be addressed and managed.Haemorrhage should be addressed and managed. Antibiotics (IV). Antibiotics (IV).

T etanus prophylaxis.T etanus prophylaxis. Analgesics. Analgesics.Irrigation of wound and removal of foreign bodies.Irrigation of wound and removal of foreign bodies.Coverage of wound with sterile dressing.Coverage of wound with sterile dressing.T emporary splinting of Fracture.T emporary splinting of Fracture.

Consideration of early amputation in severe cases.Consideration of early amputation in severe cases.Decompression of compartment Decompression of compartment

Wound exploration and debridement, and definitive fractureand soft tissue management should not be done in the ER .Increases the chance of contamination!


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P revention of InfectionP revention of InfectionIV AntibioticsIV Antibiotics

Local AntibioticsLocal Antibiotics

Treatment of WoundTreatment of WoundWound extensionWound extension

Wound DebridementWound DebridementSkinSkinFat and FasciaFat and FasciaMuscle, Nerve and T endonMuscle, Nerve and T endonBoneBoneJ

ointJ

oint

Wound Lavage (Irrigation)Wound Lavage (Irrigation)Secondary DebridementSecondary Debridement

Wound Closure:Wound Closure:Delayed primary or secondaryDelayed primary or secondaryClosureClosure

Fracture StabilizationFracture StabilizationExternal FixationExternal Fixation

Internal FixationInternal FixationSoft tissue cover or Soft tissue cover or reconstructionreconstruction

TREATMENT OF O P EN FRACTURE


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TREATMENT OF OPEN FRACTURETREATMENT OF OPEN FRACTURE

P revention of InfectionP revention of Infection

TheThe first first orthopaedicorthopaedic procedureprocedure hashas asas oneone of of itsits objectivesobjectives thetheremovalremoval of of microorganismsmicroorganisms contaminatingcontaminating thethe fracturefracture fromfrom thethescenescene of of thethe injuryinjury..

HoweverHowever byby farfar thethe greatest greatest micromicro--biologicalbiological threat threat comescomes fromfromorganismsorganisms inin thethe hospitalhospital environment environment manymany of of whichwhich willwill havehavedevelopeddeveloped antibioticantibiotic resistanceresistance. . ContaminationContamination cancan occuroccur veryveryquicklyquickly andand must must bebe preventedprevented. .


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TREATMENT OF O P EN FRACTURETREATMENT OF O P EN FRACTUREP revention of InfectionP revention of Infection

IV Antibiotics:IV Antibiotics:S ome 60% to 70% of open wounds are associated withS ome 60% to 70% of open wounds are associated withpositive cultures in the emergency department.positive cultures in the emergency department.Gustilo type I and II open fracturesGustilo type I and II open fractures

CephalosporinCephalosporinGustilo type III open fracturesGustilo type III open fractures

Cephalsporin +AminogycosidesCephalsporin +AminogycosidesI f the patient is allergic toI f the patient is allergic to penicillin, clindamycin orpenicillin, clindamycin ormetronidazolemetronidazole should be used.should be used.


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IV Antibiotics: DurationIV Antibiotics: Duration

Antibiotics should be started as soon as possible after the Antibiotics should be started as soon as possible after theinjury occurs because a delay >3 hours increases the risk of injury occurs because a delay >3 hours increases the risk of

infection.infection.

The duration of antibiotic administration is controversial.The duration of antibiotic administration is controversial.Dellinger et al16 demonstrated that a prolonged course of 5Dellinger et al16 demonstrated that a prolonged course of 5- -daydayantibiotic administration was not superior to a 1antibiotic administration was not superior to a 1- -day course forday course forprevention of fracture site infections.prevention of fracture site infections.

The duration of therapy should be limited to 3 days, withThe duration of therapy should be limited to 3 days, withrepeated 3repeated 3- -day administration of antibiotics at woundday administration of antibiotics at woundclosure, bone grafting, or any major surgical procedure.closure, bone grafting, or any major surgical procedure.


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Local Antibiotics:Local Antibiotics:

Antibiotic Antibiotic--impregnated polymethylmethacrylate (PMMA)impregnated polymethylmethacrylate (PMMA)

beads can be placed into the wound after debridement hasbeads can be placed into the wound after debridement hasbeen undertaken.been undertaken.These beads usually containThese beads usually contain gentamycingentamycin oror tobramycin.tobramycin.

The advantages of the bead pouch technique includeThe advantages of the bead pouch technique include

a high local concentration of antibiotics, often 10 to 20 timesa high local concentration of antibiotics, often 10 to 20 timeshigher than that with systemic administration;higher than that with systemic administration;a low systemic concentration, which protects from the adversea low systemic concentration, which protects from the adverseeffects of aminoglycosideseffects of aminoglycosides


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TREATMENT OF O P EN FRACTURETREATMENT OF O P EN FRACTURETreatment of WoundTreatment of Wound

Wound extension and Debridement:Wound extension and Debridement:The size of the traumatic skin wound does not always reflect the degree of The size of the traumatic skin wound does not always reflect the degree of

damage to the soft tissues of the leg.damage to the soft tissues of the leg.Therefore the skin wounds in all open fractures, including Gustilo type I Therefore the skin wounds in all open fractures, including Gustilo type I fractures, must be extended to allow adequate inspection of both the soft fractures, must be extended to allow adequate inspection of both the soft tissues and bone ends.tissues and bone ends.Wound extensions should be longitudinal and transverse incisions should beWound extensions should be longitudinal and transverse incisions should beavoided.avoided.The exact direction and length of the wound extension will depend on theThe exact direction and length of the wound extension will depend on theextent and location of the subcutaneous damage.extent and location of the subcutaneous damage.be aware of the position of the medial and lateral perforators so that thesebe aware of the position of the medial and lateral perforators so that theseare not damaged during the procedure.are not damaged during the procedure.The surgeon should also avoid cutting undamaged skin overlying theThe surgeon should also avoid cutting undamaged skin overlying thesubcutaneous border of the tibia.subcutaneous border of the tibia.


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Treatment of WoundTreatment of WoundDebridement really means exposure and that is the key to theseDebridement really means exposure and that is the key to theseprocedures.procedures.


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Treatment of Wound

Wound Debridement:

T he objective of wound excision is to removeall devitalised or contaminated tissue so that at

the end of the procedure the remaining tissuelooks clean and healthy and has an adequateblood supply.


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Treatment of WoundTreatment of WoundWound Debridement Wound Debridement

S kin and S ubcutaneous Tissues:S kin and S ubcutaneous Tissues:

The wound edges must be excised until good dermal bleeding isThe wound edges must be excised until good dermal bleeding isencountered however large a skin defect this creates.encountered however large a skin defect this creates.S hearing forces may produce extensive degloving injuries, whichS hearing forces may produce extensive degloving injuries, whichparticularly affect the lower limb and may be circumferential.particularly affect the lower limb and may be circumferential.ElderlyElderly patientspatients areare particularlyparticularly at at riskrisk of of deglovingdegloving andandcircumferentialcircumferential deglovingdegloving inin anan elderlyelderly multiplymultiply injuredinjured patient patient maymayrequirerequire amputationamputation. .


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Wound Debridement Wound Debridement

S kinS kin andand S ubcutaneousS ubcutaneous TissuesTissues::

All All degloveddegloved skinskin shouldshould bebe resectedresected untiluntil dermaldermal bleedingbleeding isisencounteredencountered. .I f I f aa largelarge areaarea of of degloveddegloved skinskin isis excised,excised, split split skinskin graft graft cancan bebeharvestedharvested fromfrom thethe excisedexcised skinskin forfor laterlater useuse..I f there are several wounds in close proximity, they should beI f there are several wounds in close proximity, they should beexcised en bloc, as there will be extensive associated soft tissueexcised en bloc, as there will be extensive associated soft tissuedamage.damage.

All devitalized fat must be removed. All devitalized fat must be removed.


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Wound Debridement


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Wound Debridement Wound Debridement Muscle:Muscle:

Dead and devitalized muscles should be removedDead and devitalized muscles should be removed ..MuscleMuscle maymay appearappear toto bebe quitequite healthyhealthy inin thethe initialinitial debridement debridement

andand bebe completelycompletely necroticnecrotic 4848 hourshours laterlater.. TheThe basicbasic rulerule of of musclemuscleisis whenwhen inin doubt doubt taketake it it out out becausebecause that that cancan bebe aa significant significant problemproblem if if necroticnecrotic musclemuscle isis left left inin situsitu..The key to determining if muscle is viable are the four C'sThe key to determining if muscle is viable are the four C's

Dead muscle is purplish

Mushy consistencyFail to contract and bleed

Dead muscle is heaven

for bacteria


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Wound Debridement Wound Debridement Bone:Bone:

All devitalized separate bone fragments should be removed All devitalized separate bone fragments should be removedregardless of their size.regardless of their size.


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Nerve and Tendon:

Wound Debridement


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J oint:For open joint injuries you want to perform an arthrotomy.Irrigate the joint and debride it.

Wound Debridement


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Wound L avage (Irrigation)

Treatment of Wound

L avage with fluids such as normal isotonic saline or antibiotic solutions is anessential part of the debridement procedure.T en to 15 liters of lavage fluid should be used to remove bone clots and other devitalized debris and ideally reduce the level of bacterial contamination.


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Treatment of WoundTreatment of Wound

Secondary DebridementSecondary Debridement

ItIt isis suggestedsuggested thatthat allall openopen longlong--bonebone andand pelvicpelvic fracturesfractures bebe rere--exploredexplored 3636 toto 4848 hourshours after after thethe initialinitial debridementdebridement. .

T heT he woundwound shouldshould notnot bebe closedclosed untiluntil allall devitalizeddevitalized or or contaminatedcontaminated tissuetissue hashas beenbeen removedremoved. .

If If thethe woundwound doesdoes requirerequire further further debridement,debridement, thisthis shouldshould bebeundertaken,undertaken, andand thethe patientpatient returnedreturned toto thethe operatingoperating roomroom 3636 toto 4848hourshours later later for for aa further further debridementdebridement. .


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Treatment of WoundTreatment of Wound

Wound Closure:Wound Closure:P rimary Closure:P rimary Closure:

Open wounds should not be closed primarily.Open wounds should not be closed primarily.

If wound closure is possible, it should be undertaken at the reIf wound closure is possible, it should be undertaken at the re- -looklookprocedure 36 to 48 hours after the initial surgery.procedure 36 to 48 hours after the initial surgery.

Even closure of the wound extensions may cause tissue tension.Even closure of the wound extensions may cause tissue tension.

It is impossible to close an excised wound in an oedematous areaIt is impossible to close an excised wound in an oedematous areawithout tension.without tension.


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Wound Closure:Wound Closure:

Soft tissue cover or Reconstruction:Soft tissue cover or Reconstruction:T he most frequently used plastic procedures involveT he most frequently used plastic procedures involve

split skin grafting,split skin grafting,local muscle flaps such as the gastrocnemius flap,local muscle flaps such as the gastrocnemius flap,local flaps such as the proximal or distal fasciocutaneous flap ,local flaps such as the proximal or distal fasciocutaneous flap ,or free flaps.or free flaps.


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Fracture StabilizationFracture Stabilization

Fracture stability is essential for initial wound care and for fractureFracture stability is essential for initial wound care and for fractureunion .union .

Restoring normal length and alignment of the extremity minimizesRestoring normal length and alignment of the extremity minimizesdead space and restores muscle planes to their normal position.dead space and restores muscle planes to their normal position.T his reduces the space available for serum and hematoma, whichT his reduces the space available for serum and hematoma, whichare pabulum for bacterial growth.are pabulum for bacterial growth.Bone fixation often eliminates the need for casts, splints, andBone fixation often eliminates the need for casts, splints, andskeletal traction, thereby allowing optimal access to the limb for skeletal traction, thereby allowing optimal access to the limb for

wound care.wound care.Early stability provides an opportunity for early muscle and jointEarly stability provides an opportunity for early muscle and jointrehabilitation, which, in turn, reduces edema, facilitates lymphaticrehabilitation, which, in turn, reduces edema, facilitates lymphaticand venous return, lowers the incidence of deep vein thrombosis,and venous return, lowers the incidence of deep vein thrombosis,and improves the overall physiology of the limb.and improves the overall physiology of the limb.


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Fracture StabilizationFracture Stabilization1.1. External FixationExternal Fixation2.2. Internal FixationInternal Fixation

O penO pen fracturesfractures shouldshould bebe treatedtreated byby surgicalsurgical stabilizationstabilization. .CastCast managementmanagement is is associatedassociated withwith poorer poorer resultsresults thanthanoperativeoperative managementmanagement in in openopen longlong--bonebone fracturesfractures andandusuallyusually usedused for for typetype II andand lowlow--gradegrade typetype IIII fracturesfractures withwithstablestable configurationsconfigurations whenwhen externalexternal or or internalinternal fixationfixation isisunnecessaryunnecessary. . T hisT his usuallyusually appliesapplies toto fracturesfractures distaldistal toto thethe

elbowelbow andand kneeknee. .SurgicalSurgical stabilizationstabilization minimizesminimizes later later softsoft tissuetissue injuryinjury andandpromotespromotes capillarycapillary ingrowthsingrowths. .T hereT here isis alsoalso goodgood evidenceevidence it it isis associatedassociated withwith aadecreaseddecreased infectioninfection raterate..


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Fracture StabilizationFracture Stabilization

Internal Fixation:Internal Fixation:

1.1. P eriarticular FractureP eriarticular Fracture2.2. Diaphyseal FractureDiaphyseal Fracture

ImplantsImplantsScrews and P lateScrews and P late

IM NailIM Nail


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Fracture StabilizationFracture StabilizationIf plating is employed care must be taken not to strip soft tissues from theIf plating is employed care must be taken not to strip soft tissues from thebone unnecessarily and thereby reduce its vascularity. T he plate must bebone unnecessarily and thereby reduce its vascularity. T he plate must becovered with soft tissues at the end of treatment and this may necessitatecovered with soft tissues at the end of treatment and this may necessitatethe use of local or free flaps.the use of local or free flaps.

Intramedullary nailing of open diaphyseal fractures has become anIntramedullary nailing of open diaphyseal fractures has become anaccepted technique.accepted technique.

If external skeletal fixation is used care must be taken to place the pins soIf external skeletal fixation is used care must be taken to place the pins soas not to compromise either the potential skin flaps or access to the vesselsas not to compromise either the potential skin flaps or access to the vessels

for microvascular anastomoses.for microvascular anastomoses.

If plastic surgery is required, fracture stabilization is mandatory.If plastic surgery is required, fracture stabilization is mandatory.T raction should not be employed for open fractures.T raction should not be employed for open fractures.


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Fracture StabilizationTiming


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Fracture Stabilization


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The Decision to AmputateThe Decision to Amputate

SomeSome limbs,limbs, particularlyparticularly thosethose subjectedsubjected toto prolongedprolonged ischaemia,ischaemia,crushingcrushing or or nervenerve damage,damage, althoughalthough theoreticallytheoretically salvageablesalvageable maymayfunctionfunction veryvery poorlypoorly.. T heT he patientpatient maymay wellwell havehave multiplemultiple operationsoperationscarriedcarried outout over over aa prolongedprolonged periodperiod of of timetime andand endend upup withwith aa leglegwhichwhich isis painfulpainful andand functionsfunctions poorlypoorly

CircumferentialCircumferential deglovingdegloving of of skinskin..

MESSMESS ScoreScore moremore thanthan 77

ISSISS ScoreScore moremore thanthan 2020


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At At thethe endend of of thethe firstfirst orthopaedicorthopaedic procedureprocedure thethe followingfollowinggoalsgoals shouldshould havehave beenbeen metmet::

All All devitaliseddevitalised tissuestissues shouldshould havehave beenbeen excisedexcised withwith thethe woundwoundbeingbeing extendedextended asas far far asas isis requiredrequired toto achieveachieve thisthis..

T heT he fracturefracture shouldshould havehave beenbeen stabilisedstabilised toto permitpermit subsequentsubsequentplasticplastic surgerysurgery preferablypreferably usingusing aa methodmethod whichwhich isis definitivedefinitive andanddoesdoes notnot requirerequire toto bebe changedchanged atat aa later later datedate. .


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ComplicationComplication

I nfectionI nfectionCellulitisCellulitisOsteomyelitisOsteomyelitis

Defects in U nionDefects in U nionMalunionMalunionDelayed unionDelayed unionNonunionNonunion

Compartment S yndromeCompartment S yndrome

TheThe most most important important prognosticprognostic factorfactor that that determinesdetermines thethe longlong--termterm result result inin openopen fracturesfractures isis thethe amount amount of of energyenergy absorbedabsorbed bybythethe limblimb at at thethe timetime of of initialinitial injuryinjury.. ThisThis determinesdetermines thethe amount amount of of devitalizeddevitalized soft soft tissuetissue andand thethe levellevel of of contamination,contamination, whichwhich arearemoremore important important thanthan thethe configurationconfiguration of of thethe fracturefracture

ReasonGross contamination

Retained foreign body

Soft tissue compromise

Multisystem injury


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SUMMARYSUMMARYO penO pen fracturesfractures areare complexcomplex injuriesinjuries thatthat involveinvolve bothboth thethe bonebone andand surroundingsurrounding softsofttissuestissues. .

ManagementManagement goalsgoals areare preventionprevention of of infection,infection, unionunion of of thethe fracture,fracture, andand restorationrestoration of of functionfunction. .

Achievement Achievement of of thesethese goalsgoals requiresrequires a a carefulcareful approachapproach basedbased onon detaileddetailed assessmentassessmentof of thethe patientpatient andand injuryinjury..

T heT he classificationclassification of of openopen fracturesfractures isis basedbased onon typetype of of fracture,fracture, associatedassociated softsoft--tissuetissueinjury,injury, andand bacterialbacterial contaminationcontamination presentpresent. .

T etanusT etanus prophylaxisprophylaxis andand intravenousintravenous antibioticsantibiotics shouldshould bebe administeredadministered immediatelyimmediately. .LocalLocal antibioticantibiotic administrationadministration is is aa usefuluseful adjunctadjunct. .T heT he openopen fracturefracture woundwound shouldshould bebe thoroughlythoroughly irrigatedirrigated andand debrideddebrided, ,

ExtensiveExtensive softsoft--tissuetissue damagedamage maymay necessitatenecessitate thethe useuse of of locallocal or or freefree musclemuscle flapsflaps..T echniquesT echniques of of fracturefracture stabilizationstabilization dependdepend onon thethe anatomicanatomic locationlocation of of thethe fracturefracture andandcharacteristicscharacteristics of of thethe injuryinjury..


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ENDEND

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