OPEN FRACTURES

Dr. M. Ravi Chandra YadavPIMS

OPEN FRACTURES - INTRODUCTIONOPEN FRACTURES ARE ALSO KNOWN AS COMPOUND FRACTURES

Definition

• Open fracture implies communication between external environment and the fracture.

• A soft tissue injury complicated by a broken bone.

Components of open fracture

• Fracture• Soft-tissue damage• Neurovascular compromise• Contamination

Extent of each component must be assessed individually in order to achieve a comprehensive understanding of the injury, upon which the treatment plan can be based.

History

• A century ago, the high mortality of patients with open fractures led to early amputations to prevent death.

• Trueta recommended open wound treatment and subsequent enclosure of extremity in a cast

• In 1943, the use of Penicillin reduced the rate of wound sepsis

• Hampton recommended closure between 4th-7th day after injury

Mechanism of injury

• Open fractures occur as a result of direct high energy trauma either from Road traffic collisions or falls from height.

Epidemiology

• Diaphyseal fractures were more common than metaphyseal fractures. Highest rate of diaphyseal fractures were seen in tibia(21.6%) followed by femur(12.1%), radius and ulna(9.3%), and humerus(5.7%)

Microbiology

• Poor tissue oxygenation and devitalization of the surrounding tissues including the bone provide a perfect medium for infection and bacterial multiplication.

• When left open >2weeks – prone to nosocomial infection such as pseudomonas species and gram negative bacteria.

• This phenomenon of hospital acquired infection emphasizes the importance of a strict protocol for in-hospital management and early wound coverage.

OPEN FRACTURES - COMPLICATIONS

WHY OPEN FRACTURES CAN BE DANGEROUS

Early Complications

• Infection• Hypovolemic shock• Compartment syndrome• Fat embolism• Ards • Neurovascular injuries

Hypovolemic shock

Hypovolemic shock - management

• Two large-bore IV lines should be started. • Once IV access is obtained, initial fluid

resuscitation is performed with an isotonic crystalloid, such as Ringer lactate solution or normal saline. An initial bolus of 1-2 L is given in an adult (20 mL/kg in a pediatric patient), and the patient's response is assessed.

Hypovolemic shock

• Type of fluid-• Colloid – albumin, dextran, plasma• Crystalloid – NS, D5, RL• Blood – uncrossed ‘O’ –ve

• Based on 3:1 rule when using crystalloids• Eg. If blood loss is 100cc the patient should receive

300cc of normal saline or Ringer lactate• 1:1 rule for colloids

Compartment syndrome

Compartment syndrome

• Classically 5 "Ps" associated with compartment syndrome —

• Pain out of proportion to what is expected• Paresthesia• Pallor• Paralysis• Palpable pulse

Measurement of compartment syndrome-gauging pressure by introducing needle into compartments

Stryker 295 quick-pressure monitor set

Compartment syndrome

• Treatment - Fasciotomy

Fat embolism

• Definition - Occlusion of small vessels by fat globules

• Types- • 1. cerebral – drowsy, restless and disoriented• 2.pulmonary – tachypnea, tachycardia,

petechial rash(in front of neck, ant axillary fold, chest and conjuctiva)

Fat embolism

• Diagnosis – • signs of retinal artery emboli(striate

hemorrhages and exudate) may be present.• Sputum and urine may reveal presence of fat

globules.• X-ray of chest shows patchy pulmonary

infarcts.• Blood Po2 <50mm

Fat embolism

• Treatment-• Respiratory support• Heparinization• Intravenous low-molecular weight dextran and

corticosteriods

ARDS

• Is caused by release of inflammatory mediators which cause disruption of pulmonary vasculature.

• Signs and symptoms – Tachypnea, low BP, Cyanosis

• Treatment – 100% oxygen

Injury to blood vessels

• Absent peripheral pulses in an injured limb should be considered to be due to vascular damage unless proved otherwise.

• hard signs of arterial injury• (a) absent pulses• (b) active hemorrhage• (c) expanding hematoma, and • (d) bruit or thrill.

Vascular injury

Investigations-• Colour doppler study• Arteriography

Treatment-• Arterial reconstruction• Bypass grafts

• Timing- loss of total blood supply to the limb for > 8 hours nearly always results in amputation.

Nerve injury

• Nerve repair should be done within 3 weeks of injury for better results

OPEN FRACTURES – GRADING AND CLASSIFICATION

TO ACCURATELY DESCRIBE SIMILAR INJURIES IN ORDER TO PROVIDE A BASIS FOR TREATMENT, TO ESTIMATE PROGNOSIS AND TO ENABLE COMPARISON BETWEEN CENTERS.

Gustilo and Anderson

Gustilo and Anderson

Tscherne

• Grade I – small puncture without associated contusion, negligible contamination, low-energy mechanism of fracture.

• Grade II- small laceration, skin and soft tissue contusions, moderate bacterial contamination

• Grade III- large laceration with heavy bacterial contamination, extensive soft tissue damage

• Grade IV- incomplete or complete amputation with variable

Hannover fracture scale

• Total score - This considers every detail of the injury to the involved extremity and is made up as a checklist. The fracture type according to the AO classification, the skin laceration, the underlying soft tissues, the vascularity, the neurological status, the level of contamination, a compartment syndrome, the time interval between injury and treatment, and the overall severity of the injury to the patient

are added up to prove the total score.

Hannover fracture scale

Interpretation• minimum score: 0• maximum score: 22• The higher the score the worse the injury.• A score ≥ 11 indicates significant trauma, with

amputation recommended.

AO classification

AO classification

Io 1 – skin breakage from inside out

Io 2- skin breakage from outside in <5cm, contused edges

Io3 – skin breakage from outside in >5cm, increased contusion, devitaised edges

IO 4 – Considerable, full thickness contusion, abrasion, extensive open degloving, skin loss

IO5 – extensive degloving

Neurovascular injury - AO

Muscle/tendon injury – AO

Ganga hospital score

• Interpretation:• The total score was used to address the

question of salvage and the outcome was measured by dividing the injuries into four groups (Group I - < 5; II - 6-10; III - 11-15 and IV - 16 and above of the total score)

• All limbs in Group IV and one in Group III underwent amputation

Mangled extremity severity index

Mangled extremity severity score(MESS)

LSI- limb salvage index

Limb Salvage Index Outcome0−5 limb salvage successful (51 of 51)6−14 amputation (19 of 19)

Interpretation-•minimum score: 0•maximum score: 14•The higher the score the more severe the injury.

Predictive salvage index

Interpretation• minimum score: 3 (based on the point assignments; if no

vascular, bone or muscle injury then the score could reach 1, but then it would not be a seriously injured limb)

• maximum score: 13• The higher the score the worse the chances for a successful

limb salvage.PSI Outcome≤ 7 good (12 of 14

limbs salvaged≥ 8 poor (7 of 7

amputated)

NISSSA

Parameters• N = nerve injury• I = ischemia• S = soft tissue contamination• S = skeletal injury• S = shock• A = age of the patient

NISSSA

NISSSA

NISSSA

Interpretation• minimum score: 0• maximum score: 19• The higher the score, the more severe the

injury.• A score ≥ 7 was 100% sensitive for amputation,

but with specificity of 46%.• A score ≥ 11 had a 100% specificity and positive

predictive value for amputation.

OPEN FRACTURES - MANAGEMENT

THE TREATMENT OF HIGH ENERGY INJURIES AIM TO PRESERVE LIFE, LIMB AND FUNCTION.

Goals of treatment

The intermediate objectives are-• Prevention of infection• Fracture stabilization• Soft-tissue coverage

Stages of care

Initial assessment

• Important components in assessing traumatized extremity

1. History and mechanism of injury2. Neurovascular status3. Size of skin wound4. Muscle crush or loss5. Periosteal stripping or bone loss6. Fracture pattern, fragmentation7. Contamination8. Compartment syndrome

Primary surgery

Irrigation

• Supplements systemic debridement in removing foreign material and decreasing bacterial load.

Fracture type Vol of fluid used for irrigation

Type I 3 L

Type 2 6L

Type 3 9L

Irrigation

2 adages….

• If a little does some good, a lot will do a great deal more

• solution to pollution is dilution

Irrigation • NS normally used for

irrigation.

• Antibiotic solution is no better than soap for open fracture irrigation

• Antiseptic solutions have been not shown to decrease infection rates.

• Surfactant(non sterile soap) same effectiveness, less tissue damage n more economical.

Timing of debridement and irrigation

• Most guidelines recommend debridement within 6 hrs.

• Serial debridement may be necessary every 24-48hrs until the wound viability is ensured

Antibiotics

• Systemic administration:

Antibiotics

• Local antibiotics:• In gustilo type III fractures additional use of

local aminoglycoside impregnated polymethylmethacrylate(PMMA) beads reduces overall infection rate.

Tetanus prophylaxis

• Tetanus Toxoid(TT), dose is 0.5ml i.m. regardless of age

• Immunoglobulin • 75IU <5yrs of age• 125IU 5-10yrs• 250IU >10yrs

Primary surgery

Timing :• Surgical emergency• Operating room with 6-8hrs of injury –

contaminated wounds not treated within this time will have sustained bacterial multiplication to result in early infection.

Primary surgery

Fracture stabilization:• As soon as primary wound care is completed,

treatment should proceed to fracture reduction and fixation.

• Surgeon should rescrub, regown and reglow. Different set of instruments than those used for debridement is necessary.

Relative Indications for Type of Skeletal Fixation in Open Fractures

External fixation

• Severe contamination any site • Periarticular fractures

– Definitive • Distal radius • Elbow dislocation • Selected other sites

– Temporizing • Knee • Ankle • Elbow • Wrist • Pelvis

• Distraction osteogenesis • In combination with screw fixation for severe soft tissue injury

Relative Indications for Type of Skeletal Fixation in Open Fractures

Internal fixation

• Periarticular fractures – Distal/proximal tibia – Distal/proximal femur – Distal/proximal humerus – Proximal ulnar radius – Selected distal radius/ulna – Acetabulum/pelvis

• Diaphyseal fractures – Femur – Tibia – Humerus – Radius/ulna

Plates

• Open diaphyseal fractures of the radius and ulna as well as the humerus are best managed with plate fixation.

• The plate fixation of lower extremity diaphyseal fractures is generally not recommended due to higher rate of infections.

Intramedullary nailing

• Locked intramedullary nailing has been established as the treatment of choice for most diaphyseal fractures in lower extremity.

• The technique has particular value for open fractures. Intramedullary nails can be inserted with no further disruption of the already injured soft-tissue envelope and preserves the remaining extra osseous blood supply to cortical bone.

IM nailing

• Data showing that solid intramedullary nails inserted without reaming have a lower risk of infection.

• On the other hand reamed intramedullary nails can reliably maintain fracture reduction with regards to angulation, rotation, displacement, and length.

• Prospective randomised trails that compared reamed with unreamed interlocked IM nails did not show any significant difference concerning outcome and risk of complication.

External fixation

• Advantages of ext Fixation-• Can be applied relatively easily and quickly• It provides relatively stable fracture fixation• There is no further damage done if applied

correctly• It avoids implantation of hardware in open

wound.

Ext fixator

• Major problems with external fixation are related to pin tract infection, malalignment , delayed union, poor patients compliance.

• External fixators are particularly useful in fractures with severe damage and contamination, where metallic implants – with risk of bacterial adherence – are best avoided.

• Ring fixators may be an option in diaphyseal fractures

• Types –• Ring fixators• Joint spanning external fixator

Open wound coverage after primary surgery

Primary Closure

If it is to be done, the following criteria must be met:

1. The original wound must have been fairly clean, and not have occurred in a highly contaminated environment.

2. All necrotic tissue and foreign material have been debrided.3. Circulation to the limb is essentially normal.4. Nerve supply to the limb is intact.5. The patient's general condition is satisfactory and allows careful

postoperative assessment.6. The wound can be closed without tension.7. Closure will not create a dead space.8. The patient does not have multisystem injuries.

Delayed primary closure

• closure before the fifth day is termed delayed primary closure

• As long as closure is achieved before the fifth day, wound strengths at 14 days are comparable with those in wounds closed on the first day

• leaving the wound open minimizes the risk of anaerobic infection, and the delay allows the host to mount local wound defensive mechanisms that permit safer closure than is possible on the first day.

• Current standard of care for all open fracture wounds is to be left open initially.

• Delayed closure is accomplished within 2-7days

• VAC assisted wound closure is presently recommended for temporary management of open fracture wounds.

VAC

• The wound bed is exposed to mechanically induced negative pressure in a closed system .

• The system removes fluid from extravascular space, reduces edema, improves micro circulation and enhances the proliferation of preparative granulation tissue.

• Polyurethane foam dressing is placed in wound and ensures an even distribution of negative pressure.

VAC

Antibiotic bead pouch technique

References

• AO principles of fracture management 2nd Ed• Rockwood and green – fractures in adults 7th

Ed• Campbell - operative orthopedics 11th Ed.• Management of open fractures by Dr. TSE

Lung Fung• Various sources on Internet

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