the management of open fracture - aado
TRANSCRIPT
Wound Management Workshop
Dr. WH Yip Department of O&T
Queen Elizabeth Hospital Sept 2013
Open Fracture Fracture communicates through a traumatic wound to
surrounding environment
Resulting in contamination, devascularization & disruption of soft tissue envelope
Open Fracture High energy
Outcome depends on the extent of soft tissue injury
Treatment of
Soft tissue trauma with contamination
Skeletal injury
Classification: Gustilo & Anderson
Grade Size (cm) Energy of trauma Infection rate (%)
I <1 Low energy 0-2
II >1 Moderate energy 2-5
III >10 High energy
5-50
Principles of Management
ATLS: Save life first, then save limb
Prevent infection: Wound debridement & lavage,
IV / local antibiotics, Tetanus prophylaxis
Fracture stabilization: Temporarily & Definitive
Early soft tissue coverage: Initial flap preservation, delayed 1°
suture, secondary intention, skin graft, flap
Mx of bone defect: Shortening, bone graft / transport
Rehabilitation: To minimize disability & optimize functional
recovery
Initial Wound Management Wound assessment & documentation, take clinical photo
Initial cleansing ( 1 L NS at bedside) if possible
Sterile cover - do not open until in the OT Multiple inspections before debridement increase infection
Realign the limb with well-padded splint Immediate systemic antibiotics
OT as soon as fasted enough for GA or regional anesthesia - It is an Emergency!
Analyze needs, prioritize aims, and plan for the worst Non-salvageable limb Amputation
Wound Assessment
Aseptic techniques
Wound condition
Neurovascular injuries
Associated fracture open fracture ?
Look out for compartment syndrome
Control the bleeding
Direct pressure, wound packing, elevation, tourniquet, direct clamping
Any major vascular injury requires emergency repair
No pulse & Pallor !!
Vascular Injury
Gustilo-Anderson Classification of Open Fractures
Grade Size of wound
I </= 1cm Minimal soft tissue stripping, minimal # comminutions
II >1cm Moderate soft tissue damage, moderate # comminutions
III >10cm Extensive soft tissue damage
IIIa: adequate soft tissue coverage, # comminuted
IIIb: extensive soft tissue injury with periosteal stripping, massive contamination, # comminuted
IIIc: with an arterial injury, poor soft tissue coverage
First Operation “EOT” Detail assessment and document wound location, size,
contamination - photos
Debridement and copious lavage (6 - 10 L.), discard loose bony fragments
Initial wound swab x C/ST: limited value not suggested
Preserve flaps
Stabilize fracture – Ext. Fix. or Nail
Do NOT close the wound
Great demand on appropriate decision making and surgical proficiency
Experienced surgical team makes a difference!
Prevent Infection: Wound Debridement & Lavage
Remove all devitalized tissue (esp. muscle), debris, loose fragments & foreign body
NS / antiseptic irrigation
Copious pulsatile lavage (6 - 10 L)
Wound left open
+/- 2nd look debridement every 24 - 72 hrs until completely clean
1st debridement 2nd debridement
Handling of Tissues
Skin: preserve if viability is uncertain
Fascia: excise if viability is uncertain
Tendon: preserve paratenon
Muscle: excise if viability is uncertain
Nerve: preserve
Periosteum: preserve whenever possible
Bone: preserve with intact periosteum
Viability of Muscle Circulation
Color
Contraction
Consistency
Lavage Wound irrigation is the key to prevent infection
Decrease bacterial load and remove foreign body
“Copious”: up to 10 L. “The best solution to pollution is dilution”
Pulsatile seems to be better - enhance dislodgement of particulate matter
Pressure High pressure (>8psi): cause bone damage & spread bacteria into
intramedullary cavity
Low pressure: equally effective
Controversy: sterile NS, antiseptic, antibiotic, soap, tap water
Drainage
Prevent potentially harmful collection of body fluid, blood
By 1) elevation, 2) tissue drain, or 3) Suction drain
Prevent Infection: IV Antibiotics
Broad spectrum cephalosporin (Gm +ve & -ve)
adequate for Grade I & II Zinacef / Cefazolin
Aminoglycoside (Gm -ve) additional for Grade III
Gentamicin
Metronidazole (anaerobes) additional for farm injury Flagyl / Penicillin
Duration: No optimal regimen!
Depends on the
wound condition !!
Prevent Infection: Local Antibiotics
Antibiotic loaded beads
1. High local concentration
2. Temporary spacer
Prevent Infection: Tetanus Prophylaxis Previously immunized
toxoid booster
Not immunized
toxoid + immune globulin
Wound Care Reconstruction Ladder
Early Soft Tissue Coverage: Initial Flap Preservation
Esp. where local flaps are not readily available
Distal 1/3 of tibia and beyond
Don’t jeopardise blood supply by insertion of pins, drains etc. thro’ the flap
No tension
Minimise soft tissue motion - to enhance regeneration of microvasculature - skeletal immobilisation
Early Soft Tissue Coverage “Very early fix and flap” protocol
Usually within 3 days to 1 week
Prevent nosocomial infection (main source of infection in open #) and improve outcome
Balanced by soft tissue tension & infection
Methods:
- Delayed 1° closure (Sutures, adhesives, strips, surgical staples )
- Skin graft (PTSG, full thickness)
- Flap (local, free) bring in blood supply
Soleal flap
Vacuum Assisted Closure (VAC) Sub-atmospheric pressure therapy
Negative pressure assists with removal of interstitial fluid, decreasing localised oedema and increasing blood flow → Decreases tissue bacterial levels
Accelerates wound healing by promoting the formation of granulation tissue, collagen, fibroblasts, and inflammatory cells
Vacuum Assisted Closure (VAC)
Piece of foam with an open-cell structure is introduced into the wound
Wound drain with lateral perforations is laid on top of it
Entire area is covered with a transparent adhesive membrane
Connection to a vacuum source
Foam
Ensures that the entire surface area of the wound is uniformly exposed to the negative pressure effect
Prevents occlusion of the perforations in the drain
Eliminates the theoretical possibility of localised areas of high pressure and resultant tissue necrosis
Plastic membrane
Prevents ingress of air
Allow a partial vacuum to form within the wound, reducing its volume and facilitating the removal of fluid
Vacuum Assisted Closure (VAC) Intermittent or continuous pressure
Pressure: 125mm Hg (50 - 200mmHg)
Infected wound: change every 24 hours
Clean wound: change every 2 days
Indications and Contraindications
Fracture Stabilization: Optimize Fracture Healing
Fracture reduction
Stable fixation
Dynamize and weight bear at appropriate time
Bone graft: bring in blood supply
Fracture Stabilization: Temporarily
Standard: External Fixation
Quick & easy
Minimal invasive
Good stability
Prevent infection
Temporarily stabilization
Fracture Stabilization: Definitive Usually done after wound conditions (infection
& coverage) stabilized
Timing & method depends on fracture pattern & wound conditions
Choices of Definitive Fixation
1. Primary Internal Fixation (Nailing / MIPO)
2. Conversion from External Fixation to Internal Fixation
Nailing/ MIS implants/ Percutaneous screw/ K-wire
3. Keep External Fixation (Simple / Hybrid)
4. Conversion from External Fixation to Casting
Case 1: Nailing
Case 2: Nailing
Case 3: MIPO
Case 1: Type I Open Fracture M/53
Wound debridement + Primary Nailing
Case 2: Type I Open Fracture
M/24
Case 3: F/53
Type I wounds on medial aspect
CT done, fracture extended very distally. Too distal for Distal Nailing.
Distal Tibial LCP
Day 1
Case 1: Conversion to Nailing
Case 2: Conversion to Plate & Screw
Conversion of Ext. Fix. to Reamed Nailing Tibia - generally not later than one week For I, II and IIIa #’s One stage (<3 wks) or “cooling” period (>3 wks) Better access for flap surgery Less prone to delayed or mal-union Generally more acceptable to patients Shorter hospital stay Only if fracture location and type amenable to
nailing
Open wounds at left leg Case 1: M/23
Initial debridement
and Hoffmann II
External Fixation
Before and after initial external fixation
Day 3, fixation revised
Injured limb supported
and raised on the fixator
frame to facilitate
drainage, nursing care
and surgery.
Skin graft
4 weeks
Fixation removed (already the 9th operation).
Pin holes “rested” for 4 weeks.
8 weeks after injury
IC Tibial nail
inserted.
1 year after injury
2 years after injury
Case 2: F/68
Emergency Treatment
Wound Lavage +
Debridement +
External Fixation
Day 5 Debridement + PTSG + ORIF
Ext. Fix. kept for soft tissue injury
2 Months
Case 1: Comminuted Fracture
Case 2: Infection
Case 3: Severe Soft Tissue Injury
Case 4: Polytrauma with complex management
Pin Fixators
AO Orthofix
Stryker: Hoffmann II
Ring & Hybrid Fixators
AO Orthofix
Half pin
Tensioned wire
Stryker: Tenxor
Case 1: Comminuted Open Fracture
M/40
Emergency Treatment Wound Lavage + Debridement + External Fixation
Definitive Treatment
PTSG + Conversion to Hybrid
External Fixation
16 Weeks
Case 2: Infected Open Fracture
M/50
Type IIIA
Conversion from Ext. Fix. to IM nail on Day 2
ORIF for calcaneal
& navicular fracture
on Day 11
MRSA Infection: repeated debridement from 3 to 8 weeks
10 weeks Loosening of distal
fixation detected, fracture went into valgus & recurvatum
Subsequent Management
(11 weeks) Wound debridement
Removal of nail
Conversion to hybrid external fixation
14 weeks
14 weeks
Then Ext.
Fix removed
on 17 weeks
43 weeks from
hybrid
fixation
13 months
after injury
Stick walking 30 min, unaided 10 min
Case 3: Severe Soft Tissue Injury
F/75
Emergency Treatment Wound Lavage +
External fixation
2 Weeks
Debridement + PTSG +
Limited Percutaneous
Internal Fixation
4 Weeks
Fracture Healed Up
Right Forearm
Case 4: M/57
Polytrauma
Right Femur
Right Knee
Right Tibia
Requires
Bone Grafting
Left Side
Stellate wound at the front of knee
Shattered patella
Shattered distal femur – intercondylar and lower shaft
Left Knee – after 1st Debridement
Left Knee – after 2nd Debridement Followed by MRSA infection and
multiple debridement
Left Knee
(12 weeks)
What to do?
Intercondylar screw fixation with limb shortening at 13 Week
Gastrocnemius Flap with BG & PTSG 3 days later
Post-Flap 2 week
9 Months
Case 1: Minor Open Wound with osteosporosis, poor pre-morbid
F/74
Limited Internal Fixation + Pin & Cast
Case 1: Delayed Amputation
Case 2: Primary Amputation
Amputation: Guideline
Non-viable limb
Non-functional limb
Life-threatening limb
Too extensive & prolonged reconstruction
MESS >7
Amputation: MESS
MESS for limb salvage
<4 good prognosis
>7 poor prognosis (100% predictive value for amputation)
Case 1: M/54 Knocked down by a car
MESS=7
Day 1, 2nd Debridement
MESS Very high energy : 4
Age 54 : 2
Transient shock : 1
Limb ischaemia : 0
Total: 7 / 14
Amputation recommended for score of >= 7.
What next ?
Keep fixator, skin graft, wait for bone healing; Or
BKA
Change to Ring Fixation to buy more time
Day 3
Hybrid Fixator
with tensioned wire
Soft tissue defect anticipated!
Local antibiotics:
Gentamicin beads
Bone defect also anticipated!
Day 10: Complicated with Infection despite Repeated Debridement
Agreed to BKA
Salvaged limb Functional limb
Never forget prosthesis
Case 2: Jump Railway
Primary Amputation
Summary Outcome depends extent of soft tissue injury
Treatment of
Soft tissue trauma with contamination Primarily important
Skeletal injury Secondary
Management Protocol
Adequate debridement
is the single most
important factor in
minimizing infection
with open fracture !
The End