DR Sagar K

Pt JNMC ,

DR BRAMH

RAIPUR.

DEFINATION An injury where the fracture and fracture hemetoma

communicate with the externel environment through the traumatic defect in the surrounding soft tissue and overlying skin.

PATHOPHYSIOLOGY Recent data quotes freq. of long bone # is

11.5/ 100,000 per year.

MC cause: RTA

Any high energy trauma

MC is tibial diaphysial #

Amount of energy absorbed is KE = MV²/ 2

Bone and soft tissue absorb energy …but when this energy exceeded>>>> leads to communition of the bone and periosteal striiping….

When skin is torn >> temporary vacum is created

>>>sucks in all adjacent foreign material

>>>and dirt and debris is deposited in depth of wound.

That’s why during wound debridement meticulous examination of all possible areas must be done…

INITIAL ASSESSMENT Its an emergency

Its an “ Orthoplastic approach”

ON GROSS>>>

i. Thorough physical examination

ii. All constrictive cloth should be removed

iii. Check for Vascularity of all 4 limbs .

Injured limb that is grossly deformed/shortened >> must be gently reduced and splinted.

Persistent dislocation may compress vascularity must be reduced in emergency room.

Limb must be examined fr Compartment syndrome.

Persistent oozing >> if it carries fat globules suggest dicharging # hematoma.

WOUND

1) Size

2) Site

3) Location of wound

4) Depth of the wound

5) If it is transverse , longitudinal, irregular

6) Skin around the wound

7) Photographic documentation.

After initial examination wound must be covered with sterile dressing

Significant bleeding prevented by

- Pressure bandage

-By tourniquet

Blind clamping of blood vessels must be avoided bcoz it may compress NERVES .. >>> which may cause irreversible neurovascilar damage….

SEE FOR ANY VASCULAR INJURY…… Signs of vascular injury HARD SIGNS1) Absent pulsation2) Severe hemorrhage from wound3) Expanding and pulsatile hematoma4) Bruit or thrill

ASSOCIATED SIGNS1. Ass. Numbness and neurologic deficit2. Diff in skin temperature3. Absence of venous filling4. Absence of pulse oximeter reading.5. No capillary blanching…

ROLE OF CULTURE IN EMERGENCY

Studies have shown that ,, there is marked disparity between org. grown in initial wound and org. in subsequent wound.

Commonly isolated organism

E.COLI

PSEUDOMONAS

STAPH AUREUS

This org. Are frequent due to hospital contamination .

ROLE OF ANTIBIOTICS

according to Latest British Orthopaedic Association recommendations

Give antibiotic as soon as possible..

AntibioticUntil first DebridementAmoxiclav (1.2g 8 hourly)Cephalosporin (1.5g 8 hourly)

At first debridement continued until soft tissue closure or max of 72 hrs

Co-amoxiclav (1.2g) or a cephalosporin (such as cefuroxime 1.5 g) and gentamicin (1.5 mg/kg)

Induction of anaesthesia at the time of skeletal stabilisation and definitive soft tissue closure.Gentamicin 1.5 mg/kg /either vancomycin 1g or teicoplanin 800mg. Not be continued post-operatively.

Anaphylaxis to penicillin Clindamycin (600mg iv pre-op/qds) in place of co-

amoxiclav/cephalosporin

GUSTILO AND ANDERSONS CLASSIFICATION

MANGLED EXTRIMITY SEVERITY SCORE

(MESS)

GHOIS was descrebed by Rajeskaran in 2005, to especialy address the issue of salvage and reconstruction pathways in type 3B injuries.

The basis of the score is that three main components 1)bone, 2)muscle, 3)skin

are injured to different severity and they are graded seperately.

In addition , seven comorbodities are also included, are also known to influence the outcome.

The totel score is used to assess the need for ampution, and individual scores provide mx for each seperately…..

Score

<14 = limb salvage

>17 = Amputation

15 , 16 = Grey zone : where decision to salvage or amputation must be based on factors like

ass. Injuries, expert opinion, educational and cultural background of the patient, personality of the patient.

In practise GHOIS has many advantage over MESS and Gustilo classification..

ADVANTAGE………

Specifically designed for type 3B injuries.

1) Assess severity of injury to skin , muscle, bone seperately.

2) Total score predict amputation.

3) Individual score provide guidelines for reconstruction.

4) Scoring includes comorbidites which influnceoutcome.

5) Better intra and inter observer agreement compared to Gustilo classification.

TREATMENT OPTIONS1) LaVage and debridement

2) Skeleton stabilization

3) Plaster cast and traction

4) External skeleton fixation

5) Primary internal fixation

6) Acute mx of bone loss

7) Wound cover

WOUND LAVAGE AND DEBRIDEMENT

SKELETON STABILIZATION Stable skeleton stabilization must be achieved bcoz it

helps to alleviate pain and prevent further soft tissue damage.

During stabilization , limb length must be restored because it restores the correct tension to the soft tissue and

thus reduce swelling & improve circulation, & aids venous and lymphatic return.

In high energy injuries associated with contamination.

our preference is to use temporery externel fixatorfollowed by secondary internal fixation at a later operation.

In case of good soft tissue coverage as in UL trauma,, primary internal fixation can be considered.

External fixator It’s a method of immobilizing fractures by means of

pins passed through the skin and bone…

Two types

1) Pin fixator and

2) Ring fixator

The aim is to achieve an environment conducive to frature and soft tissue healing.

There are grey areas as far as the optimal stiffness is concerned.

The pin diameter

the optimal diameter for tibial and femoral pin is

4.5 mm & 5.5 mm.

for radius & ulna = 3.5 mm.

For metacarpls & metatarsals = 2.5 mm.

The core diameter determines the torsional and bending strength of the pin.

OPTIMAL DISTANCE…….

The optimal distance between rod and the bone appears to be 4 cm…..

Increasing the number of rods from 1 to 2 substantially improves the stiffness of the frame.

4CM

The pin – bone interface…...Achillis heel of the externel fixator……

It can be reduced by prevention and reduction of weight bearing and pre loading…..

PRELOADING….

IT’S A STATIC FORCE OF SUFFICIENT MAGNITUDE APPLIED TO AN IMPLANT TO OVERCOME ALL DYNAMIC AND MUSCULAR FORCES AND MAINTAIN UNINTERRUPTED PIN-BONE CONTACT…

COPMPLICATIONS….

Acute mx of bone loss Bony part without softtissue ,,should be removed.

Metaphyseal fragment with cancellous bone containing articular margins are usually retained after adequate cleaning even after there is no soft tissue coverage.

Bone gap in UL managed by bone shortening followed by bone grafting.

In LL loss < 2 cm is well tolerated.

When loss < 4cm, a decision is made b/w primary bone shortening and subsequent lengthening or bridging the gap by bone transport.

WOUND COVER PRIMARY CLOSURE OF THE WOUND

TIMING OF THE WOUND COVER.

TYPE OF COVER

Soft tissue cover

SSG

Local flap

Distant flap

Free flap

NEGATIVE PRESSURE WOUND THERAPY..

NPWT has largely replaced wet dressing.

Repeat dressings lead to increased exposure and susceptibility to nosocomial infection.

NPWT systems include… open pore sponge, a semi occlusive dressing, a negative pressure source .

COMPLICATIONS…

C/I in pt taking anticoagulant..

Loss of suction and failure of device increase the chance of wound infection.

12 deaths have reported till date due to bleeding when used in wounds near groin or presternal area.

List of articles on compound wound and mx…….

The impact of a dedicated orthoplastic operating list on time to soft tissue coverage of open lower limb fractures

Author information

1University Hospitals Coventry and Warwickshire NHS Trust , UK.

Ann R Coll Surg Engl. 2015 Sep;97(6):456-9. doi: 10.1308/rcsann.2015.0015. Epub 2015 Aug

Controversies in Initial Management of Open Fractures

Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA

Scott P. Ryan, M.D. Department of Orthopaedic Surgery Tufts Medical Center Biewend 8th floor 800 Washington St. Box 306 Boston, MARCH 2015. USA

Background: Treatment of open fractures continues to be a challenge for orthopedic and trauma surgeons, and early treatment recommendations, which persist in the literature for decades, often do not have supporting data.

Methods: This is a critical review of the literature surrounding controversies in the initial management of open fractures. It also focuses on the utility of negative pressure dressings in the care of associated complex wounds. Studies were selected based on their relevance to the treatment of open fractures.

Results: A total of 40 studies were included. The following topics were critically discussed: timing of initial debridement, antibiotic coverage, utility of obtaining cultures, and timing of wound closure.

Conclusion: The majority of open fractures require urgent, not emergent, irrigation and debridement. Antibiotics are essential in preventing infection in open fractures. Timely wound closure after all necrotic tissue has been debrided decreases complications in open fractures. Finally, negative pressure wound therapy has dramatically changed the care of associated complex wounds.

3)Cell-based biological evaluations of 5-(3-bromo-4-phenethoxybenzylidene)thiazolidine-2,4-dione as promising wound healing agent.

Piao YL, Ram Song A, Cho H.

Bioorg Med Chem. 2015 May 1;23(9):2098-103. doi: 10.1016/j.bmc.2015.03.010. Epub 2015 Mar 11.

PMID: 25801150

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