LOWER LIMB FRACTURES LOWER LIMB FRACTURES Identifying problems earlyIdentifying problems early
Professor Jegan KrishnanProfessor Jegan KrishnanFlinders UniversityFlinders University
Adelaide, South AustraliaAdelaide, South Australia
Specialists Without BordersSeminar in Surgery
Rwanda, September 2010
Specialists Without BordersSeminar in Surgery
Rwanda, September 2010
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Learning ObjectivesLearning Objectives
Emergency care of traumatised patient Acute care of compound fractures Assessment and Management of Neurovascular
Injury Recognition and Management of Compartment
Syndrome
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Emergency Care of Traumatised LimbEmergency Care of Traumatised Limb
General assessment of patient – Emergency Medical and Surgical Trauma (EMST)
Clinical assessment Neurovascular assessment Limb stabilisation Wound inspection dressings Preliminary radiology
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Compound FracturesCompound Fractures
Goals of open fracture management include: Prevention of infection Achievement of bony union Restoration of function
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Compound FracturesCompound Fractures
Compound fractures according to Gustilo and Anderson: Grade I: skin wound < 1 cm, clean
no contamination Grade II: skin wound > 1 cm
no major soft tissue damage Grade III: high energy, major soft tissue injury or crush injury
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Compound FracturesCompound Fractures
Grade I compound #
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Compound FracturesCompound Fractures
Grade IIIc compound #
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Compound FracturesCompound Fractures
Grade III A: adequate soft tissue coverage of bone, although major soft
tissue damage B: major soft tissue damage with periostal stripping and no coverage of bone C: arterial damage requiring reconstruction
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Management PrinciplesManagement Principles
Antibiotic utilisation Timing of initial surgery Type of wound closure Antibiotic delivery methods Tetanus coverage Wound irrigation Adjunctive therapies
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Compound FracturesCompound Fractures
Need immediately: Bandage and splint Antibiotics (Cephazolin 1gram IV) Immediate referralFollows: Arteriography? Surgery (<6 hrs) At least 5 days of IV antibiotics
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Compound FracturesCompound Fractures
Surgery Grade I and II: - no plates
- intramedullary nail possible Grade III: - external fixator - plastic surgeon – flap
- intramedullary nail possible
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External FixationExternal Fixation All over ………………………All over ………………………
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Compound FracturesCompound Fractures
Standard treatment for open tibial fractures undergone changes over the last 20 years
Prompt assessment in emergency room required Early aggressive soft tissue and bone debridement High volume pulsatile lavage Administration of IV antibiotics
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Compound Fractures – current conceptsCompound Fractures – current concepts
Delayed wound closure or soft tissue coverage with local or distant flaps proven highly effective
Minimise the risk of late deep infection, overall infection rate between 3 and 5% for all open fractures
Risk of infection related to severity of associated soft tissue injury; Gustilo-Anderson Grade II fractures reported incidence as high as 10%, with Grade III reporting as high as 20%
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Compound Fractures – current conceptsCompound Fractures – current concepts
Heitmann et al and Faisham et al have both reported 60-64% of all open tibial fractures are contaminated on presentation in emergency room
Robson et al demonstrated nearly all open fractures are contaminated to some degree, introduced the concept of “Golden Period of Opportunity” – initial 4 to 12 hr period following injury.
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Compound Fractures – current conceptsCompound Fractures – current concepts
Early soft tissue coverage generally believed to limit risk of subsequent deep infection after open fracture
Very early wound closure is not a radical or new concept in trauma surgery
No universal agreement regarding the potential advantages of primary wound closure
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SUMMARYSUMMARY
Early EMST wound dressing and splintage Wound debridement Appropriate antibiotics Tetanus prophylaxis Wounds coverage Amputation