Management of Management of Open FracturesOpen Fractures

IntroductionIntroduction

An open fracture is one in which a break in An open fracture is one in which a break in the skin and underlying soft tissue leads the skin and underlying soft tissue leads directly into or communicates with the directly into or communicates with the fracture and its hematoma.fracture and its hematoma.

When wound occurs in the same limb When wound occurs in the same limb segment as a fracture, the fracture must segment as a fracture, the fracture must be considered open until proven be considered open until proven otherwise.otherwise.

Methods of ClassificationMethods of Classification

Grading System- Focus on severity of limb Grading System- Focus on severity of limb injury only. Ex: Gustilo Anderson, Tscherne injury only. Ex: Gustilo Anderson, Tscherne and Gotzen, Bryd and Spicer etc.and Gotzen, Bryd and Spicer etc.

Scoring System-Focus on limb injury and Scoring System-Focus on limb injury and general health; also gives Amputation general health; also gives Amputation Score. Ex: MESS, NISSA, LSI, PSI etc.Score. Ex: MESS, NISSA, LSI, PSI etc.

Comprehensive System- Combines the Comprehensive System- Combines the above two systems. Ex: AO System, Ganga above two systems. Ex: AO System, Ganga hospital score.hospital score.

GradeGrade WoundWound Level of Level of ContaminationContamination

Soft Tissue Soft Tissue InjuryInjury

Bone InjuryBone Injury

11 < 1 cm long< 1 cm long CleanClean MinimalMinimal Simple # Simple # Minimal Minimal comminution comminution

22 > 1 cm long > 1 cm long ModerateModerate No extensive No extensive soft tissue soft tissue damage. damage. Moderate Moderate crushing injurycrushing injury

Moderate Moderate comminutioncomminution

3 A3 A Severe with Severe with crushingcrushing

Segmental or Segmental or severely severely comminuted. comminuted. Soft tissue Soft tissue coverage of coverage of bone possiblebone possible

BB Usually > 10 Usually > 10 cmscms

High High Very severe loss Very severe loss of coverage. of coverage. Usually requires Usually requires soft tissue soft tissue reconstructive reconstructive surgery.surgery.

Periosteal Periosteal stripping. May stripping. May be moderate to be moderate to severe severe comminution.comminution.

CC Very severe loss Very severe loss of coverage + of coverage + vascular injury vascular injury requiring repair requiring repair

Bone coverage Bone coverage poor. May be poor. May be moderate to moderate to severe severe comminution. comminution.

Tscherne system- this system Tscherne system- this system includes compartment syndrome includes compartment syndrome which is not included in the other which is not included in the other grading systems.grading systems.

Byrd and Spicer- lacks sophistication Byrd and Spicer- lacks sophistication and hence not widely used.and hence not widely used.

Scoring systemScoring system

MESS( Mangled Extremity Severity MESS( Mangled Extremity Severity Score) for prediction of amputationScore) for prediction of amputation

Developed to identify patients who Developed to identify patients who will be benefited by primary will be benefited by primary amputation in retrospective analysis.amputation in retrospective analysis.

The outcome of injured limb is either The outcome of injured limb is either salvage or amputation.salvage or amputation.

A score of > or equal to 7 is A score of > or equal to 7 is predicative of amputation.predicative of amputation.

NISSA-Nerve injury, ischemia, soft tissue injury, skeletal NISSA-Nerve injury, ischemia, soft tissue injury, skeletal injury, shock, age; more sensitive and specific than MESS.injury, shock, age; more sensitive and specific than MESS.

LSI- limb salvage indexLSI- limb salvage index

Applied to limbs with arterial injury.Applied to limbs with arterial injury.

Warm ischemia time together with scores for injured Warm ischemia time together with scores for injured skin, muscle, bone, NV are added to give a total score. skin, muscle, bone, NV are added to give a total score.

LSI>6 AND Grade IIIC Gustillo with major nerve injury are LSI>6 AND Grade IIIC Gustillo with major nerve injury are amputated.amputated.

Comprehensive systemsComprehensive systems

AO SystemAO System Skin lesions, muscle tendons, NV, bone injuries are graded Skin lesions, muscle tendons, NV, bone injuries are graded

separately. AO system allows better prediction of outcome separately. AO system allows better prediction of outcome when compared to Gustilo. Due to its complexity, not when compared to Gustilo. Due to its complexity, not widely accepted.widely accepted.

Ganga hospital scoreGanga hospital score

Includes additional criteria like age>65, DM, Includes additional criteria like age>65, DM, cardiorespiratory disease, trauma chest/abdomen, cardiorespiratory disease, trauma chest/abdomen, farmyard/sewage contaminations, delay in debridement farmyard/sewage contaminations, delay in debridement >12h.>12h.

Initial managementInitial management Patient assessment: ABCPatient assessment: ABC Address life threatening injuries.Address life threatening injuries. Rule out cervical injuries, chest, abdominal injuries, head injuries in Rule out cervical injuries, chest, abdominal injuries, head injuries in

polytrauma patients.polytrauma patients. Identify all injuries to extremities and assess neurovascular status of Identify all injuries to extremities and assess neurovascular status of

injured limb.injured limb. Assess skin and soft tissue damage.Assess skin and soft tissue damage. Obvious foreign bodies that are easily accessible may be removed- don’t Obvious foreign bodies that are easily accessible may be removed- don’t

do digital exploration.do digital exploration. The open wound should be covered with a sterile saline soaked gauze pad.The open wound should be covered with a sterile saline soaked gauze pad. Identify skeletal injuries and obtain necessary radiographs.Identify skeletal injuries and obtain necessary radiographs. IV TetanusIV Tetanus IV AntibioticsIV Antibiotics

Principles of TreatmentPrinciples of Treatment

Antibiotic prophylaxisAntibiotic prophylaxis

Wound debridementWound debridement

Fracture stabilizationFracture stabilization

DebridementDebridement

Most important step.Most important step. Aim-Removal of dead tissue and Aim-Removal of dead tissue and

foreign material to ensure good foreign material to ensure good blood supply.blood supply.

Debridement done as soon as Debridement done as soon as possible.possible.

Superficial DebridementSuperficial Debridement Wound margins are excised to identify and explore the entire zone Wound margins are excised to identify and explore the entire zone

of injury and to access ends of bone fragments. Extensile of injury and to access ends of bone fragments. Extensile longitudinal incision to visualize deep tissue and can be extended longitudinal incision to visualize deep tissue and can be extended till normal tissue encountered clearly.till normal tissue encountered clearly.

Nonviable skin and subcutaneous tissue excised but of marginal Nonviable skin and subcutaneous tissue excised but of marginal viability may be left for later debridement.viability may be left for later debridement.

Do not detach skin and subcutaneous tissue from the fascia. Any Do not detach skin and subcutaneous tissue from the fascia. Any nonviable shredded fascia and even the marginally viable ones nonviable shredded fascia and even the marginally viable ones excised.excised.

Deep DebridementDeep Debridement Muscle because of water content are subject to hydraulic damage Muscle because of water content are subject to hydraulic damage

by fluid waves during injury. In muscle debridement, the concept by fluid waves during injury. In muscle debridement, the concept is when in doubt take it out.is when in doubt take it out.

In type I, II, and IIIa open # all non-vital and in doubt muscle can In type I, II, and IIIa open # all non-vital and in doubt muscle can be debrided.be debrided.

IIIb and IIIc fractures- removal of entire muscle compartment may IIIb and IIIc fractures- removal of entire muscle compartment may

be needed.be needed.

Viability of muscle is checked by its color, capacity to bleed, Viability of muscle is checked by its color, capacity to bleed,

contractility, and consistency(4c’s-last 2 more reliable).contractility, and consistency(4c’s-last 2 more reliable).

IrrigationIrrigation

Usual irrigation fluid used is NSUsual irrigation fluid used is NS High volume low pressure repeated lavage is High volume low pressure repeated lavage is

performed.performed. Volume of fluid used varies- usually about 3 L is Volume of fluid used varies- usually about 3 L is

used for grade 1 #; 6-10 L is used for grade 2 or 3 used for grade 1 #; 6-10 L is used for grade 2 or 3 #.#.

Tendons, unless injured beyond repair should be Tendons, unless injured beyond repair should be preserved.preserved.

In open wounds tendons are subject to In open wounds tendons are subject to desiccation and hence it should be covered with desiccation and hence it should be covered with soft tissues if not with moist dressings.soft tissues if not with moist dressings.

In general bone devoid of soft tissue attachment In general bone devoid of soft tissue attachment are removed and large fragments with soft tissue are removed and large fragments with soft tissue attachments are preserved.attachments are preserved.

One exception to strict removal of bone without One exception to strict removal of bone without soft tissue attachment, is significant portion of soft tissue attachment, is significant portion of articular surface attached to bone fragment.articular surface attached to bone fragment.

Limb Salvage vs. AmputationLimb Salvage vs. Amputation

Limb is nonviable as evidenced by irreparable Limb is nonviable as evidenced by irreparable vascular injury, warm ischemia time >8 hrs, vascular injury, warm ischemia time >8 hrs, severe crush injury with minimal remaining viable severe crush injury with minimal remaining viable tissue.tissue.

Severely damaged limb may constitute a threat Severely damaged limb may constitute a threat to patients life especially in patients with severe to patients life especially in patients with severe debilitating c/c illness. The severity of injury debilitating c/c illness. The severity of injury would demand multiple operative procedures and would demand multiple operative procedures and prolonged reconstruction time.prolonged reconstruction time.

Mangled extremity severity score of >7 Mangled extremity severity score of >7 accurately predicts amputation.accurately predicts amputation.

Score doubles for ischemia>6 hrs.Score doubles for ischemia>6 hrs.

Skeletal StabilizationSkeletal Stabilization

Done once vascular repair is completed and limb Done once vascular repair is completed and limb salvaged or once irrigation and debridement is salvaged or once irrigation and debridement is done.done.

Restoring the length, rotational, and angular Restoring the length, rotational, and angular alignment has many benefits for healing of soft alignment has many benefits for healing of soft tissues.tissues.

Fracture reduction unkinks NV conduits and helps Fracture reduction unkinks NV conduits and helps in soft tissue healing.in soft tissue healing.

Minimizing motion of fragments also decreases Minimizing motion of fragments also decreases further damage, pain and permits mobilization of further damage, pain and permits mobilization of joints.joints.

Skeletal Stabilization-TypesSkeletal Stabilization-Types Extra osseous- In low grade open fracturesExtra osseous- In low grade open fractures

splints, plasters, wt bearing casts, etc.splints, plasters, wt bearing casts, etc.

Internal fixation- usually appropriate if wound clean, and Internal fixation- usually appropriate if wound clean, and soft tissue coverage available.soft tissue coverage available.

External fixation- in high grade open fracturesExternal fixation- in high grade open fractures

in dirty wounds, or extensive soft tissuein dirty wounds, or extensive soft tissue

injuries.injuries.

External fixationExternal fixation

Excellent stability obtained.Excellent stability obtained. Reasonable anatomic reduction Reasonable anatomic reduction

possible.possible. Minimal additional soft tissue traumaMinimal additional soft tissue trauma Risk of infection-minimized.Risk of infection-minimized. Ability to convert to internal fixation.Ability to convert to internal fixation.

Internal fixationInternal fixation

Plates and screws- to minimize complications IV Plates and screws- to minimize complications IV anti staph antibiotics should be started as soon as anti staph antibiotics should be started as soon as possible, sterile dressing, meticulous possible, sterile dressing, meticulous debridement, copious irrigation and minimal debridement, copious irrigation and minimal stripping and accurate anatomical reduction is to stripping and accurate anatomical reduction is to be done.be done.

IM nail- currently the treatment of choice for IM nail- currently the treatment of choice for grade I,II,IIIa, and IIIb fractures as ex-fix devices grade I,II,IIIa, and IIIb fractures as ex-fix devices leads to more malalignment, nonunion, and leads to more malalignment, nonunion, and delayed return to function.delayed return to function.

Wound closure and coverageWound closure and coverage Wounds without skin loss: tension free primary closure after Wounds without skin loss: tension free primary closure after

thorough debridement.thorough debridement. Contraindications for primary closureContraindications for primary closure

Delayed presentation >12 hrs.Delayed presentation >12 hrs.

Delayed administration of antibiotics>12 hrs.Delayed administration of antibiotics>12 hrs.

Deep seated contaminationDeep seated contamination

ImmunocompromisedImmunocompromised

NV injuryNV injury

Inability to achieve tension free sutureInability to achieve tension free suture

High risk of anaerobic contamination like farm yard High risk of anaerobic contamination like farm yard injuries.injuries.

Wounds with skin loss: healing by secondary intention. Wounds with skin loss: healing by secondary intention. Delayed primary closure, SSG, free flaps.Delayed primary closure, SSG, free flaps.

ComplicationsComplications

EARLY-ShockEARLY-Shock

Compartment syndromeCompartment syndrome

Crush syndromeCrush syndrome

Infection and sepsisInfection and sepsis

DVT and embolismDVT and embolism

ARFARF

Late- OsteomyelitisLate- Osteomyelitis

Non unionNon union

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