Open Fracture

7/17/2019 Open Fracture

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OPEN FRACTURES


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OPEN FRACTURES -INTRODUCTION

OPEN FRACTURES ARE ALSO KNOWN AS COMPOUNDFRACTURES


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Defnition

Open racture implie communication!et"een e#ternal en$ironment an%t&e racture'

A ot tiue in(ur) complicate% !) a!ro*en !one'


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Component o open racture

Fracture

Sot+tiue %ama,e

Neuro$acular compromie

Contamination

E#tent o eac& component mut !e aee%

in%i$i%uall) in or%er to ac&ie$e acompre&eni$e un%ertan%in, o t&e in(ur)-upon "&ic& t&e treatment plan can !e !ae%'


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.itor)

A centur) a,o- t&e &i,& mortalit) opatient "it& open racture le% to earl)amputation to pre$ent %eat&'

Trueta recommen%e% open "oun%treatment an% u!e/uent encloure oe#tremit) in a cat

0n 1234- t&e ue o Penicillin re%uce% t&erate o "oun% epi

.ampton recommen%e% cloure !et"een3t&+5t&%a) ater in(ur)


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Mec&anim o in(ur)

Open racture occur a a reult o%irect &i,& ener,) trauma eit&errom Roa% tra6c colliion or all

rom &ei,&t'


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Epi%emiolo,)

Diap&)eal racture"ere more commont&an metap&)eal

racture' .i,&etrate o %iap&)ealracture "ere eenin ti!ia781'9:;ollo"e% !)emur718'1:;- ra%iuan% ulna72'4:;- an%&umeru7


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Micro!iolo,)

Poor tiue o#),enation an% %e$itali=ation o t&eurroun%in, tiue inclu%in, t&e !one pro$i%e aperect me%ium or inection an% !acterialmultiplication'

W&en let open >8"ee* ? prone to noocomialinection uc& a peu%omona pecie an% ,ramne,ati$e !acteria'

T&i p&enomenon o &opital ac/uire% inectionemp&ai=e t&e importance o a trict protocol or in+

&opital mana,ement an% earl) "oun% co$era,e'


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OPEN FRACTURES -COMPLICATIONS

W.@ OPEN FRACTURES CAN E DANBEROUS


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Earl) Complication

0nection

.)po$olemic &oc*

Compartment )n%rome Fat em!olim

Ar%

Neuro$acular in(urie


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.)po$olemic &oc*


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.)po$olemic &oc* +mana,ement

T"o lar,e+!ore 0 line &oul% !etarte%'

Once 0 acce i o!taine%- initialui% reucitation i perorme% "it&an iotonic cr)talloi%- uc& a Rin,erlactate olution or normal aline' An

initial !olu o 1+8 L i ,i$en in ana%ult 78 mLG*, in a pe%iatricpatient;- an% t&e patientH repone

i aee%'


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.)po$olemic &oc*

T)pe o ui%+

Colloi% ? al!umin- %e#tran- plama

Cr)talloi% ? NS- D


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Compartment )n%rome


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Compartment )n%rome

Claicall) < P aociate% "it&compartment )n%rome

Pain out o proportion to "&at ie#pecte%

Paret&eia

Pallor

Paral)i

Palpa!le pule


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Meaurement o compartment )n%rome+,au,in, preure !) intro%ucin, nee%le into

compartment

Str)*er 82< /uic*+preuremonitor et


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Compartment )n%rome

Treatment + Faciotom)


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Fat em!olim

Defnition + Occluion o mall $eel!) at ,lo!ule

T)pe+

1' cere!ral ? %ro")- retle an%%ioriente%

8'pulmonar) ? tac&)pnea-tac&)car%ia- petec&ial ra&7in ront onec*- ant a#illar) ol%- c&et an%con(ucti$a;


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Fat em!olim

Dia,noi ?

i,n o retinal arter) em!oli7triate&emorr&a,e an% e#u%ate; ma) !epreent'

Sputum an% urine ma) re$ealpreence o at ,lo!ule'

+ra) o c&et &o" patc&)pulmonar) inarct'

loo% Po8


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Fat em!olim

Treatment+

Repirator) upport

.eparini=ation 0ntra$enou lo"+molecular "ei,&t

%e#tran an% corticoterio%


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ARDS

0 caue% !) releae o inammator)me%iator "&ic& caue %iruption opulmonar) $aculature'

Si,n an% )mptom ? Tac&)pnea-lo" P- C)anoi

Treatment ? 1: o#),en


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0n(ur) to !loo% $eel

A!ent perip&eral pule in an in(ure%lim! &oul% !e coni%ere% to !e %ue to$acular %ama,e unle pro$e%

ot&er"ie' &ar% i,n o arterial in(ur)

7a; a!ent pule

7!; acti$e &emorr&a,e

7c; e#pan%in, &ematoma- an%

7%; !ruit or t&rill'


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acular in(ur)

0n$eti,ation+

Colour %oppler tu%)

Arterio,rap&)

Treatment+

Arterial recontruction

)pa ,rat

Timin,+ lo o total !loo%uppl) to t&e lim! or > &our nearl) al"a)reult in amputation'


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Ner$e in(ur)

Ner$e repair &oul% !e %one "it&in 4"ee* o in(ur) or !etter reult


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OPEN FRACTURES GRADING ANDCLASSIFICATION

TO ACCURATEL@ DESCR0E S0M0LAR 0NQUR0ES 0N ORDER TO

PRO0DE A AS0S FOR TREATMENT- TO EST0MATEPROBNOS0S AND TO ENALE COMPAR0SON ETWEENCENTERS'


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Butilo an% An%eron


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Butilo an% An%eron


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Tc&erne

Grade I? mall puncture "it&out aociate%contuion- ne,li,i!le contamination- lo"+ener,)mec&anim o racture'

Grade I0+ mall laceration- *in an% ot tiuecontuion- mo%erate !acterial contamination

Grade III+ lar,e laceration "it& &ea$) !acterialcontamination- e#teni$e ot tiue %ama,e

Grade IV+ incomplete or complete amputation"it& $aria!le


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.anno$er racture cale

Total score - T&i coni%er e$er) %etail ot&e in(ur) to t&e in$ol$e% e#tremit) an% i ma%eup a a c&ec*lit' T&e racture t)pe accor%in, tot&e AO claifcation- t&e *in laceration- t&eun%erl)in, ot tiue- t&e $acularit)- t&eneurolo,ical tatu- t&e le$el o contamination- acompartment )n%rome- t&e time inter$al!et"een in(ur) an% treatment- an% t&e o$erall

e$erit) o t&e in(ur) to t&e patient are a%%e% up

to pro$e t&e total core'


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.anno$er racture cale

0nterpretation

minimum core

ma#imum core 88

T&e &i,&er t&e core t&e "ore t&ein(ur)'

A core 11 in%icate i,nifcanttrauma- "it& amputationrecommen%e%'


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AO claifcation


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AO claifcation


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0o 1 ? *in !rea*a,e rom ini%e out


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0o 8+ *in !rea*a,e rom outi%e in


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0o4 ? *in !rea*a,e rom outi%e in >


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0O 3 ? Coni%era!le- ull t&ic*ne contuion-a!raion- e#teni$e open %e,lo$in,- *in lo


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0O< ? e#teni$e %e,lo$in,


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Neuro$acular in(ur) + AO


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MucleGten%on in(ur) ? AO


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Ban,a &opital core

0nterpretation

T&e total core "a ue% to a%%ret&e /uetion o al$a,e an% t&e

outcome "a meaure% !) %i$i%in,t&e in(urie into our ,roup 7Broup 0+


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Man,le% e#tremit) e$erit) in%e#

Man,le% e#tremit) e$erit)


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Man,le% e#tremit) e$erit)

core7MESS;

LS0+ lim! al$a,e in%e#


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LS0 lim! al$a,e in%e#


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Lim Sal!a"e I#de$ O%tcome

< lim! al$a,e ucceul 7


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Pre%icti$e al$a,e in%e#


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0nterpretation minimum core 4 7!ae% on t&e point

ai,nment i no $acular- !one or mucle in(ur)t&en t&e core coul% reac& 1- !ut t&en it "oul%not !e a erioul) in(ure% lim!;

ma#imum core 14

T&e &i,&er t&e core t&e "ore t&e c&ance or aucceul lim! al$a,e'PSI O%tcome

5 ,oo% 718 o13 lim!al$a,e%

poor 75 o 5amputate%;


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N0SSSA

Parameter

N V ner$e in(ur)

0 V ic&emia

S V ot tiue contamination

S V *eletal in(ur)

S V &oc* A V a,e o t&e patient


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N0SSSA


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N0SSSA


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N0SSSA

0nterpretation

minimum core

ma#imum core 12

T&e &i,&er t&e core- t&e more e$eret&e in(ur)'

A core 5 "a 1: eniti$e or

amputation- !ut "it& pecifcit) o 39:' A core 11 &a% a 1: pecifcit) an%

poiti$e pre%icti$e $alue or amputation'


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OPEN FRACTURES -MANAGEMENT

T.E TREATMENT OF .0B. ENERB@ 0NQUR0ES A0M TOPRESERE L0FE- L0M AND FUNCT0ON'


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Boal o treatment

T&e interme%iate o!(ecti$e are+

Pre$ention o inection

Fracture ta!ili=ation

Sot+tiue co$era,e


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Sta,e o care


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0nitial aement

0mportant component in aein,traumati=e% e#tremit)

1' .itor) an% mec&anim o in(ur)

8' Neuro$acular tatu4' Si=e o *in "oun%

3' Mucle cru& or lo


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Primar) ur,er)


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0rri,ation

Supplement )temic %e!ri%ementin remo$in, orei,n material an%%ecreain, !acterial loa%'

Fract%re t&'e Vol o( )%id %sed (orirri"atio#

T)pe 0 4 L

T)pe 8 9L

T)pe 4 2L


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0rri,ation

8 a%a,e'

0 a little %oe ome ,oo%- a lot "ill%o a ,reat %eal more

olution to pollution i %ilution


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0rri,ation

NS normall) ue% orirri,ation'

Anti!iotic olution i no!etter t&an oap or openracture irri,ation

Antieptic olution &a$e!een not &o"n to%ecreae inection rate'

Suractant7non terileoap; ame eXecti$ene-le tiue %ama,e n moreeconomical'


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Timin, o %e!ri%ement an%


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Timin, o %e!ri%ement an%

irri,ation

Mot ,ui%eline recommen%%e!ri%ement "it&in 9 &r'

Serial %e!ri%ement ma) !e

necear) e$er) 83+3&r until t&e"oun% $ia!ilit) i enure%


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Anti!iotic

S)temic a%minitration


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Anti!iotic

Local anti!iotic

0n ,utilo t)pe 000 racture a%%itionalue o local amino,l)coi%e

impre,nate%pol)met&)lmet&acr)late7PMMA;!ea% re%uce o$erall inection rate'


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P i


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Primar) ur,er)

Timin,

Sur,ical emer,enc)

Operatin, room "it& 9+&r o in(ur)? contaminate% "oun% not treate%"it&in t&i time "ill &a$e utaine%!acterial multiplication to reult in

earl) inection'

P i


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Primar) ur,er)

Fracture ta!ili=ation

A oon a primar) "oun% care icomplete%- treatment &oul%

procee% to racture re%uction an%f#ation'

Sur,eon &oul% recru!- re,o"n an%

re,lo"' DiXerent et o intrumentt&an t&oe ue% or %e!ri%ement inecear)'


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Relati$e 0n%ication or T)pe o


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Relati$e 0n%ication or T)pe oS*eletal Fi#ation in Open Fracture

E#ternal f#ation

Se$ere contamination an) ite

Periarticular racture

Defniti$e

Dital ra%iu

El!o" %ilocation

Selecte% ot&er ite

Tempori=in,

Knee

An*le

El!o"

Writ

Pel$i

Ditraction oteo,enei

0n com!ination "it& cre" f#ation or e$ere ot tiue in(ur)

Relati$e 0n%ication or T)pe o


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Relati$e 0n%ication or T)pe oS*eletal Fi#ation in Open Fracture

0nternal f#ation

Periarticular racture

DitalGpro#imal ti!ia

DitalGpro#imal emurDitalGpro#imal &umeru

Pro#imal ulnar ra%iu

Selecte% %ital ra%iuGulna

Aceta!ulumGpel$i

Diap&)eal racture

FemurTi!ia

.umeru

Ra%iuGulna

Pl t


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Plate

Open %iap&)eal racture o t&era%iu an% ulna a "ell a t&e&umeru are !et mana,e% "it&

plate f#ation' T&e plate f#ation o lo"er e#tremit)

%iap&)eal racture i ,enerall) not

recommen%e% %ue to &i,&er rate oinection'


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0ntrame%ullar nailin,


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0ntrame%ullar) nailin,

Loc*e% intrame%ullar) nailin, &a !eeneta!li&e% a t&e treatment o c&oice ormot %iap&)eal racture in lo"ere#tremit)'

T&e tec&ni/ue &a particular $alue oropen racture' 0ntrame%ullar) nail can !einerte% "it& no urt&er %iruption o t&e

alrea%) in(ure% ot+tiue en$elope an%preer$e t&e remainin, e#tra oeou!loo% uppl) to cortical !one'

0M nailin,


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0M nailin,

Data &o"in, t&at oli% intrame%ullar)nail inerte% "it&out reamin, &a$e alo"er ri* o inection'

On t&e ot&er &an% reame% intrame%ullar)nail can relia!l) maintain racturere%uction "it& re,ar% to an,ulation-rotation- %iplacement- an% len,t&'

Propecti$e ran%omie% trail t&atcompare% reame% "it& unreame%interloc*e% 0M nail %i% not &o" an)i,nifcant %iXerence concernin, outcome

an% ri* o com lication'


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E#ternal f#ation


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E#ternal f#ation

A%$anta,e o e#t Fi#ation+

Can !e applie% relati$el) eail) an%/uic*l)

0t pro$i%e relati$el) ta!le racturef#ation

T&ere i no urt&er %ama,e %one i

applie% correctl) 0t a$oi% implantation o &ar%"are in

open "oun%'

E#t f#ator


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E#t f#ator

Ma(or pro!lem "it& e#ternal f#ation arerelate% to pin tract inection- malali,nment -%ela)e% union- poor patient compliance'

E#ternal f#ator are particularl) ueul inracture "it& e$ere %ama,e an%contamination- "&ere metallic implant ?"it& ri* o !acterial a%&erence ? are !et

a$oi%e%' Rin, f#ator ma) !e an option in

%iap&)eal racture


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T)pe ?

Rin, f#ator

Qoint pannin, e#ternal f#ator


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Open "oun% co$era,e ater primar)


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p , p )

ur,er)

Primar) Cloure


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Primar) Cloure

0 it i to !e %one- t&e ollo"in, criteria mut !e met

1' T&e ori,inal "oun% mut &a$e !een airl) clean- an% not&a$e occurre% in a &i,&l) contaminate% en$ironment'

8' All necrotic tiue an% orei,n material &a$e !een %e!ri%e%'

4' Circulation to t&e lim! i eentiall) normal'

3' Ner$e uppl) to t&e lim! i intact'


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Dela)e% primar) cloure

cloure !eore t&e ft& %a) i terme% %ela)e%primar) cloure

A lon, a cloure i ac&ie$e% !eore t&e ft&%a)- "oun% tren,t& at 13 %a) are

compara!le "it& t&oe in "oun% cloe% on t&efrt %a)

lea$in, t&e "oun% open minimi=e t&e ri* oanaero!ic inection- an% t&e %ela) allo" t&e

&ot to mount local "oun% %eeni$emec&anim t&at permit aer cloure t&an ipoi!le on t&e frt %a)'


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Current tan%ar% o care or all openracture "oun% i to !e let openinitiall)'

Dela)e% cloure i accompli&e%"it&in 8+5%a)

AC aite% "oun% cloure i

preentl) recommen%e% ortemporar) mana,ement o openracture "oun%'

AC


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AC

T&e "oun% !e% i e#poe% to mec&anicall)in%uce% ne,ati$e preure in a cloe%)tem '

T&e )tem remo$e ui% rom e#tra$acular

pace- re%uce e%ema- impro$e microcirculation an% en&ance t&e prolieration opreparati$e ,ranulation tiue'

Pol)uret&ane oam %rein, i place% in"oun% an% enure an e$en %itri!ution one,ati$e preure'

AC


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AC

Anti!iotic !ea% pouc&


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tec&ni/ue


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Reerence


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Reerence

AO principle o racturemana,ement 8n%E%

Roc*"oo% an% ,reen ? racture in

a%ult 5t&E% Camp!ell + operati$e ort&ope%ic 11t&

E%'

Mana,ement o open racture !) Dr'TSE Lun, Fun,

ariou ource on 0nternet


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T*AN+ ,OU

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