OPEN FRACTURE

DR THIT LWINSCHOOL OF MEDICINE &

HEALTH SCIENCEUMS

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(1)General considerations

(2)Assessment(3)Emergency

management(4)Débridement and

irrigation(5)Fracture stabilization(6)Wound management(7)Definitive treatment

• Open fractures of the tibia are the commonest of open long-bone fractures, ( thin anteromedial soft-tissue coverage).

• caused by low-energy twisting forces to high-energy motor vehicle crashes or penetrating injuries (gun shots, blasts).

• Although the principles of management for open tibial fractures are constant, the path to the final result may vary.

• can present as isolated injuries or in the context of a multiply injured patient.

• Thorough evaluation of the entire patient is essential before focusing on the injured leg.

• DEFINITION• CLASSIFICATION• MANAGEMENT

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• DEFINITION• Fracture in which there is skin damage, so that

bacteria from without may contaminate the fracture haematoma. The skin may be cut or crushed (potential skin loss) or there may be actual skin loss.

• The highest incidence is in tibial diaphyseal fracture 21%

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• The severity of open fracture can varies significantly

1. energy level (height of fall/speed of car/caliber of bullet) 2. degree of contamination (soil/broken glass/stagnant water) 3. degree of soft tissue injury (crushed/avulse)

4. complexity of fracture pattern(number of bone pieces)

5. vascular injury

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• CLASSIFICATION (GUSTILO'S)• Type I: Wound is small <1cm: clean

puncture through which a bone spike has protruded. - little soft tissue damage with no crushing and the fracture is not comminuted.

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• TYPE I OPEN FRACTURE

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TYPE I OPEN FRACTURE

• Type II: Wound is more than 1cm long but there is no skin flap. There is not much soft tissue damage and no more than moderate crushing (or) comminution of fracture.

• Type III: There is extensive damage to skin, soft tissue neurovascular structure with considerable contamination of wound.

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• TYPE II OPEN FRACTURE

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TYPE II OPEN FRACTURE

• III.A The fracture bone can be adequately covered by soft tissue.• III.B It can not and there is also periosteal Stripping & severe comminution of fracture.• III.C There is an arterial injury which needs

to be repaired, regardless of amount soft tissue damage.

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• TYPE III A OPEN FRACTURE14

• TYPE IIIB OPEN FRACTURE

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• TYPE IIIC OPEN FRACTURE

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• III.B & III.C are classified as high velocity injury although the wound is small, internal damage is severe.

• Incidence of infection directly correlate with extent of soft tissue damage, raising from less than 2% in type I to over 10% in type III.

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Gustilo and Anderson. (JBJS 1976)

Gustilo, Mendoza and Williams. (J.Trauma 1984).

AO classification (adapted from Tscherne)

• Challenging fact in open tibial fractures 1. Infection: The grade of open fracture, condition of the soft

tissues, degree of contamination and the thoroughness of surgical debridement will have influence on the risk of infection. In the worst injuries (type III b or c), open tibial fractures carry an infection risk of up to 25-50 %.

2. Soft-tissue deficiency: Soft-tissue defects require early closure with healthy tissue to reduce the risk of infection. Local or free-tissue transfers may be required, if tension-free closure is not possible.

3. Impaired bone healing: Failure to unite may require additional surgery, such as bone grafting and/or revised fixation. Stimulation of bone healing remains a developing field.

MANAGEMENT• 3 Goals -prevent infection -fracture

union -regain early good functional results• The order of priority in management of open

fracture include 1.patient 2.limb3.wound 4.fracture

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• Management• Many patients with open fractures have

multiple injuries and severe shock; for them, appropriate treatment at the scene of the accident is essential.

• Treatment at the scene of accident - immediate wound cover with sterile

dressing and left undisturbed until the patient reaches the accident department.

- Treatment of shock -Splint the limb

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• 2. Treatment at the hospital - rapid general assessment (any life threatening

condition). GCS - Wounds inspection i. What is the nature of the wound?ii. What is the state of the skin around the wound?iii. is the circulation satisfactory?iv. Are the nerve intact?- Tetanus prophylaxis- Antibiotic prophylaxis - Early wound debridement

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• Assessment • inspected the entire soft-tissue envelope -the posterior aspect of the leg.• Cover the open wound with a sterile dressing. It should not be again

inspected until the patient is in the OR for debridement.• Neurovascular assessment

The dorsalis pedis and posterior tibial pulses should be palpated in the foot. Reduced pulses require urgent further assessment.Motor function in each of the four leg compartments should be evaluated (toe flexion, toe extension, ankle eversion and plantarflexion). Sensory function : tibial (plantar surface of foot)

deep peroneal (dorsal webspace between 1st and 2nd toe) superficial peroneal (dorsal lateral foot) saphenous (medial foot)

This may not be possible in all patients (ie intubated, multiple injured, comatose), but should be always be attempted and documented.

• Emergency management• must receive anti-tetanus prophylaxis and appropriate antibiotic coverage.

Antibiotics should be given intravenously as soon as possible.• A temporary splint may be applied to protect the soft tissues while

awaiting the availability of an operating room.Definitive classification of the open fracture is best done in the OR.

• Definition:• exploration of wounds, removal of foreign body,

excision of devitalized tissue.• The wound is irrigated thoroughly with copious

amounts of physiological saline.

• SKIN : Only the merest sliver of skin is excised from the wound edges; as much skin as possible is spared .Planned the incisions to obtain adequate exposure.

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• SUBCUTANEOUS TISSUE: can excise liberally.

• FASCIA: is divided extensively so that the circulation is not impeded.

• MUSCLE : Dead muscle is dangerous. It provides food for bacteria. Dead muscle can be recognized by its purplish discoloration; mushy consistency; failure to contract when stimulated and failure to bleed when cut. All dead and doubtfully viable muscle is excised.

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• General principles of debridement • It is important to perform a thorough surgical débridement in an organized

manner. Starting with the skin, each layer is debrided systematically. One can imagine a clock face; wound débridement starts at the 12 o’clock position and continues in a clockwise manner around the circumference of the wound. This is repeated for each layer down to the level of the bone. Necrotic tissue is removed and only viable tissue is left behind. The exception is skin, where none is removed unless obviously necrotic.The quality of the muscle tissue is assessed using the classic 4 C’s:

• Color (red or brown) • Consistency (how does the muscle feel) • Capillary Circulation (does it bleed?) • Contractility (responds to pinch or electro-cautery)

4 ‘C’

Dead muscle Live muscle

Color Purplish Beefy red

Consistency Mushy Firm

Contractility - +

Capacity to bleed

- +

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• BLOOD VESSEL:Blood vessel are tied ridiculously but, to minimized amount of catgut left in the wound, small vessels are clamped with artery forceps.

NERVES:• It is usually best to leave a cut nerve

undisturbed. If, however, the wound is clean and the nerve end present without dissection the sheath is suture using non-absorbable material for ease of later identification.

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TENDON: Cut tendons are also left alone. Suture is permissible only if the wound is clean and dissection unnecessary.

BONE: The fracture surfaces are gently cleaned and replaced in correct position. Bone fragments were removed only if they are small and totally detached.

JOINT: Open joint injury are best treated by wound toilet, closure of synovium and capsule, and systemic antibiotic. Drainage or suction irrigation is used only if contamination is severe.

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• Débridement does not necessarily need to be through the open fracture wound. In fact, in certain situations it may be advisable to incorporate the débridement through the planned surgical approach for fracture fixation so as to avoid additional trauma to the injured soft tissues.The initial débridement thus requires consideration of, and planning for, the definitive surgery.

• After removing visible dirt and necrotic tissue, irrigation with several liters of fluid is a key component of the decontamination of the injury zone. If available, a balanced salt solution is routinely used. In more austere environments, any water that is “clean enough to drink” is acceptable.

• Controversies exist regarding the optimal volume and delivery methods. We recommend large volumes, with low pressure to avoid additional tissue injury. Gravity flow, with large-bore cystoscopy tubing, is a well accepted method.

• Fracture stabilization• Temporary stabilization of the tibia is chosen in situations

where future débridements are felt to be necessary. This is most common in the high-grade open fractures.Temporary stabilization, usually achieved with an external fixator, minimizes additional soft-tissue injury. This fixation facilitates access to the wound for inspection between débridements.It also allows simple, rapid disassembly for repeated wound débridements when necessary.

• External fixation • External fixation can be applied using either modular or

uniplanar techniques (see Modular external fixator and Standard external fixator). The modular frames have the advantage of being more versatile, avoiding the complex wounds that are often seen. The disadvantage of a modular frame is, that it is less rigid than the uniplanar fixator because of its multiple connections.

•Pin placement outside of the anticipated zone of the definitive implant is a consideration, although not always possible. Reduce the fracture as well as possible, to avoid soft-tissue tension.

• Wound management• Systemic antibiotics are a critical part of open fracture wound

management. Their choice and duration will depend upon several factors including severity of the wound, patient comorbidities, contamination etc.Antibiotics may also be applied locally to deliver high  concentrations directly to the wound site itself.Methylmethacrylate impregnated with heat-stable antibiotics is shaped into small beads to increase their surface area and to optimize antibiotic elution.

• After placement onto a suture, the beads are placed within the wound to fill the dead space. The wound is then closed primarily or covered with an adhesive drape.

• Generally, beads are left in for at least 2-5 days.

• Vacuum assisted closure (VAC) • Negative pressure wound dressings (“VACs”) can provide

helpful temporary coverage of an open wound. • They reduce external wound contamination, remove edema

fluid, help to shrink wounds, and promote growth of granulation tissue, even over exposed bone.

• Such dressings may allow definitive closure by the subsequent use of split thickness skin grafts, instead of more complex flaps. In this manner, a VAC can be used as a bridge to definitive soft-tissue coverage for type IIIA and IIIB wounds. They should be changed every 48-72 hours.

• Repeat débridement • Repeated débridement may be necessary in the higher grade

open fracture wounds when there is a concern for additional necrotic tissue or when initial wounds were so badly contaminated that a second look is necessary.

• This procedure should be repeated, generally every 2-3 days, until only healthy, viable tissue remains and no further necrotic tissue is found on follow-up débridements.

• WOUND CLOSURE• It is difficult to decide close or not to close.• A small uncontaminated type I, operated within few hours injury

may, after debridement, be sutured (provided it can be done without tension).

• All others wounds must be left open until the dangers of tension and infections have passed.

• The wound is lightly packed with sterile gauzed and is inspected after 3-5 days; if it is clean, it is sutured or skin grafted (delayed primary closure).

• Grade III wound have to be debrided more than once and skin closure may call for advanced plastic surgery and use of vascularized muscle flaps.

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• STABILIZATION OF THE FRACTURE• Plaster. For type I and type II wound with a stable

fracture• External fixation.• Intramedullary nailing.• Plates and screws.

AFTER CARE• The limb is elevated and its circulation carefully

watched. • Continued chemotherapy with antibiotics.• Delay primary suture.

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8 Steps in summary1. Treat all open fractures as an emergency2. Perform a thorough initial evaluation to

diagnose other life threatening injuries.3. Begin appropriate AB therapy in the

emergency room or operating room and continue therapy for 2-3 days only.

4. Immediately debride the wound using copious irrigation and for type II and III fractures, repeat the debridement in 24-72 hours.

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5. stabilize the fracture 6. Leave the wound open for 5-7 days. 7. Perform early autogenous cancellous bone

grafting. 8. Rehabilitate the involved extremities.

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Table 46-4 Mangled Extremity Severity Score

Type Characteristics Injuries point SKELETAL/SOFT TISSUE GROUP 1. Low energy : Stab wounds, simple closed factures, small-caliber gunshot wounds 1 2 . Medium energy: Open or multiple-level fractures,

dislocations, moderate crush injuries 2 3 .High energy : Shotgun blast (close range), high-

velocity gunshot wounds 3

4.Massive crush : Logging, railroad, oil rig accidents 4

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• SHOCK GROUP 1 Normotensive hemodynamics Blood pressure stable in field and in operating room 0 2 Transiently hypotensive BP unstable in field but responsive to intravenous fluids 1 3 Prolonged hypotension

blood pressure less than 90 mm Hg in field and responsive to intravenous fluid only in operating room 2

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• ISCHEMIA GROUP

1 None pulsatile limb without signs of ischemia 0

2 Mild Diminished pulses without signs of ischemia

13 Moderate No pulse by Doppler, sluggish capillary refill

paresthesia, diminished motor activity 2

4 Advanced Pulseless, cool, paralyzed and numb without capillary refill

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• AGE GROUP

• 1 <30 years 0

• 2 >30 <50 years 1

• 3 >50 years 2

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• Definitive treatment• Definitive fixation is considered, when: • the patients clinical status is optimized • the wounds are healthy and the soft-tissue envelope will allow

for chosen surgical approach • a good preoperative plan has been created.