1.OPEN FRACTURES

2. INTRODUCTION 3. Definition : An open fracture is one in which abreak in the skin and underlying soft tissuesleads directly into or communicates with fractureand its haematoma. Synonym: Compound fracture. 4. Several specific consequences mayresult according to the extent of injury ; Contamination with bacteria. Devascularisation of fascia & muscle & theunderlying bone makes the extremity moresusceptible for infection. Loss of soft tissue affects surgeons optionfor fracture stabilization 5. Lack of soft tissue coverage delays bone healing. Direct loss of function due to damaged muscles, tendons, nerves, vessels & skin. The most important and ultimate goal in thetreatment of open fractures is to restore limband patient function as early and as fully aspossible. The role of surgeon is to work towards this goal. 6. HISTORY Hippocrates considered war is the mostappropriate training ground for surgeons. Surgeons can only facilitate the healing and cannotimpose it. He opposed frequent meddling with wounds, exceptto extrude purulent material. His principle misconception was diseases not curableby steel (knife) are curable by fire (cautery). Brunschwig and Botello, in 15th & 16th centuries,advocated the removal of non vital tissue fromwounds that did not progress properly. 7. Desault, in 18th century, adopted the termdebridement for making a deep incision toexplore a wound, remove dead tissue, andprovide drainage. His pupil, Larrey, extended the principle as thesooner debridement is done after wounding, thebetter the result. Trueta brought together the combination ofdebridement and an occlussive dressing that alsoserved as a splint during spanish civil war. 8. Current recommendations for acutemanagement of open fractures: Provide airway management and urgentresuscitation. Immobilize extremity & sterile dressing. Administer early intravenous antibiotics. 9. Urgent operative debridement and irrigation,leave the wound open & stabilise skeletalinjuries. Perform repeated debridements, as needed. Delay wound closure/coverage. 10. DIAGNOSIS In most of the cases it is straightforward. All open fractures are not obvious, timely andproper diagnosis and treatment depends uponcareful clinical examination. Before detailed evaluation of an open fracture,life threatening injuries must be diagnosed andtreated according to the Advanced Trauma LifeSupport. 11. Advanced Trauma Life Support Establish Airway, Breathing and Circulation tosustain life. Once patient is stable, systemic search for otherinjuries should be performed. Cervical collar is placed until lateral cervicalspine X-ray is obtained and injury is ruled out. A chest and pelvis radiograph is taken toevaluate potential sources of hemorrhage &pulmonary dysfunction. 12. Airway : Removal of oral debris Gentle jaw thrust maneuver Nasotrachoel intubation in spontaneouslybreathing Emergency endotrachoeal intubation No patient should expire from lack of anairway because of concern over a possiblecervical injury. 13. Breathing :- Common reasons of ineffectiveventilation (breathing) after successfulestablishment of airway are malpositionof the ET tube, pneumothorax, andhaemothorax Mechanical ventilation 14. Circulation :- Hypotension following injury must beconsidered to be hypovolumic in origin untilproved otherwise Haemodynamic status can be assesed by Level of consciousness Skin colour Pulse External haemorrhage is identified andcontrolled in the primary survey 15. Compressive bandage on open, bleedingwounds. Tourniquets can only be used in traumaticamputations otherwise may cause crushing oftissues and distal ischaemia. If shock persists immediate search for occulthemorrhage in body cavities. 16. Disability (neurological evaluation) :- Determine the neurological function Level of consciousness, pupillary response,sensation and motor activity of all extremities Rectal examination to determine the sphinctertone. Precise measurement of neurological functionis provided by Glasgow Coma Scale (GCS). 17. Glasgow Coma ScaleCriteria ScoreEye opening (E)Spontaneous4To speech3To pain2Nil1Motor response (M)Obeys6Localises5Withdraws4Abnormal flexion 3Extensor response2Nil1Verbal response (V)Oriented 5Confused conversation4Inappropriate words3Incomprehensible sounds2Nil1 18. CLINICAL EXAMINATION A careful examination of extremities to diagnosefractures & dislocations. Must document neurological & vascular function: Circulatory status- Capillary blush, filling of veins &peripheral pulses. Neurological status- Sensory examination withpressure & light touch grossly and two pointdiscrimination especially in upper extremity. Motor examination may be difficult due to pain andsplinting but should be compared with normal side. 19. After documentation reduce the fractures ordislocations and give adequate splinting. If limb continues to show signs of vascularinsufficiency arterial injury should be considered & ruled out. Next, the skin: Dimensions, shape & nature of wound. Circumferential examination of extremities. Examination of back and buttocks. 20. Foreign bodies and debris in the wounds likestones, leaves or grass should be removedmanually with sterile forceps and sterile dressingapplied. To avoid subsequent opening of the wound aphotograph or a sketch can be drawn. To diagnose occult open fractures, all clothingmust be removed. 21. A pelvic fracture in case of vaginal lacerations isconsidered open fracture. A vaginal examinationwith speculum should be done to rule out occultopen pelvic fracture. Tetanus immunity must be determined andtetanus booster as well as immune globulinsshould be given. 22. History :- Age-General health Specific co morbidities-Previous disability Alcohol and drugs-Ambulatory status Residence-Cause of injury High or low energy -Potential for infection Other injuries -Previous injuries Any chronic illness Peripheral vascular disease, liver disease andimmunodeficiency disease 23. CLASSIFICATION The ideal classification system can: Accurately and reliably quantify a fracture. Give guidance in management. Allow long-term prognosis to beestimated. 24. Gustillo classification: - Open fractures are usually classified by theGustillo system. 25. Type I- Open fracture with a cleanwound 1 cm II-long and without extensive soft-tissue damage,flaps, or avulsions 27. Type IIIa-Adequate periosteal cover of a IIIa-fractures bone despite extensive soft-tissuelaceration or damage 28. Type IIIb-Extensive soft-tissue loss with IIIb-significant periosteal stripping and bone damage.Usually associated with massive contamination 29. Type IIIc-Association with arterial injury requiring IIIc-repair, irrespective of degree of soft-tissue injury 30. EPIDEMIOLOGY Very little is known about the epidemiology ofopen fractures. The incidence of open fractures varies indifferent places and in different institutionsdepending on many factors, including theincidence of road traffic accidents and gunshotinjuries. 31. Level 1 trauma centers obviously see moreopen fractures than smaller peripheral hospitals,but the overall incidence of open fractures isprobably similar in many parts of the world. The highest incidence is in tibial diaphysealfractures, where about 21% are open. 32. Fractures of the femoral diaphysis, hand and footphalanges, forearm diaphyses, tibial plafond,patella, distal femur, distal humerus, and humeraldiaphysis are all associated with incidences ofmore than 5%. In fractures of the metatarsus, scapula, pelvis,metacarpus, proximal humerus, and proximalfemur, however, the incidence is very low. 33. The incidence of open spinal fractures is so lowthat effectively they are unsurvivable. The onlyexception to this is gunshot spinal fractures,which are relatively uncommon in civilianpractice. 34. PRE-OPERATIVE ASSESSMENT A complete history and physical examination is essential. Age does not affect patient management, but older patients tend to be osteoporotic and the fractures may be associated with greater comminution. 35. Information about general health is importantbecause conditions such as diabetes mellitus,hypertension, or neuromuscular conditionsmay alter the type of operative treatment, andcardiovascular, pulmonary and other medical comorbidities may affect anesthesia and laterintensive care. 36. The pre-accident mental and physical stateof the patient is important: A Gustilo typeIIIb open tibial fracture in a dementednonambulator with medical co morbiditiesmight well be successfully treated by primaryamputation rather than by attempted bonereconstruction. 37. High-energy injuries are associated withsignificantly greater bone and soft tissue damage,and therefore open fractures following RTAs,falls from a height, crushing injuries, or gunshotinjuries, are often more difficult to manage andassociated with a worse prognosis than thosethat occur after a simple fall, a fall downstairs, ora sports injury. The mode of injury should be carefullyestablished to determine whether the openfracture has occurred as a result of a high- orlow-energy injury. 38. The physical examination must include anassessment of other injuries using ATLSprinciples. Examination of the limb should include acareful assessment of the vasculature. The surgeon should be aware that if the patientis hypotensive or peripherally shut down, anincorrect preoperative assessment of thevascular status of a limb may be made. 39. If there is any doubt about the vascular supply, aDoppler examination or angiogram should beobtained. Examination of the neurological status of thelimb is also important. Abnormal sensation ormotor power may suggest intracranial, spinal, orperipheral nerve damage. A peripheral nervelesion associated with a limb fracture suggestsconsiderable soft tissue injury and probably apoor prognosis for the limb. 40. EXAMINATION OF WOUND Ideally the open wound should not be examinedby every member of the medical and nursingstaff prior to surgery. If possible, a digital image of the wound shouldbe obtained soon after the patient is admitted tothe hospital, so that it, rather than the wound,can be repeatedly examined. This policy has been shown to be associatedwith a lower infection rate. 41. It is important, however, that the surgeonexamine the wound carefully. The location andextent of the wound may allow a preoperativedetermination of the need for plastic surgery,particularly if it is obvious there will be exposedsubcutaneous bone after debridement. The degree of wound and skin contaminationshould be assessed, as should the presence ofbone fragments in the wound. 42. The presence of skin degloving should be noted. The length of the wound is used in the Gustiloclassification, and a loose relationship existsbetween wound length and prognosis. But it should never be assumed a small woundnecessarily carries a good prognosis because theremay be significant associated contamination andtissue damage. 43. RADIOLOGICAL EXAMINATION Important features in open fracturesare;- Location and morphology of the fracture. Comminution signifying a high-energyinjury. Secondary fracture lines that may displaceon treatment. 44. The distance the bone fragments havetravelled from their normal location.(Wide displacement- avascularity.) Bone defects suggesting missing bone. Gas in the tissues. 45. MRI and CT scans are rarely required in theacute situation but may be helpful in openpelvic, intra-articular, carpal, and tarsalfractures. Angiography may be required in Gustilo IIIbor IIIc fractures. In the polytraumatized patient, the surgeonmust decide if a delay for further imaging isappropriate. 46. Operative treatment Surgeons tend to concentrate on the method offracture treatment when treating open fractures,but a number of procedures are involved iftheir treatment is to be successful. Irrigation & Debridement Skin & subcutaneous fat -Fascia Muscle-Tendons Bone-Joints Nerves & vessels-Fasciotomy Foreign bodies 47. Wound closure Antibiotics Intravenous Bead pouch technique Immediate or early amputation Fracture stabilization Secondary debridement Soft tissue cover 48. Irrigation The two adages that apply to open fractureirrigation are;- IF A LITTLE DOES SOME GOOD, A LOTWILL DO A GREAT DEAL MORE THE SOLUTION TO POLLUTION ISDILUTION Irrigation must be done thorough and copious. 49. Advantages of irrigation: - Flushing away of blood & other debris- goodinspection Fluid floats undetected necrotic fronds offascia, fat or muscle. Lavage floats contaminated blood clots andloose pieces of tissue & debris from unseenrecesses. Lavage restores normal colour of tissue. Reduces bacterial contamination. 50. Intermittent pressurelavage :- Initially, 1 to 2 litreirrigating solution shouldbe used for type I and 5to 10 L for type II & typeIII fractures. For final irrigationaround 2 L solutionshould be used. 51. Use of soap (detergent) solution withnormal saline is proven the best lavagesolution. Antibiotic solution has proven no bettermay increase the risks of wound healing.(JBJS,July2oo5) 52. Debridement The primary surgical debridement should beaggressive when required. The objectives of debridement are; - Extension of wound to allow identification. Detection and removal of foreign material. Detection and removal of necrotic tissues. Reduction of bacterial contamination. 53. Creation of wound that can heal withoutinfection. All affected tissue planes should be explored. The bone ends must be exposed and carefullyexamined for contamination and soft tissuestripping. The wound should not be closed primarily 54. Skin Skin is very resistant to direct trauma butsusceptible to shearing forces, the plane ofcleavage being outside the deep fascia. Shearing forces may produce extensive deglovinginjuries, which particularly affect the lower limband may be circumferential. Local excision of the contaminated wound edges. 55. If there are several wounds in close proximity,they should be excised en bloc, as there will beextensive associated soft tissue damage. All degloved skin should be resected until dermalbleeding is encountered. If a large area of degloved skin is excised, split skingraft can be harvested from the excised skin forlater use. 56. After the initial skin excision, extend the openwound to allow adequate exposure of theunderlying bone and soft tissues. There are no indications not to do this. Evensmall skin incisions may be associated withconsiderable contamination. The direction and length of the skin extensionsdepend on the location and size of the openwound Ideally extensions should be longitudinal and,where possible, follow normal surgical approaches 57. Fat and fascia All devitalized fat must be removed. The extent of fat necrosis may well be greaterthan was apparent preoperatively, and extensivefat resection with excision of the overlying skinmay be required in some cases. Fascial resection rarely presents a problem, but itshould be borne in mind that foreign materialmay spread between the deep fascia and theunderlying muscles. 58. Muscle All devitalized muscle should be removed. It can be difficult to assess muscle viability fully atthe initial debridement, particularly if the patientis hypotensive. The classic signs of muscle viability are; -ColourBeefy red, rarely CO exposure can bedeceivingConsistency Firm, not easily disruptedCapacity to May deceive as arterioles can bleed.bleed Typically reliableContractility Responsive to forceps pinch or lowcautery. Typically reliable. 59. Tendon Paratenon contains main blood supply of tendonand must be preserved to maintain tendonviability. If excised or destroyed, exposed tendon will notsurvive for long. Early skin coverage, primary closure, or muscleor skin flap, is necessary to preserve its viability. 60. Nerves & vessels Nerve injuries amenable to repair should besutured before delayed primary closure. Even when repaired the prognosis for associatedinjury to the posterior tibial nerve is poor,frequently leading to amputation. Brisk, small vessel or arterial bleeders requireimmediate ligation or coagulation to avoidfurther blood loss. Major vessel injuries requiring repair must beidentified before surgery and appropriatelyplanned. 61. In larger vessels, rather than carrying outimmediate end to end anastomosis or veingrafting, it may be better to insert a temporaryshunt. This permits irrigation & debridement andstabilization of bone before final vascular repair. Loss of total blood supply to the limb for morethan 8 hours nearly always results in amputation. 62. Bones Resection of bone should be dealt with in thesame way as soft tissue resection. All devitalized separate bone fragments shouldbe removed regardless of their size. As with muscle, it may be difficult to determinebone vascularity, and if the surgeon is concernedabout the viability of periosteal or muscleattachment to a bone, it may be advantageous tore-examine the bone fragments during the re-look procedure. 63. Joints Any wound that extends joint mandatesexploration. Wound itself may permit exploration orextensile incision may be necessary. If adequate exploration with arthrotomy is notpossible it should be combined witharthroscopy. Unexpected foreign bodies or osteochondralfractures may be found. 64. Fasciotomy After arterial repair, massive swelling of distallimb due to ischemia of the muscles is verycommon which necessitates fasciotomy torelease intracompartmental pressure. If there is any doubt about its indication, itshould be done. (Better to early than too late.) In calf, all four compartments should bereleased. 65. After formal fasciotomy, the skin should not beclosed as it may be as constricting as fascia ifswelling occurs. Frequently, skin grafting is required forcoverage because swelling recedes too slowly topermit suturing. 66. Foreign bodies Foreign bodies, especially organic, must besought and removed. Fragments of wound, after becoming bloodsoaked resembles muscles. The intrinsic recesses, pits of foreign bodies mayharbor pathogenic organisms or their spores. 67. Wound closure Open wounds should not be closed primarily.(adequately debrided wound can be under tension.) If wound closure is possible - Re-look procedure 36 to48 hours after the initial surgery. Even closure of the wound extensions may cause tissuetension. The only exception to the rule about closing woundsprimarily is if a primary flap is undertaken. Vacuum-assisted closure (VAC) systems have beenused for a number of years to close skin defects withgood results. 68. Vacuum assisted closure 69. Antibiotics Some 60% to 70% of open wounds areassociated with positive cultures in theemergency department. Most surgeons use a first- or second-generationcephalosporin as prophylaxis for Gustilo type Iand II open fractures. Initial dose as soon as possible after diagnosis with a three-dose intravenous regimen being used. 70. In Gustilo type III open fractures, 3 dose I V regimen of a 3rd generation cephalosporin or a combination of a 2nd generation cephalosporin and an amino glycoside. Chance of clostridial contamination, I V penicillinshould be given. If allergic - clindamycin ormetronidazole should be used. This is important in open pelvic fractures wherethe open fracture may have entered the rectum orvagina. 71. Antibiotic impregnated bids Antibiotic-impregnated polymethylmethacrylatebeads can be placed into the wound afterdebridement has been undertaken. These beads usually contain gentamycin ortobramycin. 72. They leak out at rates sufficient to producebactericidal levels in the surrounding tissues andfluids. 2.4 gm of antibiotic powder is mixed with 40 gmof PMMA and beads are prepared over a steel wireor non-absorbable suture material. Local wound levels of antibiotics produced arehigher than parenteral route alone. Beads then removed or replaced at subsequentdebridements or during the closure of wound. 73. Immediate or early amputation In general amputation isperformed when; - limb salvage poses significant risk to patient survival functional result would be better with a prosthesis duration and course of treatment would cause intolerable psychological disturbance 74. Lange proposed two absolute indications foramputation of tibia open fractures1. A typeIII C fracture in which vascular repair is required for salvage of extremity. The injury is accompanied by complete transection of posterior tibial nerve.2. The limb is nonviable. 75. Mangled Extremity SeverityScore An attempt to help guidebetween primaryamputation vs. limbsalvage A score of 7 or higherwas predictive ofamputation* Add 2 points if ischaemiatime > 6 hr*Johansen et al. J Trauma 1991 76. NISSA Score Modification of MESS score adding acomponent of nerve injury Nerve, Ischemia, Soft tissue injury, Shock, andAge Score Prospective evaluation is not available 77. Stabilization of bone When vascular repair has been completed,irrigation and debridement have been done, andlimb salvage is planned, stabilization of bone isnext concern. Unless the fracture is inherently stable, someform of skeletal stabilization is usually necessary. 78. Methods of stabilization: -1. Immobilization in a plaster slab or cast.2. Skeletal traction and suspension.3. External skeletal fixation.4. Internal skeletal fixation. 79. Goals of skeletal immobilization: - Restore length and allignment. Restore articular surfaces. Allow access to wound. Facilitate further reconstruction procedures. Allow early use of limb. Facilitate fracture union & return of function. 80. Contraindications to skeletalstabilization: - Severe communition. Minimal soft tissue injury with undisplacedfracture. Severe ongoing local infection. Severe systemic compromise precludinganesthesia. 81. Immobilization in plaster slab or cast: - Have limitations in treatment of openfractures. Access to wound is difficult. May be appropriate in type I fractures. There should be an easy way to access thewound for further management. A bubble can be made over the wound tolocate the site for creating window. 82. Skeletal traction and suspension: - Usually as a temporary method can be used forfemur and tibia. No good results are noted as a definitive treatment. Enforced recumbence and inconsistent outcomesmake the use contraindicated in adult patients. 83. External skeletal fixation Process of manipulating, aligning, andstabilizing bony structures with pins, wires,screws, or other bone fasteners that affix thebone to an external scaffold or frame. Since 1970s & early 1980s, emergence ofhalf pin frames have made external fixationas method of choice for stabilization of openfractures. Most often indicated in type IIIB & IIICand open fractures of pelvis. Many different devices are available. 84. Advantages of external fixators: - Relatively easily & quickly applied. Excellent stability & reasonably anatomicreduction of major fragments. Minimal additional soft tissue trauma. Early mobilization. Easy redisplacement of fracture at subsequentdebridements. Traveling traction- Temporary restoration oflength 85. Disadvantages of external fixators: - Application can be complex for complexfractures & large wound. Pins may entrap musculotendinous units. Interference with soft tissue reconstruction. Inappropriate technique of pin insertion-bone necrosis & pin loosening. Prolonged use- Delayed union or nonunion 86. Indications for external fixation: - Severe contamination Any site Periarticular fractures Definitive distal radius, elbow dislocation Temporizing knee, ankle, elbow, wrist,pelvis Distraction osteogenesis In combination with screw fixation (hybridfixation) for severe soft tissue injury 87. Ilizarov fixators 88. Post operative management of externalfixators:- Pin loosening leads to pin infection Loose pinmust never be left in place Most effective method of skin care is Dailywashing of frame, pins & surrounding skin with soapwater. Pin track infection is a contraindication toconversion to internal fixation. Temporary immobilization with cast or slab for 10to 14 days If the fixator has been in place for a short timeimmediate internal fixatiion can be done. 89. Internal fixation Multiple options depending on fracture patternand soft tissue injury: Plating Percutaneous plating Intramedullary nailing reamed & unreamed Choice of implant depends upon: Personality of fracture Nature of soft tissue injury Adequacy of equipments & implants 90. Plate fixation Traditional plating technique with extensive softtissue dissection and devitalization has generallyfallen out of favor for open tibia fractures Increased incidence of superficial and deepinfections compared to other techniques Newer percutaneous plating techniques usingindirect reduction may be a more beneficialalternative. 91. Tubular plate, DCP, Buttress plate& Percutaneous plating 92. Intramedullary nailing No periosteal disruption Reaming increases contact area Cross-locking Prevents rotation Maintains length Load-sharing device Studies show decreased infection rate in non-reamed nailing 93. Non-reamed & reamed nailing 94. Secondary debridement All open long-bone and pelvic fractures be reexplored36 to 48 hours after the initial debridement. Advantages of a secondary debridement areconsiderable. Residual contamination can be excised Excellent time to carry out definitive soft tissue closure because in the majority of cases there will be no residual contamination or devascularized tissue. The wound should not be closed until all devitalized orcontaminated tissue has been removed. 95. Soft tissue cover Most open wounds do not require plasticsurgery. Increasingly, however, plastic surgery techniquesare being used in open fractures. The most frequently used plastic proceduresinvolve split skin grafting, local muscle flapssuch as the gastrocnemius flap, local flaps suchas the proximal or distal fasciocutaneous flap, orfree flaps. 96. The requirement for plastic surgery ishighest in the tibia and hindfoot. Open fractures of the tibial diaphysis,plateau, and plafond are associated with thegreatest requirement for flap cover. 97. Split thickness skin graft 98. Fasciocutaneous skin flap 99. Free flap (cosmetically better) 100. Gastrocnemeous rotation flap 101. Biologic dressings When closure is not appropriate or cannot becarried out, biologic dressings of skin orsynthetic material may be of value. Homologous human skin, heterologous porcineskin and synthetic dressings may suffice. Seem to be deterrent to infection and existinginfection may be controlled or suppressed. Host granulation tissue invades such grafts andcan give readiness of a wound bed for definitiveautogenous grafting. 102. Elevation Persistent or increased swelling may keep tissuesturgid and wound surfaces moist, preventingdelayed primary closure. Edematous tissue increase tension on the sutureand may lead to marginal wound necrosis. Limb should be above the level of heart. However more than 10 cm height reducesarterial blood supply which may impendcompartment syndrome. 103. Complications Nonunion Malunion Infection- deep and superficial Compartment syndrome Fatigue fractures Hardware failure 104. Nonunion Time limits vary from 6 months toone year. Fracture shows no radiologicprogress toward union over 3 monthperiod. Important to rule out infection. Treatment options for uninfectednonunion include on lay bone grafts,free vascularized bone grafts, reamednailing, compression plating, or ringfixator. 105. Malunion More common in tibia. In general varus malunionmore of a problem thanvalgus. For symptomatic patientswith significant deformitytreatment is osteotomy. 106. Superficial infection Most superficial infections respond to elevationof extremity and appropriate antibiotics(typically gram + cocci coverage) If uncertain whether infection extends deeperand/or it fails to respond to antibiotictreatment , then surgical debridement with tissuecultures necessary 107. Deep infection Often presents with increasing pain, wounddrainage, or sinus formation. 108. Treatment involves debridement, stabilization(often with ex-fix), coverage with healthy tissueincluding muscle flap if needed, IV antibiotics,delayed bone graft of defect if needed. If treated with external fixation earlier, removefixator, wait for 2 wk and fix with internalfixation. If IM nail already in place, reamed exchange nailwith appropriate antibiotics may prove adequatetreatment. 109. Compartment syndrome Diagnosis same as inclosed fractures. Common with highenergy fractures andPost-vascular repair. Treatment iscompartmentfasciotomies. 110. Associated fatigue fractures Sometimes seen during rehab after prolongednon-weight bearing. Can present with localized tenderness inmetatarsal, calcaneus, or distal fibula. Bone scan or MRI may be required to makediagnosis as plain radiographs often normal. Treatment is temporary reduction in weightbearing. 111. Hardware failure Usually due to delayed union ornonunion. Important to rule out infectionas cause of delayed healing. Treatment depends on type offailure- plate or nail breakagerequires revision, whereasbreakage of locking screw innail may not require operativeintervention. 112. Rehabilitation Rehabilitation of the extremity: - Should be planned at the very outset oftreatment. Exercise program either active or with assistance Objectives of rehabilitation: - Prevention of muscle atrophy and disuse. Prevention of joint stiffness. Improvement of circulation in the extremity andaround the fracture site. 113. Rehabilitation of the patient: - In our hospital average stay of patients is; Type I 12 to 14 days Type II 15 to 20 days Type III around 3 months Inform the patient and family members thesocial and economic implications of the seriousinjury in the beginning. 114. Other extremities are also strengthened in orderto facilitate ambulation. A well-organized discharge planning andrehabilitation program will go a very long way inreturning the injured patient to a functionalstatus and gainful employment. 115. Outcome Outcome most affected by severity of soft tissueand neurovascular injury. Most studies show major change in resultsbetween type 3a and 3b/c fractures. For type 3b and 3c fractures early soft tissuecoverage gives best results. 116. THANK U