DEFINITION: An open fracture is one in which a break in the skin and underlying soft tissues leads directly into or communicates with the fracture and its hematoma.
Type I wound
is caused by a low-energy injury that is usually less than 1 cm long . It is usually caused by the bone piercing from the inside outward rather than by a penetrating injury.
Type II wound
is greater than 1 cm in length and has a moderate amount of soft tissue damage owing to a higher-energy injury . These are usually outside-to-inside injuries.
Type III wound
a high-energy, outside-to-inside injury and is usually longer than 10 cm with extensive muscle devitalization.
Extensive wound contamination also increases the likelihood of infection and subsequent complications.
A type IIIA open fracture
There is limited stripping of the periosteum and
soft tissues from bone .There may be loss of skin, There is adequate muscle and soft tissue coverage over bone
A type IIIB open fracture
there is extensive stripping of soft tissues and periosteum from bone. Devitalization or loss of soft tissues usually requires a local flap or free tissue transfer for coverage of exposed bone.
A type IIIC open fracture
is one in which there is a major vascular injury requiring repair for salvage of the extremity. A tibia fracture with disruption of the anterior tibial artery but preservation of the posterior tibial artery is not a type IIIC
injury.
MANAGEMENT OF OPEN FRACTURESGoals of management:
Early return to the function avoid complications
ER management: OR management:Assesment I&DReduction&splinting SK. Stabilization
Wound care Wound managmentTetanous prophylaxisAntibiotics
Tetanus ToxoidTetanus Toxoid 2.5 cc to all poly-trauma patients, otherwise:
IMMUNIZATION HISTORY
NON-TETANUS
PRONE
TETANUS PRONE*
UNKNOWN YES YES
>3 IMMUNIZATIONS<(5 YEARS)
NO NO
*Tetanus Prone: >6 hours old, complex soft tissue injury, wound >1 cm deep, missile, crush, burn, frostbite, devitalized tissues, soil contaminants, denervated, ischemic, early infection.
Tetanus Immune Globulin250-500 units IM:
IMMUNIZATION HISTORY
NON-TETANUS
PRONE
TETANUS PRONE*
UNKNOWN NO YES
>3 IMMUNIZATIONS
<(5 YEARS)
NO NO
ANTIBIOTICSIs therapeutic not prophylactic.
role :kill residual organisms ,inhibit their growth to the point where host protective mechanisms can eradicate them .
Irrigation and debridement :most important measures in preventing infection in open #,antibiotics certainly cannot be relied on to prevent infection in an inadequately debrided
wound. Early administration of antibiotics during initial phases of within 3 hrs of injury decreases incidence of infection in open fracturescommon organism :Staphylococcus aureus
Duration :48 to 72 hours after initial and any subsequent debridements, & after wound closure, bone graft & major surgical procedure
1 Gen Ceph Gent PCN
Grade I (G+ve)
Grade II (G+ve
Grade III (G+ve&
-ve) -/+
Farm & Ischemic Wounds
(anaerobic)
Recommended Antibiotic Treatment
Local Antibiotics• Numerous antibiotics can be
incorporated in polymethylmethacrylate (PMMA) without losing their bactericidal activity.
• Should prepared by surgeon• Useful for type II & III
1)Decrease infection rates2)High local antibiotic
levels(10-20times)3)Useful for dead space
management4)Decrease systemic effect of IV
antibiotics
PREPARATION FOR SURGICAL DEBRIDEMENT
All open fractures need to be formally treated in operating room on an urgent basis with meticulous irrigation&debridement.
A 2-phase surgical preparation of the limb may be advisable for severely contaminated wounds
IRRIGATION AND DEBRIDEMENT
“The solution to pollution is dilution.”
The more important is copious irrigation of the wound