Open Fractures Principles of Management

1. Open FracturesPrinciples of Management Prof. Mamoun Kremli AlMaarefa College

2. Historical fact … until WW I • Treatment of open fractures was “Amputation” • Mortality rate ~ 75% • Function in “survivors” was poor Alois Karlbauer

3. Objectives • Definition of an open fracture • Important points in history of an open fracture • Classification • Management: • Initial treatment • Importance of surgical debridement • Bone treatment initial & definitive • Soft tissue coverage • Factors affecting outcome

4. Definition • Open fracture is a fracture where the skin coverage overlying is breached • even a small puncture wound • Another name: compound fracture www.merryshannon.com

5. History in open fractures • Mechanism of injury • Date, time, type, method of impact, … • Consciousness • Size of wound • Amount of bleeding • Other injuries: often missed • Anti-Tetanus status

6. Type of injury • Determines amount of energy and • Extent of soft tissue injury

7. Type of injury • Fall: height is important • Sport: stronger impact • Heavy object falling: direct injury – soft tissue • Road traffic accident (RTA)): more severe • Car (MVA) , motorcycle, pedestrian • Assault & firearms: severe

8. Mechanism of Injury • Try to determine if injury was caused by: • Low velocity • High velocity • Crushing under objects

9. Mechanism of Injury • Field of injury: • Relatively clean • Contaminated soil

10. Mechanism of Injury • Open injury from: • In-out: usually cleaner • Out-in: usually more contamination and dirt www.aofoundation.org

11. Mechanism of Injury • Penetrating Missiles • Low velocity < 300 m/s - damage along the tract • Comminution • High velocity: >300m/s - sever comminution • Comminution with wide soft tissue damage • Some fragment inside • Some flip inside • Vacuum phenomena - cavitation

12. Signs of high energy injury • Segmental fracture • Bone loss • Compartment syndrome • Crush syndrome • Extensive de-gloving

13. Examples Low energy High energy A. Karlbauer

14. Approach – clinical exam • General medical condition should be evaluated to exclude shock and brain injury • Vital signs should be observed and followed up • Look: • special attention is to be paid to wounds

15. Approach – clinical exam • Feel: • Sensory and motor deficits • Pulse distal to injury • Compartment syndrome • Tense compartment • Move: • With care, if necessary! www.medicinabih.info

16. Approach – clinical exam • Examination of the viscera • Rib fractures • Lung, liver and spleen • Pelvic fractures • Urinary bladder and urethra • Head and spinal injury • Neurological examination

17. Management of open fractures • Initial management • Classifying the injury • Definitive treatment

18. Initial management • it is essential that the step-by-step approach in advanced trauma life support not be forgotten • Treat the patient, not the fracture! (A B C)

19. Initial management • it is essential that the step-by-step approach in advanced trauma life support not be forgotten • When the fracture is ready to be dealt with: • The wound is carefully inspected • Any gross contamination is removed • The wound is photographed • The area then covered with a saline-soaked dressing • The patient is given antibiotics • Tetanus prophylaxis is administered • The limb circulation and distal neurological status checked repeatedly

20. Grades of open fracture • Important to grade severity of open injuries and soft tissue injuries • To treat according to guidelines • To have an idea about prognosis • Several classifications • Most widely used: Gustilo Classification

21. Gustilo Classification • Grade 1: • Low-energy, minimal soft-tissue damage • (wound < 1cm) • Grade 2: • Higher energy, no flaps / crushing • moderate contamination • (wound > 1cm) • Grade 3: • High-energy, flaps / crushing • significant contamination.

22. Gustilo Classification • Sub-Types of Grade III: • Type 3A : Adequate soft-tissue cover • can cover skin primarily • Type 3B: Inadequate cover • can not cover skin primarily • may need skin graft or flap • Type 3C: Vascular injury • Requires vascular repair

23. Gustilo Grade I • Low energy • Simple fracture • Skin open byfragmentpressurewithin – out • Wound < 1 cm • No / little contamination www.orthopaedicsone.com/

24. Gustilo Grade II • Higher energy • Laceration > 1 cm • No flap / No contusion • Minimal contamination

25. Gustilo Grade IIIA • High-energy, • Adequate soft-tissue cover • Contamination • Comminution or segmental fracture

26. Gustilo Grade IIIB • High-energy, • Extensive soft-tissue stripping, and inadequate cover, • Massive contamination

27. Gustilo Grade IIIA or IIIB • An intra-operative decision

28. Gustilo Grade IIIA or IIIB • ? Adequate soft tissue coverage

29. Gastilo Grade? IIIC

30. Problem of open fractures • Infection – skin is breached • Primary: from the field • Massive contamination • Debris and foreign bodies • Devitalized tissues • Secondary infection after internal fixation • Initial bacterial contamination • Proper debridement not done • Internal fixation is a foreign body

31. Principles of treatment • All open fractures, no matter how trivial they mayseem, must be assumed to be contaminated • The basic guidelines: • Antibiotic prophylaxis • Urgent and proper wound and fracture debridement • Stabilization of the fracture – ? External Fixation • Early definitive wound cover

32. Primary surgery • The aims of primary surgery are: • Preservation of life and limb • Definitive injury assessment • Staged wound debridement • May need to repeat after 48-72 hours • Fracture stabilization

33. Primary surgery – Debridement • Trim skin edges • Remove foreign material • Remove all dead muscles and lacerated tissues • Remove fully detached small bone pieces • Saline wash: 5 Liters (wash–wash–wash) • ? Delayed secondary closure

34. Primary surgery – Debridement www.us.elsevierhealth.com / Principles of Fracture Treatment

35. Alois Karlbauer

36. Alois Karlbauer

37. Alois Karlbauer

38. Alois Karlbauer

39. “Dilution is the solution to pollution” Alois Karlbauer

40. Surgical Debridement • Surgical debridement demands meticulous excision of all dead and devitalized tissues • Start from outside working inwards: • Skin • Fat • Muscle • Bone • Neurovascular Leaving dead tissue invites infection Alois Karlbauer

41. Treatment guidelines • Gustilo I and II: • Can treat by primary internal fixation • Rate of infection low – if follow guidelines Alois Karlbauer

42. Treatment guidelines • Gustilo IIIA • Usually defer internal fixation until soft tissue condition allows • Gustilo IIIB • External fixation • Later, internal fixation • Gustilo IIIC • Vascular repair is a priority • External fixator

43. Higher infection rate Increased contamination: • Exposure to soil • Exposure to water • Exposure to fecal material • Exposure to oral material • Gross contamination • Delay > 12 hours

44. Case example - 1 • 26y male, motorbike accident, stable • Gustilo Type? • Management: • Swab taken • Antibiotics, anti- tetanus • Debridement, skin closure • External fixator • Later on, Intramedullary nail IIIA / IIIB Tadashi Tanaka, Chiba, Japan

45. Case example - 1 Tadashi Tanaka, Chiba, Japan

46. Case example - 2 • 32y old, sever car accident, hit by a truck on bridge and car fell into canal

47. Case example - 2 • Sever contamination, commination, and crushing • Un-salvaged after several attempts

48. Summary • Definition of open fracture • Important points in history of an open fracture • Gustilo classification • Management: • Importance of early surgical debridement • Bone treatment initial & definitive • Soft tissue coverage