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Open Fracture Management

Open Fracture Management. P. Blachut Division of Ortho Trauma Vancouver General Hospital University of British Columbia. Introduction Assessment Classification Management. Open fractures. Goals of Fracture Management. Fracture healing with satisfactory length and alignment

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Open Fracture Management

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  1. Open Fracture Management P. Blachut Division of Ortho Trauma Vancouver General Hospital University of British Columbia

  2. Introduction • Assessment • Classification • Management Open fractures

  3. Goals of Fracture Management • Fracture healing with satisfactory length and alignment • Avoidance of complications • infection • nonunion • malunion • stiffness • Early restoration of function

  4. Fracture Healing • Biologic factors • Biomechanical factor

  5. Avoidance of Complications (Infection) • No necrotic tissue • No dead space • No contamination • Well vascularized tissue

  6. Early Restoration of Function • Early mobilization • Stable fixation • Early wound healing • Avoid excessive scarring • Early wound coverage with quality tissue • Preservation of “critical tissues” • Nerves • Tendons

  7. Therefore: • The soft tissues are paramount to the successful management of fractures

  8. A bone healing complication with good soft tissues is easier to deal with than a complication with poor soft tissues

  9. Consequences of an Associated Soft Tissue Injury • healing potential • resistance to infection • contamination

  10. Assessment • Look for associated life threatening injuries!!! • Carefully assess and document neurovascular status

  11. ATLS (Advanced Trauma Life Support) • Primary Survey • A irway • B reathing • C irculation • D isability • E xposure • Secondary Survey

  12. Compartment Syndrome • Always look for in fractures with soft tissue injuries • Open fractures - up to 10% have compartment syndrome

  13. Amputation vs. Salvage • Multidisciplinary decision • Based on the assessment of likely ultimate function of limb compared to function with amputation

  14. Factors Favoring Amputation • Warm ischemia time > 8 hrs • Severe crush • minimal remaining functional tissue • Chronic debilitating disease • Severe polytrauma • Mass casualty • complexity of reconstruction

  15. Classification

  16. Classification - Open Fractures • Reflection of amount of energy imparted and consequently, the prognosis • Skin wound size • Level of contamination • Extent of soft tissue injury/ periosteal stripping • Fracture configuration

  17. Classification - Open Fractures • Classification can really only be done at the completion of debridement

  18. Classification - Open Fractures • Open injuries • Gustilo & Anderson • AO

  19. Open Fracture - Gustilo Classification • Type I • Small wound • Inside out • No/minimal contamination • Minimal soft tissue trauma • Low energy fracture pattern

  20. Open Fracture - Gustilo Classification • Type II • Moderate wound • Some contamination • Some muscle damage • Moderate energy fracture pattern

  21. Open Fracture - Gustilo Classification • Type III • Large wound • Significant comtamination • Major soft tissue trauma • crushing • periosteal stripping • High energy fracture pattern

  22. Open Fracture - Gustilo Classification • IIIA • enough soft tissue to cover bone • IIIB • insufficient soft tissue • need flap (local, free) • IIIC • vascular injury requiring repair

  23. Open Fracture - Gustilo Classification • Type III - Additional Factors • Barnyard • Shotgun • High velocity gunshot • Displaced segmental fracture • Neglected open fracture (> 8 hrs) • Bone loss

  24. Management • First aid • Emergency Room • Definitive • Rehabilitation

  25. First Aid • Control bleeding • direct pressure • Realign • further soft tissue damage/ compromise • Splint • comfort • further damage

  26. Emergency • First aid if not already given • Remove gross debris/irrigate/dress/ splint • Tetanus prophylaxis - if necessary • Antibiotics

  27. Emergency • The open wound should be assessed and documented only once

  28. Antibiotics • ? Prophylactic vs. treatment Closed with operative Rx Cephalosporin Grade I Grade II / III Add aminoglycoside High Risk Add penicillin

  29. Antibiotics • Antibiotics can not compensate for an inadequate surgical management

  30. Timing of Administration of Antibiotics • The Prevention of Infection in Open Fractures An Experimental Study of the Effect of Antibiotic Therapy Worlock, et al JBJS 1988 No antibiotics 1-4 hrs post-inoculation 1 hr. pre-inoculation 91% infection 51% infection 30% infection

  31. Antibiotics • The Role of Antibiotics in the Management of Open Fractures • Patzakis, et al JBJS, 1974 Control Pen./Streptomycin Cephalothin 13.9% infection 9.7% infection 2.3% infection

  32. Definitive Treatment • Wound excision • Wound extension • Debridement • Irrigation • Bone stabilization • Wound dressing • +/- re-debridement • Early wound closure/coverage

  33. Timing of Operative Intervention • General standard - within 6-8 hours • Not evidence based!!

  34. Operating Room • Scrub/remove gross debris/ irrigate • Double setup • debridement/irrigation • bone stabilization if internal fixation planned • Tourniquet • apply/not inflated • in case of bleeding

  35. Wound Excision • Excise crushed/ contaminated skin edge

  36. Wound Extension • Sufficient extension to fully evaluate and treat soft tissue injury (approximately 1 diameter of limb) • Anticipate incisions for bony stablization/soft tissue reconstruction • Avoid incision that will compromise skin further

  37. Wound Extension

  38. Debridement • Layer by layer • Remove all devitalized and contaminated tissue (including bone)

  39. Debridement - Objective: • To leave a wound with: • No/minimal contamination • Well vascularized tissue for healing and to resist infection

  40. Debridement • “When in doubt, take it out”

  41. Irrigation • 10 litres for significant wounds • saline • ? antibiotics • ? pulsed lavage • ? detergent

  42. Irrigation • Improves visualization • Float out necrotic tissue • Flush out debris • Reduce bacterial population

  43. Irrigation • The solution to pollution is dilution

  44. Stabilization The Prevention of Infection in Open Fractures: An Experimental Study of the Effect of Fracture Stability Worlock, et al Injury 1994

  45. Bony Stabilization • Second prep if internal fixation • Principles • Minimize further trauma • Sufficient stability to allow early rehab • Should not impede subsequent soft tissue management • Restoration of anatomy

  46. Bony Stabilization • Diaphyseal Fractures • Humerus • Forearm • Femur • Tibia ORIF IM nail

  47. Bony Stabilization • Articular Fractures • primary ORIF • spanning external fixator + / - articular ORIF  delayed ORIF • external fixation

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