Managment of Open fractures

OPEN FRACTURES

By Dr Shahid Latheef

TREATMENT OF OPEN FRACTURES

HIPPOCRATES – “ SURGEONS CAN ONLY FACILITATE HEALING THEY CANNOT IMPOSE IT”.

EMERGENCY DEPARTMENT

A B C D E

Compressive bandages - Open, actively bleeding wounds.

Associated injuries. Spine , Chest & Pelvis

A careful examination of the extremities to diagnose fractures and dislocations

EMERGENCY DEPARTMENT.....

Assess neurovascular status

Documentation of wound

Photograph

IV antibiotics, Tetanus prophylaxis

Can I take pictures with my phone and send it to my senior?

EMERGENCY DEPARTMENT.....

Local irrigation with saline

Sterile compressive dressing and splint – Betadine soaked

Repeat wound examinations associated with higher infection rate

Do not culture wound in casualtyTscherne et al, Fractures with Soft Tissue

Injuries. 1984

DEBRIDEMENT

Pierre JosephTiming

At the earliest Within 6 hours from time of injury

Retrospective Study 47 Grade II/III open fractures Initial debridement

Less than 5 hours - 7% infection rateMore than 5 hours - 38% infection rate

Kindsfater et al, J Orth Trauma, Apr 1995,9(2) p121-7

Debridement Goals

Remove foreign material

Detection and removal of nonviable tissue

Reduction of bacterial contamination

Creation of wound that can heal without infection and promote fracture healing

Fasciotomy as indicated

HOW….. Not in CASUALTY but in THEATRE

5 to 10 liters of saline

Pulse lavage preferable

Iodine/Hydrogen peroxide not beneficial

Tourniquet used – may interfere with evaluation of muscle viability

Incision

Extensile incision

extend wound in longitudinal direction both proximally and distally

Expose: fracture, damaged tissue, and healthy tissue

“wound should be equal in length to the diameter of the limb at that level”

Evaluate muscle for:Color, Consistency, Contractility, and Capacity to

bleed

Necrotic muscle is culture medium for infection, especially anaerobic

“when in doubt, take it out”

Tendons Left if clean, and preserve blood supply Cover properly

Bone If devoid of soft tissue attachments, must

be removed Soft tissue attachments to remaining bone

must be preserved

ANTIBIOTICS

Minimal contamination 1st gen Cephalosporins

Moderate contamination, higher energy Amikacin (5mg/kg) IV Q 24

Soil contamination/severe contamination Penicillin Metrogyl

DURATION

Clinical decision Type I wounds 12 – 24 hours Type II and III wounds 2-3 days No role for prolonged use of antibiotics

Surgical Irrigation >10 Liters Normal Saline results in lower

incidence of infection

Pulse lavage is more effective than bulb syringe with NS resulting in 100 fold decrease in Staph Aureus in the wound

Anglen et al, J Ortho Trauma,2008 :390-396

Antibiotic Beads Provides high local concentration of

antibiotics in the wound

Prepared in the OR PMMA with Tobramycin made into bead

shapes, threaded on large non-absorbable suture, placed directly in the wound and covered with impervious dressing, creating “bead pouch”

STABILISATIONSplint Good option if operative fixation not required Synthetic splints preferred

External Fixation (Damage Control Orthopaedics in polytrauma patients)

Great option in contaminated wounds, or extensive soft tissue injury

Internal fixation Usually appropriate if wound clean, and soft tissue

coverage available

External Fixation

• Easily and rapidly applied• Excellent stability obtained• Damage Control Surgery• Reasonable anatomic reduction possible

Ex Fix…

Risk of infection minimized

Ability to convert to internal fixation when wound is clean with adequate soft tissue coverage available

Facilitates bone transport/acute shortening

Internal Vs External Fixation

Grade I to IIIA: Early –Internal fixation Late – External. Convert

to Internal fixation at the earliest

Grade IIIB: External fixation. Convert to Internal fixation when possible

Nail/ plate

Nail preferrable

Stable biological fixation – Plate or Nail

Supplement with bone grafts

Wound Closure

Delayed Primary Closure Local Soft Tissue Flap Free Tissue Transfer Best if wound is covered or closed within 5-7

days Decreases infection rate

Role of Amputation

“Saving a functional limb versus saving the patient”

Decision to be made early (48 – 72 hrs) Mangled Extremity Score Ganga Hospital Score

AO RECOMENDATIONS

1. Treat open fractures as emergencies.

2. Perform a thorough initial evaluation to diagnose life-threatening and limb-threatening injuries.

3. Begin appropriate antibiotic therapy in the emergency department or at the latest in the operating room, and continue treatment for 2 to 3 days only.

AO…4. Immediately debride the wound of

contaminated and devitalized tissue, copiously irrigate, and repeat debridement within 24 to 72 hours

5. Stabilize the fracture with the method determined at initial evaluation.

6. Leave the wound open (controversial).

AO…

7. Perform early autogenous cancellous bone grafting.  

8.  Rehabilitate the involved extremity aggressively.

SUMMARY Provide Airway and Urgent resuscitation

Immobilise injured extremity and cover wound with sterile dressing

Prophylactic IV antibiotics

Urgent optimum wound debridement

External fixation for damage control, definitive internal fixation at the earliest

Early bone grafting

Delayed wound closure with SSG/Flap

COMPLICATIONS GAS GANGRENE

TETANUS THROMBO EMBOLIC COMPLICATION

LATE COMPLICATION DELAYED UNION NON-UNION MAL-UNION CHRONIC INFECTION

REFERENCES

Rockwood and Green’s fractures in adults- 6th

Campbells Operative orthopaedis- 11th edn

Text book of orthopaedics – Kulkarni Anglen et al, J Ortho Trauma,2008 :390-

396

Dr Shahid Latheef+917795664142

Thank you…