Management of Management of Open Fractures Open Fractures AADO/HKSSH Conjoint Scientific AADO/HKSSH Conjoint Scientific Meeting 2009 Meeting 2009 Dr TSE Lung Dr TSE Lung ‐ ‐ fung fung Specialist Specialist Department of O&T Department of O&T Pricne of Wales Hospital Pricne of Wales Hospital
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Management of Management of Open FracturesOpen Fractures
Dr TSE LungDr TSE Lung‐‐fungfungSpecialistSpecialist
Department of O&TDepartment of O&TPricne of Wales HospitalPricne of Wales Hospital
Classification & Principle of Classification & Principle of Emergency ManagementEmergency Management
High Energy TraumaHigh Energy TraumaHigh Risk of ComplicationsHigh Risk of ComplicationsHigh Social Economic Cost High Social Economic Cost
Open FracturesOpen Fractures
High energy trauma; injury to soft tissue and bone High energy trauma; injury to soft tissue and bone impair local tissue vascularityimpair local tissue vascularity
Communicate with the exterior, resulting contamination Communicate with the exterior, resulting contamination of the wound with microof the wound with micro‐‐organismsorganisms
Increased risk of infection and complications of fracture Increased risk of infection and complications of fracture healing; Incidence of wound infection healing; Incidence of wound infection extent of soft extent of soft tissue damage, <2% type I to >10% type IIItissue damage, <2% type I to >10% type III
Tendon, nerve and articular cartilage subjected to damageTendon, nerve and articular cartilage subjected to damage
Assessment of the patientAssessment of the patient
Advanced Trauma Life SupportAdvanced Trauma Life SupportAirwayAirway
Assessment of the woundAssessment of the woundFrom AED to OT theatreFrom AED to OT theatre
What is the nature of the wound?What is the nature of the wound?
What is the state of the skin around the wound? What is the state of the skin around the wound?
Is the circulation satisfactory?Is the circulation satisfactory?
Are the nerves intact?Are the nerves intact?
Gustilo& Anderson ClassificationGustilo& Anderson Classification
Type I:Type I: clean wound clean wound < 1 cm< 1 cm longlong
Type II:Type II: wound wound > 1 cm> 1 cm, without extensive soft tissue damage, without extensive soft tissue damage
Type IIIA:Type IIIA: extensive soft tissue lacerations extensive soft tissue lacerations (> 10 cm)(> 10 cm) but but maintain adequate maintain adequate soft tissue coveragesoft tissue coverage of bone, or they result of bone, or they result from highfrom high‐‐energy trauma regardless of the size of the wound, energy trauma regardless of the size of the wound, includes segmental or severely comminuted fracturesincludes segmental or severely comminuted fractures
Type IIIB:Type IIIB: extensive soft tissue loss with extensive soft tissue loss with periosteal strippingperiosteal strippingand bony exposure, usually massively contaminatedand bony exposure, usually massively contaminated
Type IIIC:Type IIIC: with with arterial injury that requires repairarterial injury that requires repair regardless of regardless of the size of wound. the size of wound.
Gustilo RB, Anderson JT; Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976 Jun;58(4):453-8.
Type IType IWound size :Wound size :small <1cm, clean small <1cm, clean puncture, a bone spike puncture, a bone spike has protrudedhas protrudedSoft tissue damage: Soft tissue damage: little, no crushinglittle, no crushingFracture: Fracture: not comminutednot comminutedEnergy of trauma: Energy of trauma: lowlow‐‐energyenergy
Type IIType IIWound size :Wound size :more than 1 cm, no skin more than 1 cm, no skin flapflapSoft tissue damage: Soft tissue damage: Moderate crushingModerate crushingFracture: Fracture: moderate comminutionmoderate comminutionEnergy of trauma: Energy of trauma: lowlow‐‐energyenergy
Type IIIAType IIIAWound size :Wound size :Large wound usu> 10cmLarge wound usu> 10cmSoft tissue damage: Soft tissue damage: Extensive, contaminatedExtensive, contaminatedFractured bone can be Fractured bone can be adequately covered by adequately covered by soft tissuesoft tissueFracture: Fracture: comminutedcomminutedEnergy of trauma: Energy of trauma: highhigh‐‐energyenergy
Type IIIBType IIIBWound size :Wound size :Large wound, fractured bone Large wound, fractured bone cancan’’t be covered by soft tissue t be covered by soft tissue (vs Type IIIA)(vs Type IIIA)Soft tissue damage: Soft tissue damage: periosteal stripping (intraperiosteal stripping (intra‐‐op)op)Fracture: Fracture: Severely comminutedSeverely comminutedEnergy of trauma: Energy of trauma: highhigh‐‐energyenergy
Type IIICType IIICWound size :Wound size :Large, not adequate Large, not adequate coverage of the bonecoverage of the boneSoft tissue damage: Soft tissue damage: Vascular injury, needs to Vascular injury, needs to be repairedbe repairedFracture: Fracture: Severely comminutedSeverely comminutedEnergy of trauma: Energy of trauma: highhigh‐‐energyenergy
Question 1. How to classify Question 1. How to classify patient with gun shot wound?patient with gun shot wound?
By By definition, it is already Gustilo III injurydefinition, it is already Gustilo III injury
Question II. When to make the Question II. When to make the definitive classification?definitive classification?
Make in the Make in the operating room operating room during first debridement, full during first debridement, full exploration of the extend of wound and soft tissue injuryexploration of the extend of wound and soft tissue injury
Extend of soft tissue injury and viabilityExtend of soft tissue injury and viability
Size of skin defectSize of skin defect
Periosteal strippingPeriosteal stripping
Principles of treatmentPrinciples of treatment
1. Resuscitation1. Resuscitation2. Wound management2. Wound management3. Anti3. Anti‐‐tetanustetanus4. Antiobiotics4. Antiobiotics5. Stabilization of fracture5. Stabilization of fracture6. Early wound coverage6. Early wound coverage7. Early return of function7. Early return of function
I. Wound I. Wound debridementdebridement
Debridement & IrrigationDebridement & Irrigation
Gustilo et al 1984. Gustilo et al 1984.
Adequate debridement is the single most important factor in Adequate debridement is the single most important factor in the attainment of a good result in the treatment of an open the attainment of a good result in the treatment of an open fracturefracture
Systemic debridement Systemic debridement Removal of gross contamination and debrisRemoval of gross contamination and debrisFrom superfical to deep structuresFrom superfical to deep structuresAll necrotic tissue should be excisedAll necrotic tissue should be excised
Use of tourniquet shoud be minimizedUse of tourniquet shoud be minimized
Wound extension for full evaluation of soft tissue injuryWound extension for full evaluation of soft tissue injury
Systemic debridementSystemic debridement
Muscle viability is determined by the four C's: Muscle viability is determined by the four C's: contractilitycontractilitycolorcolorConsistencyConsistencycapacity to bleedcapacity to bleed..
Evaluation of the bone: Periosteum& any completely free Evaluation of the bone: Periosteum& any completely free cortical fragmentscortical fragments
When it is difficult to fully determine the viability of all tisWhen it is difficult to fully determine the viability of all tissues sues at the time of initial debridement, repeated debridements at at the time of initial debridement, repeated debridements at 2424‐‐48 hour intervals can be employed to eliminate devitalized 48 hour intervals can be employed to eliminate devitalized tissuetissue
Debridement of the woundDebridement of the wound
IrrigationIrrigation
Supplement a systematic debridement in removing Supplement a systematic debridement in removing foreign material and decreasing bacterial loadforeign material and decreasing bacterial load
Anglen et al. 3L of irrigation for Type 1 fractures, 6L for TypeAnglen et al. 3L of irrigation for Type 1 fractures, 6L for Type2 fractures and 9L for Type 3 fractures2 fractures and 9L for Type 3 fractures
Antiseptic solutions (eg. povidoneAntiseptic solutions (eg. povidone‐‐iodine, Dakiniodine, Dakin’’s solution s solution and chlorhexidine) have not been shown to decrease and chlorhexidine) have not been shown to decrease infection rates. They have been linked to tissue damage and infection rates. They have been linked to tissue damage and thus should be avoidedthus should be avoided
Surfactant (nonSurfactant (non‐‐sterile soap) same effectiveness, less tissue sterile soap) same effectiveness, less tissue damage and more economicaldamage and more economical
Antibiotic solution no better than soap Antibiotic solution no better than soap for open fracture irrigation for open fracture irrigation
Anglen J. A comparison of soap Anglen J. A comparison of soap and antibiotic solution for and antibiotic solution for irrigation of lower extremity open irrigation of lower extremity open fracture wounds. #352. Presented at fracture wounds. #352. Presented at the American Academy of the American Academy of Orthopaedic Surgeons 72nd Annual Orthopaedic Surgeons 72nd Annual Meeting. Feb. 23Meeting. Feb. 23--27, 2005. 27, 2005. Washington. Washington. 400 patients, 458 open fractures of 400 patients, 458 open fractures of lower extremitylower extremityGp A: 166 patients with 194 FxtGp A: 166 patients with 194 Fxt
Bacitracin solutionBacitracin solution
Gp B: 177 patients with 105 fxtGp B: 177 patients with 105 fxtCastile soap solutionCastile soap solution
No significant difference btw 2 No significant difference btw 2 groupsgroups
Jeffrey Anglen and colleagues found that the soap group had a 13% infection rate vs. 18% for the antibiotic group.
IrrigationIrrigation
Simpulse irrigation (HPPL: High pressure pulsatilelavage) Simpulse irrigation (HPPL: High pressure pulsatilelavage) systemsystem
Pressures greater than 50psi have been shown to be Pressures greater than 50psi have been shown to be detrimental to bone and soft tissue, slow bone healing and detrimental to bone and soft tissue, slow bone healing and potentially drive bacteria further into the woundpotentially drive bacteria further into the wound
BrushBrush‐‐suction irrigation & bulb syringe removal inorganic suction irrigation & bulb syringe removal inorganic contamination not less than HPPLcontamination not less than HPPL
Debridement of cancellous bone: A comparison of irrigation methods. Reid W Draeger et al. J Orthop Trauma Volume 20, Number 10, Nov 2006
Timing of Debridement & Timing of Debridement & IrrigationIrrigation
Freidrich's 1898 study of guinea pigs. Debridement within Freidrich's 1898 study of guinea pigs. Debridement within 6 hours6 hours
Most guideline recommended within 6 hours. The timing Most guideline recommended within 6 hours. The timing of effective initial surgical debridement of open tibia of effective initial surgical debridement of open tibia fractures remains controversial.fractures remains controversial.
The majority of current literature is unable to demonstrate The majority of current literature is unable to demonstrate an improved infection rate for open fractures initially an improved infection rate for open fractures initially debrided within 6 hours of injurydebrided within 6 hours of injury
Definite timing for surgeryDefinite timing for surgery
Association btw time to Association btw time to definitive surgical definitive surgical management and the rates of management and the rates of nonunion and infection in open nonunion and infection in open fractures resulting from blunt fractures resulting from blunt trauma. trauma.
Time was not a significant Time was not a significant factor in predicting either factor in predicting either nonunion or infection (p>0.05)nonunion or infection (p>0.05)
Grade of injuryGrade of injuryPresence of infectionPresence of infectionLower limb open fractureLower limb open fracture
II.AntiobioticII.Antiobiotic
Antiobiotics& InfectionAntiobiotics& Infection
2424‐‐70% of open fractures are contaminated with bacteria70% of open fractures are contaminated with bacteria
1414‐‐15% of open fracture complicated with infections in the 15% of open fracture complicated with infections in the absence of antitiotic prophylaxisabsence of antitiotic prophylaxis
Is Wound culture preIs Wound culture pre‐‐debridement and postdebridement and post‐‐debridement debridement useful?useful?
Answer is Answer is NO!NO!
AntiobioticsAntiobiotics
Patzakis et al 1974. Patzakis et al 1974.
Strong evidence for the efficacy of first generation Strong evidence for the efficacy of first generation cephalosporins in the management of open fractures in a cephalosporins in the management of open fractures in a prospective, randomised placeboprospective, randomised placebo‐‐controlled study.controlled study.
Type I &II : cefazolin 1g iviType I &II : cefazolin 1g ivi
Type III: + Aminoglycosides (Gentamicinivi)Type III: + Aminoglycosides (Gentamicinivi)
Timing & Duration of prophylaxisTiming & Duration of prophylaxis
Antibiotic prophylaxis should be initiated as soon after the Antibiotic prophylaxis should be initiated as soon after the injury as possible as the timing of the antibiotic injury as possible as the timing of the antibiotic prophylaxis has been shown to be important for prophylaxis has been shown to be important for prevention of infectionprevention of infection
Duration of prophylaxis should be limited to a 24 hour Duration of prophylaxis should be limited to a 24 hour course with repeated 24 hour courses likely indicated for course with repeated 24 hour courses likely indicated for subsequent debridements, wound closures, bone grafting subsequent debridements, wound closures, bone grafting or other major surgical procedures.or other major surgical procedures.
Stabilization Stabilization of fractureof fracture
Stabilization of the fractureStabilization of the fracture
NONNON‐‐OPERATIVEOPERATIVESplintageSplintagePOP slab for temporarily POP slab for temporarily fixation of fracturefixation of fracture
Goal: Goal: Pain reliefPain relief
Facilitate nursing careFacilitate nursing care
Skeletal stability achieved in OTSkeletal stability achieved in OT
OPERATIVE FIXATION
Early stabilization Early stabilization of fracturesof fractures
Stabilizing the open Stabilizing the open fracturefractureProtects the soft tissues Protects the soft tissues from further injury by from further injury by fracture fragmentsfracture fragmentsFacilitates the host Facilitates the host response to microbe response to microbe despite the presence of despite the presence of implantsimplantsImproves wound care, and Improves wound care, and allows early motion of allows early motion of adjacent joints and early adjacent joints and early mobilization of the patient.mobilization of the patient.
Open Open fractures & Compartment fractures & Compartment syndromesyndrome
Irrigation and debridement +/‐ fasciotomy +/‐ EF or IF
Compartment syndromeCompartment syndrome
Rockwood et al 2006Rockwood et al 2006Compartment syndrome is a Compartment syndrome is a complication in open and complication in open and closed tibia fractureclosed tibia fracture
Internal pressure or external Internal pressure or external confinement or restriction can confinement or restriction can proceed to the point that the proceed to the point that the cellular exchange is cellular exchange is disminished. This sets up an disminished. This sets up an ischaemic environment that ischaemic environment that when left untreated can lead when left untreated can lead to tissue damageto tissue damage
PostPost‐‐op Monitoringop Monitoring
PainPainNeurovascular statusNeurovascular statusCompartment syndromeCompartment syndromeGas gangrene esp soil or form Gas gangrene esp soil or form contamination (clostridium contamination (clostridium myonecrosis)myonecrosis)InfectionInfection
Keep dressing intactKeep dressing intactElevationElevationReport and marking of any Report and marking of any oozing from the dressingoozing from the dressingAdequate analgesiaAdequate analgesiaAntiobiotic administrationAntiobiotic administration
Early wound Early wound cover surgerycover surgery
Wound managementWound management
Multiple wound debridement if in doubt, within 24Multiple wound debridement if in doubt, within 24‐‐48 48 hours intervalhours interval
Early wound covering preferrably within one weekEarly wound covering preferrably within one week
Occlusive dressing, allow no pressureOcclusive dressing, allow no pressure
Circulation and neurological monitoringCirculation and neurological monitoring
S. Rajasekaran et alS. Rajasekaran et alIndia study w/ Strict criteria: India study w/ Strict criteria: Debridement within 12 hours Debridement within 12 hours of injury, no sewage or organic of injury, no sewage or organic contamination, no skin loss contamination, no skin loss either primary or secondarily either primary or secondarily during debridementduring debridement
Polytrauma patients excludedPolytrauma patients excludedPhysiological status stable, Physiological status stable, presence of bleeding skin presence of bleeding skin margins, ability to margins, ability to approximate wound edges approximate wound edges without tension and the without tension and the absence of peripheral vascular absence of peripheral vascular diseasedisease
Mean FU 6.2 years; Outcome studyMean FU 6.2 years; Outcome studyExcellent in 150 (86.7%)Excellent in 150 (86.7%)Good in 11 (6.4%)Good in 11 (6.4%)Poor in 12 (6.9%)Poor in 12 (6.9%)
33 total complications in 23 patients33 total complications in 23 patients11 superficial infection11 superficial infection5 deep infection (3 require flap surgery)5 deep infection (3 require flap surgery)6 nonunion (require further surgery)6 nonunion (require further surgery)1 established infected nonunion1 established infected nonunion
Bone graft for definitive Bone graft for definitive fracture managementfracture managementDefinitive fracture fixation Definitive fracture fixation methodmethodSkin coverage reconstruction Skin coverage reconstruction ladderladder
Summary : Open Summary : Open FractureFractureResuscitationResuscitationWatch out for life Watch out for life threatening complicationsthreatening complicationsCleansing & DressingCleansing & DressingDebridement & IrrigationDebridement & IrrigationAntiobiotic prophylaxis & Antiobiotic prophylaxis & antianti‐‐tentanustoxoidtentanustoxoidStabilization of Stabilization of fracturesfracturesDefinite fracture and soft Definite fracture and soft tissue managementtissue managementNutritional support & Nutritional support & Nursing careNursing careRehabilitationRehabilitation
Reference:Reference:
Gustilo RB, Anderson JT; Prevention of infection in the treatmenGustilo RB, Anderson JT; Prevention of infection in the treatment of one thousand and twentyt of one thousand and twenty--five open five open fractures of long bones: retrospective and prospective analyses.fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976 J Bone Joint Surg Am. 1976 Jun;58(4):453Jun;58(4):453--8.8.
Gustilo RB, Mendoza RM, Williams DN; Problems in the management Gustilo RB, Mendoza RM, Williams DN; Problems in the management of type III (severe) open fractures: a of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984 Aunew classification of type III open fractures. J Trauma. 1984 Aug;24(8):742g;24(8):742--6. 6.
Reid W Draeger et al. Debridement of Cancellous bone: A comparisReid W Draeger et al. Debridement of Cancellous bone: A comparison of irrigation methods. J Orthop on of irrigation methods. J Orthop Trauma Vol 20, Number 10, Nov/Dec 2006.Trauma Vol 20, Number 10, Nov/Dec 2006.
Bhandari M et al. High Pressure PulsatileLavage of contaminated Bhandari M et al. High Pressure PulsatileLavage of contaminated Human tibia: An inHuman tibia: An in--vitro study. J Orthop vitro study. J Orthop Trauma Vol 1. Sep/Oct 1998Trauma Vol 1. Sep/Oct 1998
Brian J. et al. The Effect of Time to Definite Treatment on the Brian J. et al. The Effect of Time to Definite Treatment on the Rate of Nonunion and infection in open Rate of Nonunion and infection in open fractures. JOT Vol 16. No 7 pp484fractures. JOT Vol 16. No 7 pp484--4949
Rockwood, C. A., Green, D. P., &Bucholz, R. W. (2006). Rockwood, C. A., Green, D. P., &Bucholz, R. W. (2006). Rockwood and GreenRockwood and Green’’s fractures in adults (6th ed., s fractures in adults (6th ed., Vol. 2). Vol. 2). Philadelphia: Lippincott Williams & Wilkins.Philadelphia: Lippincott Williams & Wilkins.