Management of open fractures

Management of Open Fractures

Introduction

•An open fracture is one in which a break in the skin and underlying soft tissue leads directly into or communicates with the fracture and its hematoma•When wound occurs in the same limb segment as a fracture, the fracture must be considered open until proven otherwise

Classification

•Gustilo classification of open fractures• Type I: These are fractures with a clean wound of

less than 1 cm in size with little or no contamination. The wound results from an inside-out perforation by one of the fracture ends. The fracture pattern is simple (eg, spiral or short oblique fractures)• Type II: Skin laceration is longer than 1 cm but the

surrounding tissues have minor or no signs of contusion. There is no dead muscle present and the fracture instability is moderate to severe• Type III: There is extensive soft-tissue damage,

frequently with compromised vascularity with or without severe wound contamination. The fracture pattern is complex with marked fracture instability

• Type IIIA: It usually results from an high-energy trauma. There is still adequate soft-tissue coverage of the fractured bone, despite extensive soft-tissue laceration or flaps• Type IIIB: There is extensive soft-tissue loss with periosteal stripping and bone exposure. These injuries are usually associated with massive contamination• Type IIIC: This is associated with any open fracture associated with arterial injury requiring repair. It is independent of the fracture type

• Tscherne classification• Open fracture grade I (Fr. O 1): The skin is lacerated by a bone

fragment from the inside. There is no or minimal contusion of the skin, and these simple fractures are the result of indirect trauma

• Open fracture grade II (Fr. O 2): There is a skin laceration with a circumferential skin or soft-tissue contusion and moderate contamination. All open fractures resulting from direct trauma

• Open fracture grade III (Fr. O 3): There is extensive softtissue damage, often with an additional major vessel and/ or nerve injury. Every open fracture that is accompanied by ischemia and severe bone comminution belongs in this group. Farming accidents, high-velocity gunshot wounds, and compartment syndrome are included because of their high risk of infection

• Open fracture grade IV (Fr. O 4): These are subtotal and total amputations. Subtotal amputations are defined by the Replantation Committee of the International Society for Reconstructive Surgery as a “separation of all important anatomical structures, especially the major vessels, with total ischemia”. The remaining soft-tissue bridge may not exceed 1/4 of the circumference of the limb

•AO classification• IO 1 – Skin breakage from inside out

• IO 2 - Skin breakage from outside in < 5 cm, contused edges

• IO 3 - Skin breakage from outside in > 5 cm, increased contusion, devitalized edges

• IO 4 - Considerable, full-thickness contusion, abrasion, extensive open degloving, skin loss

• IO 5 - Extensive degloving

Treatment• Goals of treatment

1. Preserve life2. Preserve limb3. Preserve function

• Also• Prevent infection• Fracture stabilization• Soft tissue coverage

• Principles of treatment• Antibiotic prophylaxis• Wound debridement• Fracture stabilization

Initial Management

• Patient assessment: ABC• Address life threatening injuries.• Rule out cervical injuries, chest, abdominal injuries, head injuries in

polytrauma patients.• Identify all injuries to extremities and assess neurovascular status of injured

limb.• Assess skin and soft tissue damage.• Obvious foreign bodies that are easily accessible may be removed- don’t do

digital exploration.• The open wound should be covered with a sterile saline soaked gauze pad.• Identify skeletal injuries and obtain necessary radiographs.• IV Tetanus• IV Antibiotics

Primary Surgery

• Objectives of initial surgical management• Preservation of life and limb• Wound debridement• Definitive injury assessment• Fracture stabilization

Debridement

• Most important step.• Aim - Removal of dead tissue and foreign material to

ensure good blood supply.• Debridement done as soon as possible. (within 6 hours

of initial injury)• With delay risk of infection increases

Superficial Debridement

•Wound margins are excised to identify and explore the entire zone of injury and to access ends of bone fragments. Extensile longitudinal incision to visualize deep tissue and can be extended till normal tissue encountered clearly.•Nonviable skin and subcutaneous tissue excised but of marginal viability may be left for later debridement.•Do not detach skin and subcutaneous tissue from the fascia. Any nonviable shredded fascia and even the marginally viable ones excised.

Deep Debridement

• Muscle because of water content are subject to hydraulic damage by fluid waves during injury. In muscle debridement, the concept is when in doubt take it out.

• In type I, II, and IIIa open - all non-vital and in doubt muscle can be debrided.

• IIIb and IIIc fractures- removal of entire muscle compartment may be

needed. • Viability of muscle is checked by its color, capacity to bleed,

contractility, and consistency (4c’s-last 2 more reliable)

• Tendons, unless injured beyond repair should be preserved.• In open wounds tendons are subject to desiccation and

hence it should be covered with soft tissues if not with moist dressings.• In general bone devoid of soft tissue attachment are

removed and large fragments with soft tissue attachments are preserved.• One exception to strict removal of bone without soft

tissue attachment, is significant portion of articular surface attached to bone fragment

Irrigation

• Usual irrigation fluid used is normal saline• High volume low pressure repeated lavage is

performed.• Volume of fluid used varies- usually about 3 L is used for

grade 1 ; 6-10 L is used for grade 2 or 3 • Pulse lavage is more effective than bulb syringe with NS

resulting in 100 fold decrease in St.Aureus in the wound

Limb salvage and Amputation

• Limb is nonviable as evidenced by • irreparable vascular injury • warm ischemia time >8 hrs • severe crush injury with minimal remaining viable tissue

• Severely damaged limb may constitute a threat to patients life especially in patients with severe debilitating c/c illness. The severity of injury would demand multiple operative procedures and prolonged reconstruction time.• Mangled extremity severity score of >7 accurately predicts

amputation.• Score doubles for ischemia >6 hrs

MESS

• MESS( Mangled Extremity Severity Score) for prediction of amputation• Developed to identify patients who will be benefited by

primary amputation in retrospective analysis.• The outcome of injured limb is either salvage or

amputation.• A score of > or equal to 7 is predicative of amputation

Skeletal Stabilization

• Done once vascular repair is completed and limb salvaged or once irrigation and debridement is done.• Restoring the length, rotational, and angular alignment

has many benefits for healing of soft tissues.• Fracture reduction frees nerve conduits and helps in soft

tissue healing.• Minimizing motion of fragments also decreases further

damage, pain and permits mobilization of joints

• Extra osseous- In low grade open fractures splints, plasters, weight bearing casts,

etc.

• Internal fixation- usually appropriate if wound is clean, and soft tissue coverage available.

• External fixation- • in high grade open fractures• in dirty wounds, • or extensive soft tissue injuries.

External Fixation

• Excellent stability obtained.• Reasonable anatomic reduction possible.• Minimal additional soft tissue trauma• Risk of infection-minimized.• Ability to convert to internal fixation

Internal Fixation

• Plates and screws- to minimize complications IV anti staphylococcus antibiotics should be started as soon as possible, sterile dressing, meticulous debridement, copious irrigation and minimal stripping and accurate anatomical reduction is to be done.• IM nail- currently the treatment of choice for grade

I,II,IIIa, and IIIb fractures as ex-fix devices leads to more malalignment, nonunion, and delayed return to function

Wound Closure

• Wounds without skin loss: tension free primary closure after thorough debridement.• Contraindications for primary closure

• Delayed presentation >12 hrs.• Delayed administration of antibiotics>12 hrs.• Deep seated contamination• Immunocompromised• Nerve injury• Inability to achieve tension free suture• High risk of anaerobic contamination like farm yard injuries.

• Wounds with skin loss: healing by secondary intention. Delayed primary closure, split skin grafts, free flaps