Open Fractures
Dec 26, 2015
Goals of Open Fracture
ManagementPrevent InfectionAntibioticsDebridementIrrigation
Salvage LimbFixationSoft Tissue
CoverageRestore Function
Soft Tissue InjuryAll Fractures Have Some Degree
Of Soft Tissue InjuryPrognosis Determined By:
Amount Of Energy Transferred To The Soft Tissue And Bone
Degree Of Contamination & Type Of Bacteria
Patient Factors
Energy AbsorbedKE = ½ mv2
Energy TransferFall from curb
100 ft-lbsSkiing
300-500 ft-lbsHigh-Velocity GSW
2000 ft-lbsAutomobile Bumper @ 20 MPH
100,000 ft-lbs
Classification
Attempt To Quantify The Amount Of Energy Imparted And Therefore, The Prognosis
• Skin Wound Size• Extent Of
Contamination• Extent Of Deep Soft
Tissue Injury/ Periosteal Stripping
• Fracture Configuration
• Gustilo & Anderson; J Trauma, 24(8): 742-6., 1984
Type II> 1cm Without
Extensive Soft Tissue Damage, Minimal To Moderate Crush, Simple Transverse Or Short Oblique With Minimal Comminution
Type IIIAExtensive Soft
Tissue Injury With Adequate Bone Coverage, Segmental Fractures, High-energy Gunshot Injuries; High Energy Trauma Despite Size Of WoundPrimary Closure Or
STSG
Type IIIBExtensive Soft-
tissue Loss, Periosteal Stripping And Bone Exposure, Usually Associated With Massive ContaminationRequires Flap
Coverage
Initial TreatmentExamine Wound
OnceRemove Gross
ContaminationApply Sterile
DressingDocument Wounds
PhotographAssess &
Document N/V Status
Reduce Fx / DxParental
AntibioticsTetanus
AntibioticsEarly Parenteral Administration
1st Gen Cephalosporin+/- Aminoglycoside+/- PCN
Continue IV ATB 24 – 48 Hours After Wound Closure Coverage
Excisional Debridement
Surgical Urgency
? EmergencyClinical
Studies Have Not Demonstrated Significant Negative Outcome In Delay To OR
Depends On Severity Of Injury
Excisional Debridement
Convert Traumatic Wound Into Surgical WoundExcise
Nonviable & Contaminated Tissue
SkinSQFascia MuscleBone
Excisional Debridement
TechniqueExtend
WoundsDeliver Bone
EndsExcise &
Debride All Devitalized & Contaminated TissueIncluding Bone
IrrigationCopious
Lavage? High
Pressure Vs Low Pressure
? ATB Vs Soap Vs No Additives
Wash It Until It Is Clean
Irrigation No Substitute For Debridement
FixationRestoration Of
Length & Alignment
Minimizes Inflammation And Repetitive InjuryReduces Risk
Of InfectionStabilizing
Fracture Treats The Soft Tissue
Wound Management
Early Coverage BeneficialHowever,
Unclear How Early?
Wound ClosureTraditionally
3 Debridements
RealityWhen Healthy
Wound Bead Obtained
Wound ManagementDead Space
VACAssist In
Wound Management
TemporizingPossible VAC
To ClosureATB Bead
PouchMaintains
Sterile ? Environment
High Concentration Local ATB
Lessons Learned from LEAP Study
No one does really well
Scoring systems do not predict outcome (MESS)
Psycho-social issues play important role in long term outcomes
Outcomes continue to worsen with time
Absent plantar sensation not an indication for amputation
Avoid complications regardless of treatment path
Short term-Amp cheaperLong term-Limb salvage cheaper
Open Fracture - Summary
Aggressive RxEarly IV
AntibioticsComplete
Excisional Debridement
Early Bone / Soft Tissue Stablization
Early (???) Soft Tissue Coverage