Open Fractures Principles of Management

Prof. Mamoun KremliAlMaarefa College

Open FracturesPrinciples of Management

Historical fact … until WW ITreatment of open fractures was “Amputation”

Mortality rate ~ 75%

Function in “survivors” was poor

Alois Karlbauer

ObjectivesDefinition of an open fracture

Important points in history of an open fracture

Classification

Management:Initial treatmentImportance of surgical debridementBone treatment initial & definitiveSoft tissue coverage

Factors affecting outcome

DefinitionOpen fracture is a fracture where the skin

coverage overlying is breachedeven a small puncture wound

Another name: compound fracture

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History in open fracturesMechanism of injury

Date, time, type, method of impact, …

Consciousness

Size of wound

Amount of bleeding

Other injuries: often missed

Anti-Tetanus status

Type of injuryDetermines amount of energy and

Extent of soft tissue injury

Type of injuryFall: height is important

Sport: stronger impact

Heavy object falling: direct injury – soft tissue

Road traffic accident (RTA)): more severeCar (MVA) , motorcycle, pedestrian

Assault & firearms: severe

Mechanism of InjuryTry to determine if injury was caused by:

Low velocityHigh velocityCrushing under objects

Mechanism of InjuryField of injury:

Relatively cleanContaminated soil

Mechanism of InjuryOpen injury from:

In-out: usually cleanerOut-in: usually more contamination and dirt

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Mechanism of InjuryPenetrating Missiles

Low velocity < 300 m/s - damage along the tractComminution

High velocity: >300m/s - sever comminutionComminution with wide soft tissue damageSome fragment insideSome flip insideVacuum phenomena - cavitation

Signs of high energy injurySegmental fracture

Bone loss

Compartment syndrome

Crush syndrome

Extensive de-gloving

A. Karlbauer

ExamplesLow energy High energy

Approach – clinical examGeneral medical condition should be evaluated

to exclude shock and brain injury

Vital signs should be observed and followed up

Look:special attention is to be paid to wounds

Approach – clinical examFeel:

Sensory and motor deficitsPulse distal to injuryCompartment syndrome

Tense compartment

Move:With care, if necessary!

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Approach – clinical examExamination of the viscera

Rib fracturesLung, liver and spleen

Pelvic fracturesUrinary bladder and urethra

Head and spinal injuryNeurological examination

Management of open fracturesInitial management

Classifying the injury

Definitive treatment

Initial managementit is essential that the step-by-step approach in

advanced trauma life support not be forgotten

Treat the patient, not the fracture! (A B C)

Initial managementit is essential that the step-by-step approach in

advanced trauma life support not be forgotten

When the fracture is ready to be dealt with:The wound is carefully inspectedAny gross contamination is removedThe wound is photographedThe area then covered with a saline-soaked dressingThe patient is given antibioticsTetanus prophylaxis is administeredThe limb circulation and distal neurological status

checked repeatedly

Grades of open fractureImportant to grade severity of open injuries and

soft tissue injuriesTo treat according to guidelinesTo have an idea about prognosis

Several classificationsMost widely used: Gustilo Classification

Gustilo ClassificationGrade 1:

Low-energy, minimal soft-tissue damage(wound < 1cm)

Grade 2:Higher energy, no flaps / crushingmoderate contamination (wound > 1cm)

Grade 3:High-energy, flaps / crushingsignificant contamination.

Gustilo ClassificationSub-Types of Grade III:

Type 3A : Adequate soft-tissue covercan cover skin primarily

Type 3B: Inadequate covercan not cover skin primarilymay need skin graft or flap

Type 3C: Vascular injuryRequires vascular repair

Gustilo Grade ILow energy

Simple fracture

Skin open by fragment pressure within – out

Wound < 1 cm

No / little contamination

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Gustilo Grade IIHigher energy

Laceration > 1 cm

No flap / No contusion

Minimal contamination

Gustilo Grade IIIAHigh-energy,

Adequate soft-tissue cover

Contamination

Comminution or segmental fracture

Gustilo Grade IIIBHigh-energy,

Extensive soft-tissue stripping

Inadequate cover,

Massive contamination

Gustilo Grade IIIA or IIIBAn intra-operative decision

Gustilo Grade IIIA or IIIB? Adequate soft tissue coverage

Gastilo Grade? IIIC

Problem of open fracturesInfection – skin is breached

Primary: from the fieldMassive contaminationDebris and foreign bodiesDevitalized tissues

Secondary infection after internal fixationInitial bacterial contaminationProper debridement not doneInternal fixation is a foreign body

Principles of treatmentAll open fractures, no matter how trivial they

may seem, must be assumed to be contaminated

The basic guidelines:Antibiotic prophylaxisUrgent and proper wound and fracture debridementStabilization of the fracture – ? External FixationEarly definitive wound cover

Primary surgeryThe aims of primary surgery are:

Preservation of life and limbDefinitive injury assessmentStaged wound debridement

May need to repeat after 48-72 hoursFracture stabilization

Primary surgery – DebridementTrim skin edges

Remove foreign material

Remove all dead muscles and lacerated tissues

Remove fully detached small bone pieces

Saline wash: 5 Liters (wash–wash–wash)

? Delayed secondary closure

Primary surgery – Debridement

www.us.elsevierhealth.com / Principles of Fracture Treatment

Alois Karlbauer

Alois Karlbauer

Alois Karlbauer

Alois Karlbauer

“The solution to pollution is Dilution”

Alois Karlbauer

Surgical DebridementSurgical debridement demands meticulous

excision of all dead and devitalized tissues

Start from outside working inwards:SkinFatMuscleBoneNeurovascular

Alois Karlbauer

Leaving dead tissue

invites infection

Treatment guidelinesGustilo I and II:

Can treat by primary internal fixationRate of infection low – if follow guidelines

Alois Karlbauer

Treatment guidelinesGustilo IIIA

Usually defer internal fixation until soft tissue condition allows

Gustilo IIIBExternal fixationLater, internal fixation

Gustilo IIICVascular repair is a priorityExternal fixator

Higher infection rateIncreased contamination:

Exposure to soil Exposure to water Exposure to fecal material Exposure to oral material Gross contamination Delay > 12 hours

Case example - 126y male, motorbike accident, stable

Gustilo Type?

Management:Swab takenAntibiotics, anti- tetanusDebridement, skin closureExternal fixatorLater on, Intramedullary nail

Tadashi Tanaka, Chiba, Japan

IIIA / IIIB

Case example - 1

Tadashi Tanaka, Chiba, Japan

Case example - 232y old, sever car accident, hit by a truck on

bridge and car fell into canal

Case example - 2Sever contamination, commination, and crushingUn-salvaged after several attempts

SummaryDefinition of open fracture

Important points in history of an open fracture

Gustilo classification

Management:Importance of early surgical debridementBone treatment initial & definitiveSoft tissue coverage