Management of Open Management of Open FracturesFractures

Dr.David Samaroo MBBS,MS Department of Orthopedic Surgery Georgetown Public Hospital Corporation, University of Guyana School of Medicine.

Open FractureOpen Fracture

• defect in skin/soft defect in skin/soft tissuestissues

• fracture fracture communicates with communicates with the outside the outside environmentenvironment

• higher risk of higher risk of infection/nonunioninfection/nonunion

• Causes of non unionCauses of non union

GeneralGeneral

SpecificSpecific

Diastasis of fx fragmentDiastasis of fx fragment

Compromise blood supplyCompromise blood supply

Excessive motionExcessive motion

InfectionInfection

• CAUSES OF NONUNION:CAUSES OF NONUNION:

1) General: age, nutrition, steroids, anticoagulants, radiation, burns, 1) General: age, nutrition, steroids, anticoagulants, radiation, burns, immunosupression -predisposure to nonunionimmunosupression -predisposure to nonunion

2)Diastasis of fx fragment2)Diastasis of fx fragment

a. Soft tissue interpositiona. Soft tissue interposition

b. Distraction from traction or internal fixationb. Distraction from traction or internal fixation

c. Malposition d. Loss of bonec. Malposition d. Loss of bone

3)Compromised blood supply3)Compromised blood supply

a. Damage to nutrient vesselsa. Damage to nutrient vessels

b. Stripping or injury to periosteum & muscleb. Stripping or injury to periosteum & muscle

c. Free fragments; severe comminutionc. Free fragments; severe comminution

d. Avascularity due to internal fixation devicesd. Avascularity due to internal fixation devices

4) Excessive motion: inadequate immobilization4) Excessive motion: inadequate immobilization

5) Infection5) Infection

a) Bone death (sequestrum)a) Bone death (sequestrum)

b) Osteolysis (Gap)b) Osteolysis (Gap)

c) Loosening of implants (motion)c) Loosening of implants (motion)

GoalsGoals

• prevent infectionprevent infection

• restore soft-tissue enveloperestore soft-tissue envelope

• promote fracture healingpromote fracture healing

• restore functionrestore function

ClassificationClassification• Gustilo & Anderson Gustilo & Anderson JBJS 1976JBJS 1976

– Preliminary classification in ERPreliminary classification in ER

– Definitive classification after I+DDefinitive classification after I+D

– Grade 1Grade 1

• < 1 cm < 1 cm

• Low-energy injuryLow-energy injury

• 'Inside-out’'Inside-out’

- Grade-II- Grade-II

• 1-10 cm1-10 cm

• moderate moderate energy/ energy/ contaminationcontamination

- - Grade-IIIGrade-III

• >10 cm>10 cm

• extensive soft-extensive soft-tissue tissue disruptiondisruption

• major major comminution/ comminution/ contaminationcontamination

• high energy high energy injuryinjury

Automatic Type III (?)Automatic Type III (?)

• High Velocity GSW High Velocity GSW

• Farmyard Injuries Farmyard Injuries

• Crush InjuriesCrush Injuries

• Late presentations (>8h)Late presentations (>8h)

• Grade-IIIA Grade-IIIA – good soft-tissue coveragegood soft-tissue coverage

• Grade-IIIBGrade-IIIB– flap coverageflap coverage

• Grade-IIIC Grade-IIIC – Neurologic or vascular injury that Neurologic or vascular injury that

requires repair/amputationrequires repair/amputation

Initial TreatmentInitial Treatment

• ATLS (ABC)ATLS (ABC)

• life-threatening life-threatening injuries take injuries take precedence over limb-precedence over limb-threatening injuriesthreatening injuries

Initial TreatmentInitial Treatment

• cover woundcover wound– dry sterile dressingdry sterile dressing

– avoid repeated evaluation avoid repeated evaluation (infection)(infection)

• reduce/splint fracturereduce/splint fracture– comfortcomfort

– prevent further soft tissue prevent further soft tissue damagedamage

Infection RatesInfection Rates• Type-IType-I 0-2%0-2%

• Type-IIType-II 2-7%2-7%

• Type-III Type-III (overall) (overall) 10-25%10-25%

– Type-IIIA Type-IIIA 7%7%

– Type-IIIBType-IIIB 10-25%10-25%

– Type-IIICType-IIIC 25-50%25-50%

Typical OrganismsTypical Organisms

• Type I, II, & IIIAType I, II, & IIIA

– Staph aureus Staph aureus 43%43%

– GNR GNR 14%14%

• Type IIIB/IIICType IIIB/IIIC

– Staph aureus Staph aureus 7%7%

– GNR GNR 67%67%

Antibiotic choice?Antibiotic choice?• Type-I, Type-I,

– Ancef (cefazolin)Ancef (cefazolin)

• Type- II, IIIAType- II, IIIA– ancef + gentamicinancef + gentamicin

• IIIB, IIIC Farm/sewage related injuryIIIB, IIIC Farm/sewage related injury– ancef + gentamicin + penicillin (clostridia)/flagylancef + gentamicin + penicillin (clostridia)/flagyl

Tetanus ProphylaxisTetanus Prophylaxis

• Farm/sewage injuriesFarm/sewage injuries

• Immunized within 5 Years - Immunized within 5 Years - No TreatmentNo Treatment

• Immunized > 5 Years - Immunized > 5 Years - Tetanus ToxoidTetanus Toxoid

• Status Unknown - Status Unknown - Tetanus Toxoid & Tetanus IGTetanus Toxoid & Tetanus IG

Irrigation & DebridementIrrigation & Debridement

• the most important interventionthe most important intervention

• obtain deep cultures (reliable)obtain deep cultures (reliable)

• debridementdebridement– outside in (skin, subcut tissue, fascia, muscle, bone)outside in (skin, subcut tissue, fascia, muscle, bone)

• irrigate with 9L NSirrigate with 9L NS

• repeat every 48 to 72 Hours repeat every 48 to 72 Hours – wound appears cleanwound appears clean

– devoid of non-viable tissuedevoid of non-viable tissue

Skin Debridement Skin Debridement

• excise margins excise margins • extend woundextend wound

Fascia Fascia

• fasciotomy for fasciotomy for compartment syndromecompartment syndrome

• open fractures do not open fractures do not necessarily decompress necessarily decompress compartmentcompartment

Muscle Debridement Muscle Debridement

• dead muscle - major nidus for infectiondead muscle - major nidus for infection

– reddish colorreddish color

– contracts contracts

– bleedsbleeds

Why Stabilize Fractures?Why Stabilize Fractures?

inflammation/paininflammation/pain respiratory complicationsrespiratory complications morbiditymorbidity

increase mobilityincrease mobility

Fracture Stabilization Fracture Stabilization

• Performed after irrigation and debridementPerformed after irrigation and debridement

• Nonoperative management (casting) Nonoperative management (casting)

– TYPE1 and 11 fractures TYPE1 and 11 fractures or no roleor no role

– hard to observe woundhard to observe wound

• Surgical ManagementSurgical Management

– external fixationexternal fixation

– ORIF with platesORIF with plates

– intramedullary nailingintramedullary nailing

External FixationExternal Fixation • AdvantagesAdvantages

– good wound accessgood wound access

– quickly appliedquickly applied

– minimal soft tissue traumaminimal soft tissue trauma

• DisadvantageDisadvantage

– pin looseningpin loosening

• soft tissue inflammationsoft tissue inflammation

• infectioninfection

External FixationExternal Fixation

• IndicationsIndications

– Type-IIIBType-IIIB

• flapsflaps

– Type-IIIC Type-IIIC

• vascular repairvascular repair

Plate & Screw FixationPlate & Screw Fixation • AdvantagesAdvantages

– anatomic reduction anatomic reduction

– rigid stabilizationrigid stabilization

– early mobilization early mobilization

• DisadvantagesDisadvantages

– more extensive exposuremore extensive exposure

– devascularizationdevascularization

– minimized with submuscular minimized with submuscular platingplating

Intramedullary FixationIntramedullary Fixation • AdvantagesAdvantages

– minimal soft tissue minimal soft tissue strippingstripping

– good wound accessgood wound access– good stabilitygood stability

• DisadvantagesDisadvantages– impairs endosteal impairs endosteal

circulation (reaming)circulation (reaming)– longer OR timelonger OR time

Wound ClosureWound Closure

• Operative wounds closedOperative wounds closed

• Traumatic Wounds Left OpenTraumatic Wounds Left Open (VAC dressing)(VAC dressing)

• Repeat debridements Q48-72hRepeat debridements Q48-72h– wound cleanwound clean– no remaining devitalized tissueno remaining devitalized tissue

Summary (Open Fracture)Summary (Open Fracture)

– Dry sterile dressingDry sterile dressing

– Reduce/splint fractureReduce/splint fracture

– Determine grade Determine grade • Grade I – ancefGrade I – ancef

• Grade II,IIIA – ancef/gentGrade II,IIIA – ancef/gent

• massive contamination massive contamination – Penicillin/flagylPenicillin/flagyl

– tetanus toxoid +/- IGtetanus toxoid +/- IG

– OR for I+D and fixationOR for I+D and fixation• 9L NS9L NS

• don’t close open wounds (use VAC)don’t close open wounds (use VAC)• return for repeat I+D and definitive coverage within 1 weekreturn for repeat I+D and definitive coverage within 1 week

CaseCase 30M leg bumper injury after being crushed between 2 cars30M leg bumper injury after being crushed between 2 cars

CaseCase 30M leg bumper injury after being crushed between 2 cars30M leg bumper injury after being crushed between 2 cars

ER ManagementER Management

ER ManagementER Management

• ABCABC• Complete orthopaedic examComplete orthopaedic exam

– Ignore the obviousIgnore the obvious– Head to toeHead to toe

• Inspect (open wounds, abrasions, ecchymosis)Inspect (open wounds, abrasions, ecchymosis)• Palpate all bony prominences (upper to lower extremities)Palpate all bony prominences (upper to lower extremities)• ROM extremitiesROM extremities• NeurovascularNeurovascular

– Check pulses in all 4 extremitiesCheck pulses in all 4 extremities

Never miss …Never miss …

• Open book pelvic Open book pelvic fracturefracture– rotational rotational

instabilityinstability– vertical vertical

instabilityinstability– AP pelvisAP pelvis– close down close down

pelvic volumepelvic volume– traction pintraction pin– hemodynamic hemodynamic

stabilitystability

• Tie a sheet around greater trochanters (not abdomen)Tie a sheet around greater trochanters (not abdomen)

Never miss…Never miss…

• Spine fractureSpine fracture– Logroll patientLogroll patient– Palpate entire spinePalpate entire spine

• Tenderness/stepoffTenderness/stepoff

– Neuro statusNeuro status• Perianal sensation, rectal Perianal sensation, rectal

tonetone

– Fx/disloc with neurologic Fx/disloc with neurologic injuryinjury• Halo tractionHalo traction• Surgical decompressionSurgical decompression

ER ManagementER Management

• Open distal femur/tibial plateau/tibial shaft fxsOpen distal femur/tibial plateau/tibial shaft fxs– No palpable DP/PT pulses in affected legNo palpable DP/PT pulses in affected leg– angiogram (disruption above trifurcation)angiogram (disruption above trifurcation)– dry sterile dressingdry sterile dressing– reduce bone fragments (traction) reduce bone fragments (traction) – splint splint – Grade IIICGrade IIIC– Ancef, gentamycin, penicillin, tetanus prophylaxisAncef, gentamycin, penicillin, tetanus prophylaxis

OR ManagementOR Management

• OROR– I+D (9L NS)I+D (9L NS)– Spanning ex fixSpanning ex fix