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OPEN (compound) FRACTURES Prof. M. Ngcelwane 2013

OPEN (compound) FRACTURES Prof. M. Ngcelwane 2013. 1. MUST BE ABLE TO DIAGNOSE OPEN FRACTURES RECOGNIZE THAT THERE MAY BE ASSOCIATED INJURIES BE ABLE TO CLASSIFY OPEN FRACTURE PRINCIPLES OF EARLY MANAGEMENT DEFINITIVE MANAGEMENT COMPLICATIONS. OBJECTIVES. 2. WHAT IS A FRACTURE. 3.

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OPEN (compound) FRACTURES Prof. M. Ngcelwane 2013

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  1. OPEN (compound) FRACTURES Prof. M. Ngcelwane 2013 1

  2. MUST BE ABLE TO DIAGNOSE OPEN FRACTURES RECOGNIZE THAT THERE MAY BE ASSOCIATED INJURIES BE ABLE TO CLASSIFY OPEN FRACTURE PRINCIPLES OF EARLY MANAGEMENT DEFINITIVE MANAGEMENT COMPLICATIONS OBJECTIVES 2

  3. WHAT IS A FRACTURE 3

  4. FRACTURE OPEN (COMPOUND) FRACTURE XR: A break in the continuity of bone Clinically: swollen, deformed, tender, loss of fx COMPOUND FRACTURE Fracture where there is a skin wound communicating with the fracture 4

  5. Examples of open fractures 5

  6. An open fracture is a severe soft tissue injury in which bone is also broken. Extent of damage to soft tissue determine the prognosis IMPORTANCE OF SOFT TISSUES 6

  7. I < 1cm clean wound, simple fracture pattern II > 1cm, no extensive soft tissue damage, no flaps/avulsion, simple fracture fracture III (A) Extensive wound, bone adequately covered. (B) Bone exposed, usually contaminated. (C) Arterial injury. Gustilo and Anderson classification of open fractures NB 7

  8. High energy trauma Look for other injuries Causes 8

  9. Commonest long bone open fracture is tibia Most studied bone Poor soft tissue cover Cf. femur Anatomic considerations 9

  10. 1. Assess life threatening injuries ABC of resuscitation Physical and neurologic exam Emergency Surgery (decision) 2. Assess limb (a) Vasculature pulse doppler angiogram (b) Soft tissues Skin - site - bruising contamination muscles periosteum (c) Neurology Plantar skin sensation 3. Fracture pattern XR CLINICAL APPROACH TO PATIENT WITH OPEN FRACTURE NB 10

  11. Neurovascular assessment (tibia) Vascular: - Dorsalis pedis - Posterior tibial Motor: - all compartments of the leg: toe flexures, toe dorsiflexors, ankle evertors, plantar flexors Sensory: - Tibial n: plantar surface of foot - Deep peroneal n: dorsal web space 1st and 2nd toe - Superficial peroneal n: dorsolateral - Saphenous n: medial REMEMBER - NOT POSSIBLE IN ALL PATIENTS NB 11

  12. MAIN COMPLICATION OF OPEN FRACTURES IS INFECTION Treatment 12

  13. Open Tibial Fractures A Open Fractures: Challenges 1. Management of traumatic wound 2. Achieving bony stability 3. Decision making -limb salvage vs. amputation 4. Achieving soft tissue coverage 5. Achieving fracture union 13

  14. PRINCIPLES OF TREATMENT B 1. Wound debridement 2. Antibiotic therapy 3. Bony stabilization 4. Wound coverage 5. Maintain vascularization NB 14

  15. Emergency RoomTreatment C 1. Reduce and splint the limb 2. Document neurologic and vascular status 3. (Lavage wound) 4. Sterile compression dressing, do not open again 5. (photograph) 6. Start I/V antibiotics 7. Tetanus prophylaxis 8. X-ray evaluation 9. To surgery as soon as possible < 6 hours 15

  16. INTRAVENOUSANTIBIOTICS Type open fracture I II IIIA IIIB IIIC * * * * * * * * # # # Cefazolin Aminoglycoside Penicillin # Soil contamination (clostridia) 16

  17. Limb - specific treatment (a) debride/decontaminate No tornique Remove all dead tissue Save bone (b) Skeletal stabilization (c) Soft tissue cover (d) Bone reconstruction (e) Rehabilitation MANAGEMENT 17

  18. Sepsis cannot occur if good bleeding tissue is present “The solution to pollution is dilution” 18

  19. Principles of Debridement D. 1. Classification determined at time of debridement of future surgeries 2. Extend wound a. Visualise entire zone of injury and where hematoma traveled 3. Debride wound in a systematic way a. Skin edges subcutaneous muscle bone 4. Remove foreign material 5. Debride necrotic skin, fat, muscle, bone a. Skin: conservative b. Fat and fascia: radical 6. Prophylactic fasciotomy of compartment exposure 7. Muscle: debride non-viable tissue a. Color b. Consistency c. Contractility d. Capacity to bleed e. Response to hemostasis NB 19

  20. Colour: red/brown Consistency: feels like muscle/soft Capillary circulation: does it bleed? Contractility: does it contract with cautery or pinching MUSCLE DEBRIDEMENT 20

  21. COVER EXPOSED 9 a Neurovascular structures b Tendon c Bone d Articular surface 21

  22. EXTERNAL FIXATOR Reason: be able to clean/dress wound; difficult to eradicate infection with internal fixation/plate BONE STABILIZATION NB 22

  23. Neurovascular Compartment syndrome INFECTION (prophylaxis NB!!) Loss of limb COMPLICATIONS NB 23

  24. Skeleton Soft Tissue Points Low energy, simple fx, low velocity GSW 1 Medium, moderate comminution 2 High energy (close range shot gun, etc) 3 Massive crush 4 Shock Normotensive (SBP>90) 0 Transient hypotension 1 Persistent hypotension 2 Ischemia None 0 Decreased pulses 1* No pulse, slow cap refill, paresthias 2* Cool pulseless, insentiate 3* Points double if ischemia > 6 hrs Age < 30 Yr 0 30-50 1 >50 2 MESS > 6 Amputation Mangled Extremity Severity Score“MESS” 24 Not for studying purposes

  25. 1. General supportive measures (a) cover wounds (b) fluid resuscitation/blood (c) Antibiotics - Cephosporin (2nd generation) 2. Limb - specific treatment (a) debride/decontaminate No tornique Remove all dead tissue Save bone (b) Skeletal stabilization (c) Soft tissue cover (d) Bone reconstruction (e) Rehabilitation MANAGEMENT 25

  26. EndThank you 26

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