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Open Fracture Management

Open Fracture Management. Paul Fawson 1 st Year Resident. Goals. Treat all frx as an emergency Thorough exam of life threatening injuries Begin abx Debride type II-III frx Stabilize the frx Leave wound open for 5-7 days Early autogenous cancellous bone grafting

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Open Fracture Management

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  1. Open Fracture Management Paul Fawson 1st Year Resident

  2. Goals • Treat all frx as an emergency • Thorough exam of life threatening injuries • Begin abx • Debride type II-III frx • Stabilize the frx • Leave wound open for 5-7 days • Early autogenouscancellous bone grafting • Rehab the jacked-up extremity

  3. Classification • Type I- < 1 cm. Moderately clean puncture, little soft tissue damage, no crushing injury, little comminution. Simple, transverse, or oblique frx • Type II- > 1 cm, no extensive soft tissue damage, slight/moderate crushing injury, moderate comminution and contamination. • Type III- Extensive soft tissue damage, comminution, and contamination. • IIIA- Adequate soft tissue coverage • IIIB- Loss of soft tissue • IIIC- Arterial injury that needs repaired

  4. H & P • Preliminary Exam performed in the ER • History and Physical • Location? • Farm? Water contact to wound?

  5. Sterile Dressing • Cover the Wound with Sterile dressing to prevent further contamination

  6. Antibiotic Therapy • Immediate, appropriate and effective antibiotic therapy. • > 70% of open frx are contaminated at time of injury. • Gram – and aerobic gram + are most common • S. aureus, S. epidermitis, P. Aeruginosa, streptococcus, Enterobacteriaceae, B. fragilis

  7. Antibiotic Therapy • Type I- Start 2.0 g of Cephalosporin (Cephazolin) upon admission • Then 1.0 g q 6-8 hours for 48-72 hours • Type II-III- Ceph + aminoglycoside • Add 10 million units of penicillin if frx occurred on a farm. • 3-7 days only • 3-7 days again with delayed procedures.

  8. Debridement • Debridement of wound with copious intermittent lavage. • 5,000-10,000 mL of NS or DW • 2,000 mLbacitracin-polymyxin solution?? • Small puncture wounds and lacerations should be extended for adequate exposure. • Discard any small or large fragments or fragments of devitalized, unattached cortical bone. • Don’t put back bone found from the scene into the pt.

  9. Soft Tissue Reconstruction • Early is recommended if a clean, stable wound has been achieved. • This is the key to reduce infection in type III • Keep wound moist until complete coverage in 5-7 days.

  10. Stabilization of Fracture • Osseous stability reduces the risk of infection and protects the integrity of the remaining soft tissue • External • Ease of application with minimal operative trauma • Maintenance of access to the wound • Good option for type III

  11. Stabilization of Fracture • Intramedullary nailing with reaming • Not recommended with open tibialfrx. A large study showed 6% infx rate with IM nail compared to 0-1% infx rate in open frx management • Plate and screws • Indicated for displaced intra-articular and metaphysealfrx of LE.

  12. Splints and casts • Plaster cast can be used for a stable, isolated type I frx until wound is healed. After this, immobilized in a cast • Avoid circular cast in acute stage.

  13. Coverage and Closure of Wound • Goal is safe, early closure of wound in 7-10 days. • Type I-IIIA, delayed primary closure in 5-7 days • IIIB-IIIC, multiple debridements required • Clinical decision to determine is infection is still present.

  14. Compartment Syndrome • 3-9% of open tibialfrx found to have compartment syndrome • Recommends decompressivefasciotomies to all 4 leg compartments.

  15. Bone grafts • Blood flow is imperative • Autogenouscancellous bone grafting is indicated with loss of bone or marked comminution after wound has healed (2-3 weeks) • Type III- delay grafts to 6 weeks after wound heals.

  16. Amputation • 2 absolute indications for primary amputation • A type IIIC with disruption of post tib nerve and… • IIIC with loss of soft tissue, massive contamination, severe comminution, or massive loss of bone. • Or type IIIC remained untreated for > 8 hours. • Delayed amputation is more $$$ and tends to be a more proximal amputation vs primary amputation.

  17. References • I . BEHRENS, FRED, and SEARLS, KATE: External Fixation of the Tibia. Basic Concepts and Prospective Evaluation. J. Bone and Joint Surg. , 68- • B(2): 246-254, 1986. • 2. BLICK, S. S. ; BRUMBACK, R. J. ; POKA, ATTILA; BURGESS, A. R. ; and EBRAHEIM, N. A.: Compartment Syndrome in Open Tibial Fractures. J. • Bone and Joint Surg. , 68-A: 1348-1353, Dec. 1986. • 3. BONDURANT, F. J. ; COTLER, H. B. ; BUCKLE, R. : MILLER-CROTCHETT, P. ; and BROWNER, B. D. : The Medical and Economic Impact of Severely • Injured Lower Extremities. J. Trauma, 28: 1270-1273, 1988. • 4. BONE, L. B. ; JOHNSON, K. D.; WEIGELT, JOHN; and SCHEINBERG, R. : Early versus Delayed Stabilization of Femoral Fractures. A Prospective • Randomized Study. J. Bone and Joint Surg. , 71-A: 336-340, March 1989. • 5. BUNKIS, JURIS; WALTON, R. L. ; and MATHES, S. J. : The Rectus Abdominis Free Flap for Lower Extremity Reconstruction. Ann. Plast. Surg., • 11: 373-380, 1983. • 6. CAUDLE, R. J. , and STERN, P. J. : Severe Open Fractures of the Tibia. J. Bone and Joint Surg. , 69-A: 801-807, July 1987. • 7. CHAPMAN, M. W. : The Role of Intramedullary Fixation in Open Fractures. Clin. Orthop. , 212: 26-33, 1986. • 8. CHAPMAN, M. W. , and MAHONEY, MICHAEL: The Role of Early Internal Fixation in the Management of Open Fractures. Clin. Orthop. , 138: • 120-131, 1979. • 9. CHAPMAN, M. W. ; GORDON, J. E. ; and ZISsIM0S, A. : Compression-Plate Fixation of Acute Fractures of the Diaphyses of the Radius and Ulna. • J. Bone and Joint Surg. , 71-A: 159-169, Feb. 1989. • 10. CIERNY, GEORGE, III: BYRD, H. S. ; and JONES, R. E. : Primary versuDeslayed Soft Tissue Coverage for Severe Open Tibial Fractures. A • Comparison of Results. Clin. Orthop. , 178: 54-63, 1983. • 1 1 . DELLINGER, E. P. ; MILLER, S. D. ; WERTZ, M. J. ; GRYPMA, MARTIN; DROPPERT, BETH; and ANDERSON, P. A. : Risk of Infection after Open • Fracture of the Arm or Leg. Arch. Surg. , 123: 1320-1327, 1988. • 12. DELLINGER, E. P. ; CAPLAN, E. S. ; WEAVER, L. D.; WERTZ, M. J. ; DROPPERT, B. M.; HOYT, NANCY; BRUMBACK, ROBERT; BURGESS, A.; POKA, • ATTILA; BENIRSCHKE, S. K.; LENNARD, E. S.; and LoU, M. A. , SR.: Duration of Preventive Antibiotic Administration for Open Extremity • Fractures. Arch. Surg. , 123: 333-339, 1988. • 13. GUSTILO, R. B. , and ANDERSON, J. T. : Prevention of Infection in the Treatment of One Thousand and Twenty-five Open Fractures of Long Bones. • Retrospective and Prospective Analyses. J. Bone and Joint Surg. , 58-A: 453-458, June 1976. • 14. GUST1LO, R. B.; GRUNINGER, R. P.; and DAVIS, TRACY: Classification of Type III (Severe) Open Fractures Relative to Treatment and Results. • Orthopedics, 10: 1781-1788, 1987. • 15. GUSTILO, R. B.; MENDOZA, R. M.; and WILLIAMS, D. N.: Problems in the Management ofType III (Severe) Open Fractures. A New Classification • of Type III Open Fractures. J. Trauma, 24: 742-746, 1984. • 16. KARLSTROM, GORAN, and OLERUD, SVEN: Percutaneous Pin Fixation of Open Tibial Fractures. Double-Frame Anchorage Using the Vidal-Adrey • Method. J. Bone and Joint Surg. , 57-A: 915-924, Oct. 1975. • 17. KLEMM, K. W. , and BORNER, M.: Interlocking Nailing of Complex Fractures of the Femur and Tibia. Clin. Orthop., 212: 89-100, 1986. • 18. LANGE, R. H. ; BACH, A. W.; HANSEN, S. T. , JR.; and JOHANSEN, K. H.: Open Tibial Fractures with Associated Vascular Injuries. Prognosis for • Limb Salvage. J. Trauma, 25: 203-208, 1985. • 19. LAWRENCE, R. M.; HOEPRICH, P. D. ; HUSTON, A. C.; BENSON, D. R.; and RIGGINS, R. S.: Quantitative Microbiology of Traumatic Orthopedic • Wounds. J. Clin. Microbiol. , 8: 673-675, 1978.

  18. References • 20. LHOWE, D. W. , and HANSEN, S. T.: Immediate Nailing of Open Fractures of the Femoral Shaft. J. Bone and Joint Surg. , 70-A: 812-820, July • 1988. • 21. MCCRAW, J. B. , and ARNOLD, P. G.: McCraw and Arnold’s Atlas of Muscle and Musculocutaneous Flaps. Norfolk, Virginia, Hampton Press, • 1986. • 22. MCCRAW, J. B.; FISHMAN, J. H. ; and SHARZER, L. A.: The Versatile GastrocnemiusMyocutaneous Flap. Plast. and Reconstr. Surg. , 62: 15-23, • 1978. • 23. MCGRAW, J. M. , and LIM, E. V. A. : Treatment of Open Tibial-Shaft Fractures. External Fixation and Secondary Intramedullary Nailing. J. Bone • and Joint Surg. , 70-A: 900-91 1 , July 1988. • 24. MATHES, S. J. ; MCCRAW, J. B. ; and VASCONEZ, L. 0. : Muscle Transposition Flaps for Coverage of Lower Extremity Defects. Surg. Clin. North • America, 54: 1337-1354, 1974. • 25. MAY, J. W. ; GALLICO, G. G. , III; JUPITER, J. ; and SAVAGE, R. C. : Free LatissimusDorsi Muscle Flap with Skin Graft for Treatment of Traumatic • 304 R. B. GUSTILO, R. L. MERKOW, AND DAVID TEMPLEMAN Chronic Bony Wounds. Plast. and Reconstr. Surg. , 73: 641-649, 1984. • 26. MOED, B. R. ; KELLAM, J. F.; FOSTER, R. J.; TILE, MARVIN; and HANSEN, S. T.: Immediate Internal Fixation of Open Fractures of the Diaphysis • of the Forearm. J. Bone and Joint Surg. , 68-A: 1008-1017, Sept. 1986. • 27. NEALE, H. W. ; STERN, P. J.; KREILEIN, J. G.; GREGORY, R. 0.; and WEBSTER, K. L.: Complications of Muscle-Flap Transposition for Traumatic • Defects of the Leg. Plast. and Reconstr. Surg., 72: 512-515, 1983. • 28. OLERUD, SVEN, and KARLSTROM, GORAN: The Spectrum of Intramedullary Nailing of the Tibia. Clin. Orthop., 212: 101-112, 1986. • 29. PATZAKIS, M. J. ; HARVEY, J. P. , JR. ; and IVLER, DANIEL: The Role of Antibiotics in the Management of Open Fractures. J. Bone and Joint Surg., • 56-A: 532-541, April 1974. • 30. PATZAKIS, M. J. ; WILKINS, J. ; and MOORE, T. M. : Considerations in Reducing the Infection Rate in Open Tibial Fractures. Clin. Orthop. , 178: • 36-41, 1983. • 31 . PONTEN, BENGT: The Fasciocutaneous Flap: Its Use in Soft Tissue Defects of the Lower Leg. British J. Plast. Surg., 34: 215-220, 1981. • 32. RITTMANN, W. W. ; SCHIBLI, M. ; MATTER, P. ; and ALLGOWER, M. : Open Fractures. Long-Term Results in 200 Consecutive Cases. Clin. Orthop., • 138: 132-140, 1979. • 33. ROMMENS, P. , and SCHMIT-NEUERBURG, K. P. : Ten Years of Experience with the Operative Management of Tibial Shaft Fractures. J. Trauma, • 27: 917-927, 1987. • 34. ROSENSTE1N, B. D. ; WILSON, F. C. ; and FUNDERBURK, C. H. : The Use of Bacitracin Irrigation to Prevent Infection in Postoperative Skeletal • Wounds. J. Bone and Joint Surg. , 71-A: 427-430, March 1989. • 35. ROTH, A. I.; FRY, D. E.; and POLK, H. C. , JR.: Infectious Morbidity in Extremity Fractures. J. Trauma, 26: 757-761 , 1986. • 36. TAKAMI, HIR0SHI; TAKAHASHI, SADAO; and AND0, MASASHI: Microvascular Free Musculocutaneous Flaps for the Treatment of Avulsion Injuries • of the Lower Leg. J. Trauma, 23: 473-477, 1983. • 37. TEMPLEMAN, D. C. ; SWEENY, CHRISTOPHER T. ; CHAPMAN, M. W. ; GUSTILO, R. B.; KYLE, R. F. ; BRAY, R. J. T. ; and GORDON, J. E. : Critical • Analysis of the Management of Open Femur Fractures at Two Regional Trauma Centers. Read at the Annual Meeting of The American Academy • of Orthopaedic Surgeons, Las Vegas, Nevada, Feb. 13, 1989. • 38. TOLHURST, D. E. : Surgical Indications for Fasciocutaneous Flaps. Ann. Plast. Surg. , 13: 495-503, 1984. • 39. VELAZCO, A. ; WHITES1DES, T. E. , JR. ; and FLEMING, L. L. : Open Fractures of the Tibia Treated with the Lottes Nail. J. Bone and Joint Surg., • 65-A: 879-885, Sept. 1983.

  19. References • 40. WEILAND, A. J. ; MooRE, J. R. ; and HOTCHKISS, R. N. : Soft Tissue Procedures for Reconstruction of Tibial Shaft Fractures. Clin. Orthop. , 178: 42-53, 1983. • 41. WISS, D. A.: Flexible Medullary Nailing of Acute Tibial Shaft Fractures. Clin. Orthop., 212: 122-132, 1986. • 42. WORLOCK, PETER; SLACK, RICHARD; HARVEY, LEN; and MAWHINNEY, ROD: The Prevention of Infection in Open Fractures. J. Bone and Joint Surg. , 70-A: 1341-1347, Oct. 1988. • 43. WRIGHT, J. K. , and WATKINS, R. P.: Use of the Soleus Muscle Flap to Cover Part of the Distal Tibia. Plast. and Reconstr. Surg. , 12: 957-958,1981.

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