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Open Fracture Management

Open Fracture Management

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Open Fracture Management

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  1. Open Fracture Management P. Blachut Division of Ortho Trauma Vancouver General Hospital University of British Columbia

  2. Introduction • Assessment • Classification • Management Open fractures

  3. Goals of Fracture Management • Fracture healing with satisfactory length and alignment • Avoidance of complications • infection • nonunion • malunion • stiffness • Early restoration of function

  4. Fracture Healing • Biologic factors • Biomechanical factor

  5. Avoidance of Complications (Infection) • No necrotic tissue • No dead space • No contamination • Well vascularized tissue

  6. Early Restoration of Function • Early mobilization • Stable fixation • Early wound healing • Avoid excessive scarring • Early wound coverage with quality tissue • Preservation of “critical tissues” • Nerves • Tendons

  7. Therefore: • The soft tissues are paramount to the successful management of fractures

  8. A bone healing complication with good soft tissues is easier to deal with than a complication with poor soft tissues

  9. Consequences of an Associated Soft Tissue Injury • healing potential • resistance to infection • contamination

  10. Assessment • Look for associated life threatening injuries!!! • Carefully assess and document neurovascular status

  11. ATLS (Advanced Trauma Life Support) • Primary Survey • A irway • B reathing • C irculation • D isability • E xposure • Secondary Survey

  12. Compartment Syndrome • Always look for in fractures with soft tissue injuries • Open fractures - up to 10% have compartment syndrome

  13. Amputation vs. Salvage • Multidisciplinary decision • Based on the assessment of likely ultimate function of limb compared to function with amputation

  14. Factors Favoring Amputation • Warm ischemia time > 8 hrs • Severe crush • minimal remaining functional tissue • Chronic debilitating disease • Severe polytrauma • Mass casualty • complexity of reconstruction

  15. Classification

  16. Classification - Open Fractures • Reflection of amount of energy imparted and consequently, the prognosis • Skin wound size • Level of contamination • Extent of soft tissue injury/ periosteal stripping • Fracture configuration

  17. Classification - Open Fractures • Classification can really only be done at the completion of debridement

  18. Classification - Open Fractures • Open injuries • Gustilo & Anderson • AO

  19. Open Fracture - Gustilo Classification • Type I • Small wound • Inside out • No/minimal contamination • Minimal soft tissue trauma • Low energy fracture pattern

  20. Open Fracture - Gustilo Classification • Type II • Moderate wound • Some contamination • Some muscle damage • Moderate energy fracture pattern

  21. Open Fracture - Gustilo Classification • Type III • Large wound • Significant comtamination • Major soft tissue trauma • crushing • periosteal stripping • High energy fracture pattern

  22. Open Fracture - Gustilo Classification • IIIA • enough soft tissue to cover bone • IIIB • insufficient soft tissue • need flap (local, free) • IIIC • vascular injury requiring repair

  23. Open Fracture - Gustilo Classification • Type III - Additional Factors • Barnyard • Shotgun • High velocity gunshot • Displaced segmental fracture • Neglected open fracture (> 8 hrs) • Bone loss

  24. Management • First aid • Emergency Room • Definitive • Rehabilitation

  25. First Aid • Control bleeding • direct pressure • Realign • further soft tissue damage/ compromise • Splint • comfort • further damage

  26. Emergency • First aid if not already given • Remove gross debris/irrigate/dress/ splint • Tetanus prophylaxis - if necessary • Antibiotics

  27. Emergency • The open wound should be assessed and documented only once

  28. Antibiotics • ? Prophylactic vs. treatment Closed with operative Rx Cephalosporin Grade I Grade II / III Add aminoglycoside High Risk Add penicillin

  29. Antibiotics • Antibiotics can not compensate for an inadequate surgical management

  30. Timing of Administration of Antibiotics • The Prevention of Infection in Open Fractures An Experimental Study of the Effect of Antibiotic Therapy Worlock, et al JBJS 1988 No antibiotics 1-4 hrs post-inoculation 1 hr. pre-inoculation 91% infection 51% infection 30% infection

  31. Antibiotics • The Role of Antibiotics in the Management of Open Fractures • Patzakis, et al JBJS, 1974 Control Pen./Streptomycin Cephalothin 13.9% infection 9.7% infection 2.3% infection

  32. Definitive Treatment • Wound excision • Wound extension • Debridement • Irrigation • Bone stabilization • Wound dressing • +/- re-debridement • Early wound closure/coverage

  33. Timing of Operative Intervention • General standard - within 6-8 hours • Not evidence based!!

  34. Operating Room • Scrub/remove gross debris/ irrigate • Double setup • debridement/irrigation • bone stabilization if internal fixation planned • Tourniquet • apply/not inflated • in case of bleeding

  35. Wound Excision • Excise crushed/ contaminated skin edge

  36. Wound Extension • Sufficient extension to fully evaluate and treat soft tissue injury (approximately 1 diameter of limb) • Anticipate incisions for bony stablization/soft tissue reconstruction • Avoid incision that will compromise skin further

  37. Wound Extension

  38. Debridement • Layer by layer • Remove all devitalized and contaminated tissue (including bone)

  39. Debridement - Objective: • To leave a wound with: • No/minimal contamination • Well vascularized tissue for healing and to resist infection

  40. Debridement • “When in doubt, take it out”

  41. Irrigation • 10 litres for significant wounds • saline • ? antibiotics • ? pulsed lavage • ? detergent

  42. Irrigation • Improves visualization • Float out necrotic tissue • Flush out debris • Reduce bacterial population

  43. Irrigation • The solution to pollution is dilution

  44. Stabilization The Prevention of Infection in Open Fractures: An Experimental Study of the Effect of Fracture Stability Worlock, et al Injury 1994

  45. Bony Stabilization • Second prep if internal fixation • Principles • Minimize further trauma • Sufficient stability to allow early rehab • Should not impede subsequent soft tissue management • Restoration of anatomy

  46. Bony Stabilization • Diaphyseal Fractures • Humerus • Forearm • Femur • Tibia ORIF IM nail

  47. Bony Stabilization • Articular Fractures • primary ORIF • spanning external fixator + / - articular ORIF  delayed ORIF • external fixation