Open Fractures Principles of Management Majdi Hashem, MD Assistant professor of orthopedic Consultant orthopedic and spine Course organizer Reproduced courtesy of Prof Mamoun Kermli

Historical fact … until WW I Treatment of open fractures was “Amputation” Mortality rate ~ 75% Function in “survivors” was poor Alois Karlbauer

Objectives Definition of an open fracture Important points in history of an open fracture Classification Management: Initial treatment Importance of surgical debridement Bone treatment initial & definitive Soft tissue coverage Factors affecting outcome

Definition Open fracture is a fracture where the skin coverage overlying is breached even a small puncture wound Another name: compound fracture www.merryshannon.com

History in open fractures Mechanism of injury Date, time, type, method of impact, … Consciousness Size of wound Amount of bleeding Other injuries: often missed Anti-Tetanus status

Type of injury Determines amount of energy and Extent of soft tissue injury

Type of injury Fall: height is important Sport: stronger impact Heavy object falling: direct injury – soft tissue Road traffic accident (RTA): more severe Car (MVA) , motorcycle, pedestrian Assault & firearms: severe

Mechanism of Injury Try to determine if injury was caused by: Low velocity High velocity Crushing under objects

Mechanism of Injury Field of injury: Relatively clean Contaminated soil

Mechanism of Injury Open injury from: In-out: usually cleaner Out-in: usually more contamination and dirt www.aofoundation.org

Mechanism of Injury Penetrating Missiles Low velocity < 300 m/s - damage along the tract Comminution High velocity: >300m/s - sever comminution Comminution with wide soft tissue damage Some fragment inside Some flip inside Vacuum phenomena - cavitation

Signs of high energy injury Segmental fracture Bone loss Compartment syndrome Crush syndrome Extensive de-gloving

Examples Low energy High energy A. Karlbauer

Approach – clinical exam General 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 exam Feel: Sensory and motor deficits Pulse distal to injury Compartment syndrome Tense compartment Move: With care, if necessary! www.medicinabih.info

Approach – clinical exam Examination of the viscera Rib fractures Lung, liver and spleen Pelvic fractures Urinary bladder and urethra Head and spinal injury Neurological examination

Management of open fractures Initial management Classifying the injury Definitive treatment

Initial management it 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 management it 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: Inspect wound Remove gross contamination Photograph the wound Cover with a saline-soaked dressing Splint Give antibiotics Give Tetanus prophylaxis Check limb circulation and distal neurological status repeatedly

Grades of open fracture Important to grade severity of open injuries and soft tissue injuries To treat according to guidelines To have an idea about prognosis Several classifications Most widely used: Gustilo Classification

Gustilo Classification Grade 1: Low-energy, minimal soft-tissue damage (wound < 1cm) Grade 2: Higher energy, no flaps needed / no crushing Moderate contamination (wound > 1cm) Grade 3: High-energy, flaps needed / crushing Significant contamination.

Gustilo Classification Sub-Types of Grade III: Type 3A : Adequate soft-tissue cover Can cover skin primarily Type 3B: Inadequate cover Can not cover skin primarily May need skin graft or flap Type 3C: Vascular injury Requires vascular repair

Gustilo Grade I Low energy Simple fracture Skin open by fragment pressure within – out Wound < 1 cm No / little contamination www.orthopaedicsone.com/

Gustilo Grade II Higher energy Laceration > 1 cm No flap / No contusion Minimal contamination

Gustilo Grade IIIA High-energy, Adequate soft-tissue cover Contamination Comminution or segmental fracture

Gustilo Grade IIIB High-energy, Extensive soft-tissue stripping Inadequate cover, Massive contamination

Gustilo Grade IIIA or IIIB An intra-operative decision

Gustilo Grade IIIA or IIIB ? Adequate soft tissue coverage

Gastilo Grade? IIIC

Problem of open fractures Infection – skin is breached Primary: from the field Massive contamination Debris and foreign bodies Devitalized tissues Secondary infection after internal fixation Initial bacterial contamination Proper debridement not done Internal fixation is a foreign body 30

Principles of treatment All open fractures, no matter how trivial they may seem, must be assumed to be contaminated The basic guidelines: Antibiotic prophylaxis / Anti-tetanus Urgent and proper wound and fracture debridement Stabilization of the fracture – ? External Fixation Early definitive wound cover

Primary surgery The aims of primary surgery are: Preservation of life and limb Definitive injury assessment Staged wound debridement May need to repeat after 48-72 hours Fracture stabilization

Primary surgery – Debridement Trim 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

“Dilution is the solution to pollution” Alois Karlbauer

Surgical Debridement Surgical debridement demands meticulous excision of all dead and devitalized tissues Start from outside working inwards: Skin Fat Muscle Bone Neurovascular Leaving dead tissue invites infection Alois Karlbauer

Treatment guidelines Gustilo I and II: Can treat by primary internal fixation Rate of infection low – if follow guidelines Alois Karlbauer

Treatment guidelines Gustilo IIIA Gustilo IIIB Gustilo IIIC Usually defer internal fixation until soft tissue condition allows Gustilo IIIB External fixation Later, internal fixation Gustilo IIIC Vascular repair is a priority External fixator

Higher infection rate More contamination (may change grade II to III): Exposure to soil Exposure to water Exposure to fecal material Exposure to oral material Gross contamination Delay > 12 hours

Case example - 1 26y male, motorbike accident, stable Gustilo Type? Management: Swab taken Antibiotics, anti- tetanus Debridement, skin closure External fixator Later on, Intramedullary nail IIIA / IIIB Tadashi Tanaka, Chiba, Japan

Case example - 1 Tadashi Tanaka, Chiba, Japan

Case example - 2 32y old, sever car accident, hit by a truck on bridge and car fell into canal

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

Summary Definition of open fracture Important points in history of an open fracture Gustilo classification Management: Importance of early surgical debridement Bone treatment initial & definitive Soft tissue coverage