Open Fractures Management and Classification Presented by Dr Atif Labban Supervised by Dr M.Abbas

DEFINITION: An open fracture is one in which a break in the skin and underlying soft tissues leads directly into or communicates with the fracture and its hematoma.

Gustilo Open Fx Class JBJS, 72A: , % 7% 10-50% 25-50%

Open Fractures Type II Type IIIA Type IIIB

Negative Biology of Open Fx Contamination Crushing Stripping Devascularization Comminution

Type I wound is caused by a low-energy injury that is usually less than 1 cm long. It is usually caused by the bone piercing from the inside outward rather than by a penetrating injury.

Type II wound is greater than 1 cm in length and has a moderate amount of soft tissue damage owing to a higher- energy injury. These are usually outside-to- inside injuries.

Type III wound a high-energy, outside-to-inside injury and is usually longer than 10 cm with extensive muscle devitalization. Extensive wound contamination also increases the likelihood of infection and subsequent complications.

A type IIIA open fracture There is limited stripping of the periosteum and soft tissues from bone. There may be loss of skin, There is adequate muscle and soft tissue coverage over bone

A type IIIB open fracture there is extensive stripping of soft tissues and periosteum from bone. Devitalization or loss of soft tissues usually requires a local flap or free tissue transfer for coverage of exposed bone.

A type IIIC open fracture is one in which there is a major vascular injury requiring repair for salvage of the extremity. A tibia fracture with disruption of the anterior tibial artery but preservation of the posterior tibial artery is not a type IIIC injury.

MANAGEMENT OF OPEN FRACTURES Goals of management: Early return to the function avoid complications ER management: OR management: Assesment I&D Reduction&splinting SK. Stabilization Wound care Wound managment Tetanous prophylaxis Antibiotics

EXAMINATION OF THE WOUND AND INITIAL EMERGENCY MANAGEMENT START BY APPLYING THE PRINCIPLES OF ATLS

Tetanus Toxoid Tetanus Toxoid 2.5 cc to all poly-trauma patients, otherwise: IMMUNIZATION HISTORY NON-TETANUS PRONE TETANUS PRONE* UNKNOWNYESYES >3 IMMUNIZATIONS (<5 YEARS) NONO *Tetanus Prone: >6 hours old, complex soft tissue injury, wound >1 cm deep, missile, crush, burn, frostbite, devitalized tissues, soil contaminants, denervated, ischemic, early infection.

Tetanus Immune Globulin units IM: IMMUNIZATION HISTORY NON- TETANUS PRONE TETANUS PRONE* UNKNOWNNOYES >3 IMMUNIZATIONS (<5 YEARS) NONO

ANTIBIOTICS Is therapeutic not prophylactic. role :kill residual organisms,inhibit their growth to the point where host protective mechanisms can eradicate them. Irrigation and debridement :most important measures in preventing infection in open #,antibiotics certainly cannot be relied on to prevent infection in an inadequately debrided wound. Early administration of antibiotics during initial phases of within 3 hrs of injury decreases incidence of infection in open fractures common organism :Staphylococcus aureus Duration :48 to 72 hours after initial and any subsequent debridements, & after wound closure, bone graft & major surgical procedure

1 Gen Ceph GentPCN Grade I (G+ve)  Grade II (G+ve  Grade III (G+ve& - ve) +/- Farm & Ischemic Wounds (anaerobic)  Recommended Antibiotic Treatment

Local Antibiotics Numerous antibiotics can be incorporated in polymethylmethacrylate (PMMA) without losing their bactericidal activity. Should prepared by surgeon Useful for type II & III 1)Decrease infection rates 2)High local antibiotic levels(10- 20times) 3)Useful for dead space management 4)Decrease systemic effect of IV antibiotics

PREPARATION FOR SURGICAL DEBRIDEMENT All open fractures need to be formally treated in operating room on an urgent basis with meticulous irrigation&debridement. A 2-phase surgical preparation of the limb may be advisable for severely contaminated wounds

IRRIGATION AND DEBRIDEMENT “ The solution to pollution is dilution. ” The more important is copious irrigation of the wound

advantages of irrigation 1) Clear blood and other debris for inspection. 2)Lavage floats contaminated blood clots, loose tissue, debris from unseen places. 3)Lavage of tissue restores its normal color and facilitates determination of viability. 4) reduces the bacterial population.