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

Introduction Assessment Classification Management Open fractures

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

Fracture Healing Biologic factors Biomechanical factor

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

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

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

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

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

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

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

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

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

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

Classification

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

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

Classification - Open Fractures Open injuries Gustilo & Anderson AO

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

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

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

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

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

Management First aid Emergency Room Definitive Rehabilitation

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

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

The open wound should be assessed and documented only once Emergency The open wound should be assessed and documented only once

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

Antibiotics can not compensate for an inadequate surgical management

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

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

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

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

Scrub/remove gross debris/ irrigate Double setup 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

Excise crushed/ contaminated skin edge Wound Excision Excise crushed/ contaminated skin edge

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

Wound Extension

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

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

“When in doubt, take it out” Debridement “When in doubt, take it out”

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

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

The solution to pollution is dilution Irrigation The solution to pollution is dilution

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

Second prep if internal fixation Principles 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

Diaphyseal Fractures Humerus Forearm ORIF Femur Tibia IM nail Bony Stabilization Diaphyseal Fractures Humerus Forearm Femur Tibia ORIF IM nail

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

Occasionally close open wound primarily Open Wound Management Can close extensions Occasionally close open wound primarily No crush No contamination Small wound No dead space Closure without tension Keep wound moist - ? bead pouch

Price of Primary Open Wound Closure Open Wound Management Price of Primary Open Wound Closure Gas Gangrene Limb Loss Death  leave open

Antibiotic beads Depo of local antibiotics ? efficacy ? toxicity Open Wound Management Antibiotic beads Depo of local antibiotics ? efficacy ? toxicity

Antibiotic Bead Pouch VGH Experience 85 open tibial shaft fractures 59 antibiotic bead pouch 26 no bead pouch No statistical difference in: age, sex, ISS, time to wound coverage Keating, et al

Antibiotic Bead Pouch VGH Experience Infection Type II Type III TOTAL No Bead Pouch Bead Pouch p value 16% 0% <0.03 11% 3% 0.35 15% 2% <0.06 Keating, et al

Q 24-48 hours until wound is viable Redebridement High grade injury Severe contamination Questionable tissue viability ? adequacy of debridement Q 24-48 hours until wound is viable

Wound Closure/Coverage ? Immediate Optimally by 3-7 days Principles Durable coverage Well vascularized soft tissue envelope for bone Fill dead space

Wound Closure/Coverage Secondary intent Delayed primary closure Skin graft Flap local distant - free

Wound Closure/Coverage Role of VAC yet to be delineated

Splint joints in functional position pending soft tissue healing Rehabilitation Splint joints in functional position pending soft tissue healing Swelling control ROM/Muscle rehabilitation as soon as wound healing permits Wound management to minimize scarring

Summary The soft tissues are critical to the successful management of all fractures

Summary Aggressive, systematic management is required for fractures with significant soft tissue injuries

THANK YOU !!

ARS 31 yr old man Ped struck The most critical component Isolated injury The most critical component of this man’s treatment is: Antibiotics Tibial fixation Avoidance of reaming Soft tissue management Early fracture stabilization Open fractures

ARS 31 yr old man Ped struck After management of the soft Isolated injury After management of the soft tissues the bone is best stabilized by: Cast External fixator Plate Reamed IM nail Unreamed IM nail Open fractures

ARS 31 yr old man Ped struck How would you grade this Isolated injury II III A III B III C Open fractures

ARS 31 yr old man Ped struck The most critical component Isolated injury The most critical component of this man’s treatment is: Antibiotics Tibial fixation Avoidance of reaming Soft tissue management Early fracture stabilization Open fractures

ARS 31 yr old man Ped struck After management of the soft Isolated injury After management of the soft tissues the bone is best stabilized by: Cast External fixator Plate Reamed IM nail Unreamed IM nail Open fractures