Joseph J. Ruzbarsky, MD Trauma Conference September 22, 2014 OPEN FRACTURES Joseph J. Ruzbarsky, MD Trauma Conference September 22, 2014

Open Fracture A fracture in which a break in the skin and underlying soft tissues leads directly into or communicates with the fracture and its underlying hematoma “Compound fracture”

Goals of Treatment Prevent infection Achieve bony union Restore soft-tissue envelope Early motion and rehabilitation

Classification Gustilo and Anderson, JBJS, 58A, No.4, 1976 Reported on 1,025 open fractures of long bones and offered a classification system based largely, though not entirely, on the size of the wound

Type-I < 1 cm wound low-energy injuries 'inside-out’ minimal soft tissue damage minimal comminution minimal contamination

Type-I

Type-II > 1 cm wound mild-mod. energy 'outside-in' moderate soft tissue injury moderate comminution moderate contamination

Type-II

Type-III large wounds (> 10cm) high energy injury extensive soft-tissue injury marked comminution marked contamination

Type-III

Gustilo et al., J Trauma, Vol.24, No 8, 1984 Type-IIIa adequate soft-tissue coverage remains Type-IIIb soft-tissue coverage procedure necessary Type-IIIc vascular injury that requires repair

Automatic Type III’s shotgun wounds high velocity GSW (> 2000 ft./sec.) displaced segmental fractures diaphyseal segmental bone loss farmyard injuries highly contaminated injury severe crush injuries any open fracture seen after 8 hrs

Infection Incidence correlates directly with extent of soft-tissue injury, NOT the length of the wound. Gustilo et al., JBJS, 72A; 1990

Infection Rates Type-I: 0-2 % Type-II: 2-7 % Type-III: 10 - 25 % (overall) Type-IIIa: 7 % Type-IIIb: 10-50 % Type-IIIc: 25-50 %

Initial Treatment ABC's according to the ATLS protocols Life-threatening injuries take precedence over limb threatening injuries Thorough neurovascular exam

Tetanus Prophylaxis Clostridium tetani Immunized w/in 5 yrs - No treatment Immunized > 5 yrs - tetanus toxoid Status unknown - tetanus toxoid and tetanus immune globulin

Value of ER or Pre-debridement Cultures? organisms seen on initial culture rarely the same organisms cultured from infected wounds costly Lee, Chapman, et al., Orthop Trans, 15; 1991

Initial treatment Cover the wound Reduce and splint fracture sterile dressing Repeated evaluation leads to increased incidence of infection Reduce and splint fracture for comfort to prevent further soft tissue damage

Antibiotic Treatment should begin as soon as possible > 70 % of open fxs. are contaminated with bacteria at the time of injury

Which antibiotic? Type-I and Type-II Type-III cephazolin Type-III cephazolin plus aminoglycoside Farm or sewage related injury cephazolin, aminoglycoside and penicillin

Irrigation and Debridement The most important intervention! Repeat every 24-48 hours until wound appears clean and devoid of non-viable tissue.

Irrigation 9-10 liters of normal saline should be used during irrigation of open fx Gustilo et al., 1986; Sanders et al.,JBJS 1994. Pulsatile lavage may impede bone healing Bhandari, JOT, 1998 Dirschl, JOT, 1998

Skin Debridement avoid tourniquet excise margins (saucerize) enlarge wound with extensile incisions obtain meticulous hemostasis as needed skin is not the major source of infection

Fascia excise any non-viable, damaged or contaminated fascia limited vs. formal fasciotomy for high-energy injuries Open fractures do NOT necessarily decompress compartment

Indications for Fasciotomy after arterial repair with re-perfusion edema after sustained hypotension severe polytrauma patient is unable to communicate (i.e. closed head injury) open fxs. with a crushing component

Muscle Debridement nonviable muscle is the major nidus for infection the Four C's color consistency contractility capacity to bleed

Tendon Debridement unless severely damaged or contaminated, may be preserved preserve peritenon if possible cover tendons with local muscle

Bone Debridement "Our most common judgement error has been the delayed excision of nonviable bone” Chapman and Olson, Fractures, Ed 4, 1996.

Bone Debridement Remove small-moderate sized avascular segments Retain major articular fragments large cortical segments can often be retained initially, but must be debrided if infection intervenes.

Open Joints explore any open joint injury arthroscopy may play a helpful role during I & D

Limb Salvage vs. Amputation "Unfortunately it requires more judgement and courage to do a primary amputation that it does to salvage the limb of a patient with a severe open tibia fracture. Heatley, BMJ, 1988

Primary Amputation Lange's absolute indications: warm ischemia time > 6 hours anatomic division of the tibial nerve

Fracture Stabilization Begins after vascular repair (when needed) and adequate irrigation and debridement. Based on: fracture configuration soft-tissue injury, associated injuries patient's general condition.

Cast Immobilization Some Type-I and Type-II fractures Difficult to observe wound

External Fixation Advantages good stability to fracture site good wound access easily and rapidly applied minimal trauma to soft tissues

External Fixation Disadvantages pin tract problems (irritation, loosening, infection) limited life span may limit soft-tissue procedures

Plate and Screw Fixation Advantages anatomic reduction possible improved soft-tissue access rigid stabilization early mobilization well tolerated The role of early internal fixation in the management of open fractures. Chapman MW, Mahoney M:CORR: 138: 120-131, 1979

Plate and Screw Fixation Disadvantages need for further exposure devascularization of tenuous bone fragments

Plate and Screw Fixation Indications Type-I and some Type-II open fractures intra-articular fractures metaphyseal fractures Forearm

Intramedullary Fixation Advantages provides excellent stability improved soft-tissue access early motion and rehabilitation well-tolerated

Intramedullary Fixation Disadvantages impairs endosteal circulation (reamed> unreamed) often longer OR time than external fixation

Intra-articular Fractures Goals anatomic reduction of the articular surface stabilization of the shaft to achieve a well-aligned congruous joint Often accomplished with limited internal fixation and a 'spanning' ex-fix (hybrid).

Wound Management Operative wounds may be closed primarily Traumatic wounds left open Every 24-48 hrs, debridements to achieve a clean, stable wound.

Closure and Coverage GOAL: healthy soft tissue envelope with adequate muscle coverage over the fracture delayed primary closure split thickness skin grafting (STSG) Exposed tendon or bone necessitates flap coverage

Rehabilitation Early, aggressive rehab has the following benefits: prevention of "fracture disease” prevention of muscle disuse atrophy prevention of joint stiffness and contracture improved circulation

Type-III open tibial fractures Averages: 6 operations! 2 mos of hospitalization! > 1 year of rehabilitation! 3 mos until complete soft tissue healing! 12 mos for complete fracture healing!

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