1. Nailing compound fractures when / safety evidence
DR.G.S.KULKARNI
MIRAJ

2. American Civil War Mortality 26% France – Russian war 13000 Amputee
HISTORY of open fractures
American Civil War Mortality 26%
France – Russian war Amputee

3. Nailing in open fractures
Improved technique debridement.
Use of AB bead pouch and Rod
Vaccume assisted closure
Newer designs of nails & plates.
Perioper. AB

4. Corner stone of Open fracture-Debridement
Wound - Extend longitudinally-
Exploration Fasciotomy
Debridement
Irrigation
AB Beads
6. VAC – not a substitute

5. Adv. nailing in open # Early stabilization of open fracture controls
pain,swelling, mobility inflammation
2. Mobility-Further soft tissue damage
3. Early mobilization of jt & pt.
4 CPM

6. IMN Adv. Biomechanically superior, maintain L, alignment and rotation
Early wt. bearing
Less rate of secondary surgery

7. Adv. of immediate IF
Unkinks A,V and lymphatics , improves circulation at fracture zone

8. Ext. Fix –meta-analysis
Adv : union - 94 % infection - 16% chro. Osteo - 4% -Giamondis JBJS, Br. 2006

9. Complication of Ext. Fix
Pin loosening
Pin tract inf. 32 %
Mal-union
Exchange nailing- inf to 30%
“Non-union machine “

10. IMN
IMN is a safe, effective method for open fracture I, II, III A & B S.Malvin JAAOS, Feb 2010

11. Reamed V/s Unreamed Reaminng-- Adv 1. larger diameter – better
fracture stability
2. Implant failure less
3. Reaming deposit B.G.
4. Periosteal blood supply ++

12. Reaming .
Metaanalysis failed to show an increased risk of re-operation
No increased rate of infection or nonunion
- Bhandari Et al
JBJS B 2001 :

13. Multicentric level 1 study
open fractures 460
Reamed 210
Unreamed 196
Does not support superiority of either.
SPRINT Group
JBJS Am 2008
Debate is ongoing

14. Reamed
Disadv - 1. Reduced intramedullary blood
supply, but
Periosteal blood supply ++
2. Thermal necrosis
a) use sharp reamers, increment
by 0.5 mm
b) gentle reaming –back & forth

15. Poor result of IMN Inadequate debridement
Inappropriate soft tissue closure
Thermal necrosis
Severe contamination + late arrival
These are contra-indications

16. Literature
143 cases of open tibial shaft fractures.Primary IMN has Favourable results.
Deep infection – 3 %
- Koker & Tornetta JOT 2007

17. Exchange ex fix to IMN Safety period 10 days till soft tissue recovery
< 14 days ( Varies from 7 to 28 days)
Shorter period reduces infection rate
- JS Melion et al
JOT Feb 2010

18. Do not do primary IMN Severe contamination Inadequate debridement
Delayed arrival
AB Rod + Ex. Fix
7-10 days IMN

19. Debride A-B Rod
AO Ex Fix
1st VAC
DAY 1
JAGRUTI M

20. JAGRUTI MANCHAREKAR
DAY 1
DAY 5

21. After 3 changes of VAC, 2nd Skin graft
JAGRUTI M
DAY 9
After 3 changes of VAC, 2nd Skin graft

22. After 1 yr
JAGRUTI M

23. VAC & I.F. OF OPEN FRACTURE
With VAC it is possible to nail or plate IIIB open #
as VAC is an excellent interval coverage

24. Almost no role of plaster splint or plaster cast with window in open fracture.

25. External Fixator in Open #s
Advantages
1. Pins away from fracture zone
2. No additional open surgery
3. Access to wound dressing and
plastic surgery
4. Early mobilisation

26. External Fixator Disadvantages : Pin tract infection
Risk of infection of later ORIF
Soft – tissue impaling stiff jt.
Pin loosening
Ex fix as a definative treat not favoured

28. VAC AC V

29. 1
Nailed on day 1 of injury

30. Amar Sawant
15 days old
Amar Sawant

31. AMAR SAWANT
Amar Sawant

32. AMAR SAWANT
Amar Sawant

33. Amar Sawant

34. Chavan chandrakant

35. Chavan chandrakant

36. Kolekar Parmeshwar
Kolekar Parmeshwar

37. Open fracture+ pilon
IMN on day 1
Hebbal Hasan

38. Both united
Hebbal Hasan

39. CONCLUSION Corner stone of fracture debridement
IMN is a safe, effective method
Two stage nailing –I) AB rod II) ILIMN
a) severe contamination
b) delayed arrival