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

2. Introduction
Assessment
Classification
Management
Open fractures

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

4. Fracture Healing
Biologic factors
Biomechanical factor

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

6. 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

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

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

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

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

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

12. 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

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

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

15. Classification

16. 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

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

18. Classification - Open Fractures
Open injuries
Gustilo & Anderson AO

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

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

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

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

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

27. Management
First aid
Emergency Room
Definitive
Rehabilitation

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

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

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

31. 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

32. Antibiotics can not compensate for an inadequate surgical management

33. 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

34. 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

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

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

37. 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

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

39. 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

40. Wound Extension

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

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

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

44. 10 litres for significant wounds
Irrigation
10 litres for significant wounds
saline
? antibiotics
? pulsed lavage
? detergent

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

46. The solution to pollution is dilution
Irrigation
The solution to pollution is dilution

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

48. 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

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

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

52. 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

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

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

55. 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

56. 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

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

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

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

60. Wound Closure/Coverage
Role of VAC yet to be delineated

61. 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

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

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

64. THANK YOU !!

65. 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

66. 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

67. ARS 31 yr old man Ped struck How would you grade this Isolated injuryII
III A
III B
III C
Open fractures

68. 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

69. 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