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

2. 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”

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

4. 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

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

6. Type-I

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

8. Type-II

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

10. Type-III

11. 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

12. 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

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

14. Infection Rates Type-I: 0-2 % Type-II: 2-7 %
Type-III: % (overall)
Type-IIIa: 7 %
Type-IIIb: %
Type-IIIc: %

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

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

17. 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

18. 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

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

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

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

22. 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

23. 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

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

25. 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

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

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

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

29. 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.

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

31. 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

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

33. 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.

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

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

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

37. 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: , 1979

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

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

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

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

42. 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).

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

44. 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

45. 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

46. 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!

47. THANK YOU