1. Management of Open Fractures
Dr.David Samaroo MBBS,MS
Department of Orthopedic Surgery
Georgetown Public Hospital Corporation,
University of Guyana School of Medicine.

2. Open Fracture defect in skin/soft tissues
fracture communicates with the outside environment
higher risk of infection/nonunion

3. Causes of non union
General
Specific
Diastasis of fx fragment
Compromise blood supply
Excessive motion
Infection

4. CAUSES OF NONUNION:
1) General: age, nutrition, steroids, anticoagulants, radiation, burns, immunosupression -predisposure to nonunion
2)Diastasis of fx fragment
a. Soft tissue interposition
b. Distraction from traction or internal fixation
c. Malposition d. Loss of bone

5. 3)Compromised blood supply
a. Damage to nutrient vessels
b. Stripping or injury to periosteum & muscle
c. Free fragments; severe comminution
d. Avascularity due to internal fixation devices

6. 4) Excessive motion: inadequate immobilization
5) Infection
a) Bone death (sequestrum)
b) Osteolysis (Gap)
c) Loosening of implants (motion)

7. Goals prevent infection restore soft-tissue envelope
promote fracture healing
restore function

8. Classification Gustilo & Anderson JBJS 1976 Grade 1
Preliminary classification in ER
Definitive classification after I+D
Grade 1
< 1 cm
Low-energy injury
'Inside-out’

9. - Grade-II
1-10 cm
moderate energy/ contamination

10. - Grade-III >10 cm extensive soft- tissue disruption
major comminution/ contamination
high energy injury

11. Automatic Type III (?) High Velocity GSW Farmyard Injuries
Crush Injuries
Late presentations (>8h)

12. Grade-IIIA
good soft-tissue coverage

13. Grade-IIIB
flap coverage

14. Grade-IIIC
Neurologic or vascular injury that requires repair/amputation

15. Initial Treatment ATLS (ABC)
life-threatening injuries take precedence over limb- threatening injuries

16. Initial Treatment cover wound reduce/splint fracture
dry sterile dressing
avoid repeated evaluation (infection)
reduce/splint fracture
comfort
prevent further soft tissue damage

17. Infection Rates Type-I 0-2% Type-II 2-7% Type-III (overall) 10-25%
Type-IIIA 7%
Type-IIIB 10-25%
Type-IIIC 25-50%

18. Typical Organisms Type I, II, & IIIA Staph aureus 43% Type IIIB/IIIC
GNR 14%
Type IIIB/IIIC
Staph aureus 7%
GNR 67%

19. Antibiotic choice? Type-I, Type- II, IIIA
Ancef (cefazolin)
Type- II, IIIA
ancef + gentamicin
IIIB, IIIC Farm/sewage related injury
ancef + gentamicin + penicillin (clostridia)/flagyl

20. Tetanus Prophylaxis Farm/sewage injuries
Immunized within 5 Years - No Treatment
Immunized > 5 Years - Tetanus Toxoid
Status Unknown - Tetanus Toxoid & Tetanus IG

21. Irrigation & Debridement
the most important intervention
obtain deep cultures (reliable)
debridement
outside in (skin, subcut tissue, fascia, muscle, bone)
irrigate with 9L NS
repeat every 48 to 72 Hours
wound appears clean
devoid of non-viable tissue

22. Skin Debridement
excise margins
extend wound

23. Fascia fasciotomy for compartment syndrome
open fractures do not necessarily decompress compartment

24. Muscle Debridement dead muscle - major nidus for infection
reddish color
contracts
bleeds

25. Bone Debridement remove small-sized avascular segments
retain large cortical/articular segments
debride if infection develops

26. Why Stabilize Fractures?
inflammation/pain
respiratory complications
morbidity
increase mobility

27. Fracture Stabilization
Performed after irrigation and debridement
Nonoperative management (casting)
TYPE1 and 11 fractures or no role
hard to observe wound
Surgical Management
external fixation
ORIF with plates
intramedullary nailing

28. External Fixation Advantages Disadvantage good wound access
quickly applied
minimal soft tissue trauma
Disadvantage
pin loosening
soft tissue inflammation
infection

29. External Fixation Indications Type-IIIB Type-IIIC flaps
vascular repair

30. Plate & Screw Fixation Advantages anatomic reduction
rigid stabilization
early mobilization
Disadvantages
more extensive exposure
devascularization
minimized with submuscular plating

31. Intramedullary Fixation
Advantages
minimal soft tissue stripping
good wound access
good stability
Disadvantages
impairs endosteal circulation (reaming)
longer OR time

32. Wound Closure Operative wounds closed
Traumatic Wounds Left Open (VAC dressing)
Repeat debridements Q48-72h
wound clean
no remaining devitalized tissue

33. Summary (Open Fracture)
Dry sterile dressing
Reduce/splint fracture
Determine grade
Grade I – ancef
Grade II,IIIA – ancef/gent
massive contamination
Penicillin/flagyl
tetanus toxoid +/- IG
OR for I+D and fixation
9L NS
don’t close open wounds (use VAC)
return for repeat I+D and definitive coverage within 1 week

34. Case
30M leg bumper injury after being crushed between 2 cars

35. Case
30M leg bumper injury after being crushed between 2 cars

36. ER Management

37. ER Management ABC Complete orthopaedic exam Ignore the obvious
Head to toe
Inspect (open wounds, abrasions, ecchymosis)
Palpate all bony prominences (upper to lower extremities)
ROM extremities
Neurovascular
Check pulses in all 4 extremities

38. Never miss … Open book pelvic fracture rotational instability
vertical instability
AP pelvis
close down pelvic volume
traction pin
hemodynamic stability

39. Tie a sheet around greater trochanters (not abdomen)

40. Never miss… Spine fracture Logroll patient Palpate entire spine
Tenderness/stepoff
Neuro status
Perianal sensation, rectal tone
Fx/disloc with neurologic injury
Halo traction
Surgical decompression

41. ER Management Open distal femur/tibial plateau/tibial shaft fxs
No palpable DP/PT pulses in affected leg
angiogram (disruption above trifurcation)
dry sterile dressing
reduce bone fragments (traction)
splint
Grade IIIC
Ancef, gentamycin, penicillin, tetanus prophylaxis

42. OR Management OR
I+D (9L NS)
Spanning ex fix