1. Prof. Mamoun Kremli AlMaarefa Medical College Open Fractures Principles of Management

2. Historical fact … until WW I Treatment of open fractures was “Amputation” Mortality rate ~ 75% Function in “survivors” was poor Alois Karlbauer

3. Objectives Definition of an open fracture Important points in history of an open fracture Classification Management: Initial treatment Importance of surgical debridement Bone treatment initial & definitive Soft tissue coverage Factors affecting outcome

4. Definition Open fracture is a fracture where the skin coverage overlying is breached even a small puncture wound Another name: compound fracture www.merryshannon.com

5. History in open fractures Mechanism of injury Date, time, type, method of impact, … Consciousness Size of wound Amount of bleeding Other injuries: often missed Anti-Tetanus status

6. Type of injury Determines amount of energy and Extent of soft tissue injury

7. Type of injury Fall: height is important Sport: stronger impact Heavy object falling: direct injury – soft tissue Road traffic accident (RTA): more severe Car (MVA), motorcycle, pedestrian Assault & firearms: severe

8. Mechanism of Injury Try to determine if injury was caused by: Low velocity High velocity Crushing under objects

9. Mechanism of Injury Field of injury: Relatively clean Contaminated soil

10. Mechanism of Injury Open injury from: In-out: usually cleaner Out-in: usually more contamination and dirt www.aofoundation.org

11. Mechanism of Injury Penetrating Missiles Low velocity < 300 m/s - damage along the tract Comminution High velocity: >300m/s - sever comminution Comminution with wide soft tissue damage Some fragment inside Some flip inside Vacuum phenomena - cavitation

12. Signs of high energy injury Segmental fracture Bone loss Compartment syndrome Crush syndrome Extensive de-gloving

13. A. Karlbauer Examples Low energy High energy

14. Approach – clinical exam General medical condition should be evaluated to exclude shock and brain injury Vital signs should be observed and followed up Look: special attention is to be paid to wounds

15. Approach – clinical exam Feel: Sensory and motor deficits Pulse distal to injury Compartment syndrome Tense compartment Move: With care, if necessary! www.medicinabih.info

16. Approach – clinical exam Examination of the viscera Rib fractures Lung, liver and spleen Pelvic fractures Urinary bladder and urethra Head and spinal injury Neurological examination

17. Management of open fractures Initial management Classifying the injury Definitive treatment

18. Initial management it is essential that the step-by-step approach in advanced trauma life support not be forgotten Treat the patient, not the fracture! (A B C)

19. Initial management it is essential that the step-by-step approach in advanced trauma life support not be forgotten When the fracture is ready to be dealt with: The wound is carefully inspected Any gross contamination is removed The wound is photographed The area then covered with a saline-soaked dressing The patient is given antibiotics Tetanus prophylaxis is administered The limb circulation and distal neurological status checked repeatedly

20. Grades of open fracture Important to grade severity of open injuries and soft tissue injuries To treat according to guidelines To have an idea about prognosis Several classifications Most widely used: Gustilo Classification

21. Gustilo Classification Grade 1: Low-energy, minimal soft-tissue damage (wound < 1cm) Grade 2: Higher energy, no flaps needed / no crushing Moderate contamination (wound > 1cm) Grade 3: High-energy, flaps needed / crushing Significant contamination.

22. Gustilo Classification Sub-Types of Grade III: Type 3A : Adequate soft-tissue cover Can cover skin primarily Type 3B: Inadequate cover Can not cover skin primarily May need skin graft or flap Type 3C: Vascular injury Requires vascular repair

23. Gustilo Grade I Low energy Simple fracture Skin open by fragment pressure within – out Wound < 1 cm No / little contamination www.orthopaedicsone.com/

24. Gustilo Grade II Higher energy Laceration > 1 cm No flap / No contusion Minimal contamination

25. Gustilo Grade IIIA High-energy, Adequate soft-tissue cover Contamination Comminution or segmental fracture

26. Gustilo Grade IIIB High-energy, Extensive soft-tissue stripping Inadequate cover, Massive contamination

27. Gustilo Grade IIIA or IIIB An intra-operative decision

28. Gustilo Grade IIIA or IIIB ? Adequate soft tissue coverage

29. Gastilo Grade? IIIC

30. Problem of open fractures Infection – skin is breached Primary: from the field Massive contamination Debris and foreign bodies Devitalized tissues Secondary infection after internal fixation Initial bacterial contamination Proper debridement not done Internal fixation is a foreign body

31. Principles of treatment All open fractures, no matter how trivial they may seem, must be assumed to be contaminated The basic guidelines: Antibiotic prophylaxis Urgent and proper wound and fracture debridement Stabilization of the fracture – ? External Fixation Early definitive wound cover

32. Primary surgery The aims of primary surgery are: Preservation of life and limb Definitive injury assessment Staged wound debridement May need to repeat after 48-72 hours Fracture stabilization

33. Primary surgery – Debridement Trim skin edges Remove foreign material Remove all dead muscles and lacerated tissues Remove fully detached small bone pieces Saline wash: 5 Liters (wash–wash–wash) ? Delayed secondary closure

34. Primary surgery – Debridement www.us.elsevierhealth.comwww.us.elsevierhealth.com / Principles of Fracture Treatment

35. Alois Karlbauer

39. “The solution to pollution is Dilution” Alois Karlbauer

40. Surgical Debridement Surgical debridement demands meticulous excision of all dead and devitalized tissues Start from outside working inwards: Skin Fat Muscle Bone Neurovascular Alois Karlbauer Leaving dead tissue invites infection

41. Treatment guidelines Gustilo I and II: Can treat by primary internal fixation Rate of infection low – if follow guidelines Alois Karlbauer

42. Treatment guidelines Gustilo IIIA Usually defer internal fixation until soft tissue condition allows Gustilo IIIB External fixation Later, internal fixation Gustilo IIIC Vascular repair is a priority External fixator

43. Higher infection rate Increased contamination: Exposure to soil Exposure to water Exposure to fecal material Exposure to oral material Gross contamination Delay > 12 hours

44. Case example - 1 26y male, motorbike accident, stable Gustilo Type? Management: Swab taken Antibiotics, anti- tetanus Debridement, skin closure External fixator Later on, Intramedullary nail Tadashi Tanaka, Chiba, Japan IIIA / IIIB

45. Case example - 1 Tadashi Tanaka, Chiba, Japan

46. Case example - 2 32y old, sever car accident, hit by a truck on bridge and car fell into canal

47. Case example - 2 Sever contamination, commination, and crushing Un-salvaged after several attempts

48. Summary Definition of open fracture Important points in history of an open fracture Gustilo classification Management: Importance of early surgical debridement Bone treatment initial & definitive Soft tissue coverage