1. OPEN (compound) FRACTURES Prof. M. Ngcelwane 2013 1

2. OBJECTIVES  MUST BE ABLE TO DIAGNOSE OPEN FRACTURES  RECOGNIZE THAT THERE MAY BE ASSOCIATED INJURIES  BE ABLE TO CLASSIFY OPEN FRACTURE  PRINCIPLES OF EARLY MANAGEMENT  DEFINITIVE MANAGEMENT  COMPLICATIONS 2

3. WHAT IS A FRACTURE 3

4. OPEN (COMPOUND) FRACTURE FRACTURE XR: A break in the continuity of bone Clinically: swollen, deformed, tender, loss of fx COMPOUND FRACTURE Fracture where there is a skin wound communicating with the fracture 4

5. Examples of open fractures 5

6. IMPORTANCE OF SOFT TISSUES  An open fracture is a severe soft tissue injury in which bone is also broken.  Extent of damage to soft tissue determine the prognosis 6

7. Gustilo and Anderson classification of open fractures I < 1cm clean wound, simple fracture pattern II > 1cm, no extensive soft tissue damage, no flaps/avulsion, simple fracture fracture III (A) Extensive wound, bone adequately covered. (B) Bone exposed, usually contaminated. (C) Arterial injury. NB 7

8. Causes  High energy trauma  Look for other injuries 8

9. Anatomic considerations  Commonest long bone open fracture is tibia  Most studied bone  Poor soft tissue cover  Cf. femur 9

10. CLINICAL APPROACH TO PATIENT WITH OPEN FRACTURE 1.Assess life threatening injuries ABC of resuscitation Physical and neurologic exam Emergency Surgery (decision) 2. Assess limb (a) Vasculature pulse doppler angiogram (b) Soft tissues Skin - site - bruising contamination muscles periosteum (c) Neurology Plantar skin sensation 3. Fracture patternXR NB 10

11. Neurovascular assessment (tibia) Vascular: - Dorsalis pedis - Posterior tibial Motor: - all compartments of the leg: toe flexures, toe dorsiflexors, ankle evertors, plantar flexors Sensory: - Tibial n: plantar surface of foot - Deep peroneal n: dorsal web space 1st and 2nd toe - Superficial peroneal n: dorsolateral - Saphenous n: medial REMEMBER - NOT POSSIBLE IN ALL PATIENTS 11 NB

12. Treatment  MAIN COMPLICATION OF OPEN FRACTURES IS INFECTION 12

13. Open Tibial Fractures AOpen Fractures: Challenges 1.Management of traumatic wound 2.Achieving bony stability 3.Decision making -limb salvage vs. amputation 4.Achieving soft tissue coverage 5.Achieving fracture union 13

14. PRINCIPLES OF TREATMENT B 1.Wound debridement 2.Antibiotic therapy 3.Bony stabilization 4.Wound coverage 5.Maintain vascularization 14 NB

15. Emergency Room Treatment C 1.Reduce and splint the limb 2.Document neurologic and vascular status 3.(Lavage wound) 4.Sterile compression dressing, do not open again 5.(photograph) 6.Start I/V antibiotics 7.Tetanus prophylaxis 8.X-ray evaluation 9.To surgery as soon as possible < 6 hours 15

16. IIIIIIAIIIB IIIC ***** *** ### INTRAVENOUS ANTIBIOTICS Cefazolin Aminoglycoside Penicillin Type open fracture # Soil contamination (clostridia) 16

17. MANAGEMENT Limb - specific treatment (a) debride/decontaminate No tornique Remove all dead tissue Save bone (b) Skeletal stabilization (c) Soft tissue cover (d) Bone reconstruction (e) Rehabilitation 17

18. Sepsis cannot occur if good bleeding tissue is present “The solution to pollution is dilution” 18

19. Principles of Debridement D. 1.Classification determined at time of debridement of future surgeries 2. Extend wound a.Visualise entire zone of injury and where hematoma traveled 3.Debride wound in a systematic way a.Skin edges subcutaneous muscle bone 4. Remove foreign material 5.Debride necrotic skin, fat, muscle, bone a.Skin: conservative b.Fat and fascia: radical 6.Prophylactic fasciotomy of compartment exposure 7.Muscle: debride non-viable tissue a.Color b.Consistency c.Contractility d.Capacity to bleed e. Response to hemostasis 19 NB

20. MUSCLE DEBRIDEMENT  Colour: red/brown  Consistency: feels like muscle/soft  Capillary circulation: does it bleed?  Contractility: does it contract with cautery or pinching 20

21. COVER EXPOSED 9aNeurovascular structures bTendon cBone dArticular surface 21

22. BONE STABILIZATION  EXTERNAL FIXATOR  Reason: be able to clean/dress wound; difficult to eradicate infection with internal fixation/plate 22 NB

23. COMPLICATIONS  Neurovascular  Compartment syndrome  INFECTION (prophylaxis NB!!)  Loss of limb 23 NB

24. Mangled Extremity Severity Score “MESS” Skeleton Soft Tissue Points Low energy, simple fx, low velocity GSW1 Medium, moderate comminution2 High energy (close range shot gun, etc)3 Massive crush 4 Shock Normotensive (SBP>90)0 Transient hypotension1 Persistent hypotension2 Ischemia None0 Decreased pulses1* No pulse, slow cap refill, paresthias2* Cool pulseless, insentiate3* Points double if ischemia > 6 hrs Age < 30 Yr0 30-501 >502 MESS > 6 Amputation 24 Not for studying purposes

25. MANAGEMENT 1.General supportive measures (a) cover wounds (b) fluid resuscitation/blood (c) Antibiotics - Cephosporin (2nd generation) 2.Limb - specific treatment (a) debride/decontaminate No tornique Remove all dead tissue Save bone (b) Skeletal stabilization (c) Soft tissue cover (d) Bone reconstruction (e) Rehabilitation 25

26. End Thank you 26