Debridement in Open Fracture Aditya

8/6/2019 Debridement in Open Fracture Aditya

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OPEN FRACTURES DEBRIDEMENT


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Open fracture

osseous disruption in which a break in the

skin and underlying soft tissue communicates

directly with the fracture and its hematoma Surgical Emergencies


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ClassificationGustilloGustillo Anderson (1976)Anderson (1976)

Type 1

The wound is < 1 cm long.

It is usually a moderately clean puncture throughwhich a spike of bone pierces the skin.

There is little soft tissue damage and no sign ofcrushing injury.

The fracture is usually simple, transverse, or shortoblique with minimal comminution.


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ClassificationGustilloGustillo Anderson (1976)Anderson (1976)

Type 3

It is characterized by extensive soft-tissue

damage to the muscles, skin, and neurovascularstructures.

There is high degree of contamination.

It is often the result of high velocity injury;

considerable comminution and instability arecommonly seen.


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ClassificationGustilloGustillo MendozaMendoza Williams (1984)Williams (1984)

Type 3A

There is adequate soft tissue coverage of the fractured bonedespite extensive laceration, flaps, or other trauma.

It includes segmental or severely comminuted fractures from

high-energy trauma, regardless of the size of the wound. Type 3B

There are extensive soft tissue injury or loss with periostealstripping and bone exposure, massive contamination, andsevere fracture comminution from high-velocity injury.

Since there is exposed bone segment, it usually requires localflaps or free flaps for coverage.

Type 3C

It is associated with arterial injury requiring repair, regardless

of the degree of soft tissue injury.


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Classification


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EVALUATION

Mechanism of injury

Open fractures result from the application of aviolent force.The applied kinetic energy (0.5 mv2)is dissipated by the soft tissue and osseous

structures Contamination of the wound and fracture by

exposure to the external environment

Time of injury

The patient's tetanus immun status


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Treatment

Pre-hospital

Pressure over the wound

Splinting of fractures Placement of sterile dressings

Rapid transport to appropriate medical center


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TREATMENT

Emergency DepartmentManagement After initial trauma survey and resuscitation for life-

threatening injuries : Foreign bodies or obvious debris, such as leaves, stones, or

grass, found in open wounds that can be easily removedshould be manually removed with sterile forceps.

irrigate the wound with 1 to 2 L of saline fluid (*)

Wound hemorrhage should be addressed with directpressure rather than limb tourniquets or blind clamping

Cover the wound with a sterile bandage

Perform provisional reduction of fracture and place a splint

X ray or other exam.

Parenteral Antibiotics

Tetanus Prophylaxis


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Treatment Debridement and Irrigation

The objectives of debridement (andirrigation) are as follows: Extension of the traumatized wound to allow

identification of the zone of injury.

Detection and removal of foreign material,especially organic foreign material.

Detection and removal of nonviable tissues.

Reduction of bacterial contamination.

Creation of a wound that can tolerate the residualbacterial contamination and heal withoutinfection.


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technique

Adequate personal protection splash guards,goggles, boots, gloves

Prepare the patient and the skin

Apply a sterile torniquet, but do not inflate Wash and drape the wound, allow a wide exposure

of the involved area

The wound should be extended proximally anddistally to examine the zone of injury

Debridement of tissue begin at the skin and proceedin an orderly fashion

Remove devitalized skin until bleeding is visible inthe skin edge


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An elliptical excision ofthe fracture woundpermits properinspection of the areaof injury as well asbetter closure if thewound is sutured


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M

ethods for extending atraumatic transverse oroblique wound.

A.The Z-plasty techniqueproduces two large flaps, andrisks necrosis of the tips of

the flaps. B,C. Both of these methods

also produce large skin flapsthat risk necrosis of the distalportion of the flap.

D. Incision bisecting the

wound results in the smallestflaps.This reduces the risk offlap necrosis and is thepreferred incision in mostinstances


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technique

Remove the subcutaneous tissue, including

all contaminated tissue

Remove devitalized fat beneath the flapsdown to clean, bleeding, subcutaneous tissue

Open the fascia to allow exposure of the

muscle tendon

Removal of all devitalized muscle,


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technique

Trim completely severed tendons back to

viable tendon

Intact tendons cleaned and not excised Remove devascularized bone

Remove contamination in the medullary

canal by progressively removing bone with asaw or rongeur

Avoid curettage of the medullary canal


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Technique

Irrigate with normal saline

A number of irrigation additives have been examinedconcurrent to the focus on method of irrigationdelivery. Antisep tics investigated include hydrogenperoxide, povidone-iodine, chlorhexidine, and variousalcohol solutions . These agents inhibit pathogens bydamaging cell walls. Host toxicity through this samemechanism, to include impaired osteoblast function,has been demonstrated as well

The benefit of adding antibiotics to irrigation solutions hasnot been fully demonstrated either. Rosenstein et al (79)noted a decrease in positive cultures following instillationof bacitracin P.405


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Irrigation variables

Variable Effect Recommendation

Volume Increasing volume removes more particulatematter and bacteria, but the effect plateaus at

a level dependent of the system

Grade 1, 3 LGrade 2, 6 L

Grade 3, 9 L

P

ressureI

ncreased pressure removes more debris andbacteria; the highest pressure settings damage

bone, delay fracture healing, and may increaserisk of infection by damaging soft tissues

Use a power irrigationsystem that provides a

variety of settings, select alow or middle range setting

Pulsation In theory, improves removal of surface debrisby means of tissue elasticity

Not established

Anglen JO. Wound irrigation in musculoskeletal injury.

J Am Acad Orthop Surg 9:219, 2001


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Suture the surgically created wound first

Loosely close the remaining wound over adrain ifnecessary

If closure is not possible, leave open Keep structures such as bone, nerve, and tendon

moist

Prepare and drape again, discard all instruments,change operating gowns and gloves before applying

internal or external fixation Serial debridement(s) should be performed every 24

to 48 hours as necessary until there is no evidence ofnecrotic soft tissue or bone.


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Complication

Infection: Open fractures may result in cellulitisor osteomyelitis, despite aggressive, serial

debridements, copious lavage, appropriateantibiosis, and meticulous wound care.

Compartment syndrome:This devastating

complication results in severe loss of function,

especially in tight fascial compartments

including the forearm and leg. It may be avoidedby a high index of suspicion with serial

neurovascular examinations


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Thank you


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Case


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Mr. Ade Rizky M/ 21 Y.O

Chief complaint : pain on his left leg HOI : 9 hour before admission, the patient was

riding a motorcycle. When he was going to stop,suddenly a car right behind him crashed him.

Patient fell out from motorcycle with unknownmechanism, unconscious (-), Helmet (+). Afterthe accident patient felt pain on his left thighand leg and couldnt move it. Patient also feltpain on his right upper arm. active bleeding(+)

on left leg.Vomiting (-). Patient got transferedto a nearby clinic, then was transfered to CMHospital.


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Primary Survey

A: Clear

B: spontaneous, RR 18x/mnt,

C: Warm, PR 100x/mnt BP130/70

D: GCS 15


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GeneralCondition

Head : normal

Neck: swelling (-), deformity (-), pain (-)

Eyes: pale conjunctiva -/-,

Lungs: symetrical, vesicular, rhales -/-, wheezing -/- Heart: normal hearts sounds, murmurs (-), gallop (-)

Abdomen: no bulging at the lower abdomen, tender,

normal bowel sound

Pelvis: no deformity

Extremity: local state


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Local StateCruris Sinistra

Look:Deformity: Angulation (-),shortening -

Swelling (-); open wound (+),

in poplitea 10x 3 x3 cm ,base subcuticular. And inmid cruris anterior 5x 3x3,base subcuticular.

Feel:

tenderness (+), a dorsalispedis -, a tibialis post -, apoplitea -.

Move:

not performed


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Laboratorium

Laboratorium (5 Januari 2010) :

CBC: HB: 9,9; Ht : 30,9; Lekosit : 10.150;Trombosit:403.000

SGOT/SGPT : 71/46

Ur/Cr : 17/0,40

Na/K/Cl : 131/4,04/92,6

GDS: 123 PT: 12,0/12,3

APTT: 38,6/31,6


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DIAGNOSIS

MultipleTrauma Closed Fracture Right Humerus + Post U-Slab + Suspect

Right Radialis Nerve Injury

Closed Fracture Left Femur

Open Fracture LeftTibia-Fibula Gr. IIIC Rupture Left A.V. Femoralis + Post Repair


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Debridement in Open Fracture Aditya

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