General principles of fractures IV

More correctly 'restore function' - not only to the injured part but also to the patient as a whole. The objectives are to reduce oedema, preserve joint movement, restore muscle power and guide the patient back to normal activity.

Exercise

Prevention of oedema swelling is almost inevitable after a fracture and may cause skin stretching and blisters. Persistent oedema is an important cause of joint stiffness, especially in the hand; it should be prevented if possible, and treated if it is already present, by a combination of elevation and exercise.

Exercise

Not every patient needs admission to hospital, and less severe injuries of the upper limb are successfully managed by placing the arm in a sling: but it is then essential to insist on active use, with movement of all the joints that are free. With most closed fractures, all open fractures and all fractures treated by internal fixation it must be assumed that swelling will occur: the limb should be elevated and active exercises begun as soon as the patient will tolerate this.

Exercise

Elevation an injured limb usually needs to be elevated; after reduction of a leg fracture the foot of the bed is raised and exercises are begun. If the leg is in plaster the limb must, at first be dependent for only short periods.

Exercise

Active exercise Active movement helps to pump away oedema fluid, stimulates the circulation, prevents soft-tissue adhesion and promotes fracture healing. A limb encased in plaster is still capable of static muscle contraction and the patient should be taught how to do this. When splintage is removed the joints are mobilized and muscle-building exercises are steadily increased.

Exercise

Assisted movement passive movement should avoided because it might lead to myositis ossificans especially with injuries around the elbow. Certainly forced movement should not be permitted but gentle assistance during active exercises may help to retain function or regain movement after fractures.

Exercise

General consideration

Many patients with open fractures have multiple injuries and severe shock; for them appropriate treatment at the scene of the accident is essential. The wound should be covered with a sterile dressing or clean material and left undisturbed until the patient reaches the accident department.

Open fractures

In hospital a rapid general assessment is the first step, and any life- threatening conditions are addressed. The wound is then inspected; ideally it should be photographed, so that it can again be covered and left undisturbed until the patient is in the operating theatre.

Open fractures

Four questions need to be answered:(1) What is the nature of the wound?

(2) What is the state of the skin around the wound?

(3) Is the circulation satisfactory?

(4) Are the nerves intact?

Open fractures

All open fractures, no matter how trivial they may seem, must be assumed to be contaminated; it is important to try to prevent them from becoming infected. To this end the four essentials are:

(l) Immediate wound cover

(2) Antibiotics prophylaxis;

(3) Early wound debridement; and

(4) Stabilization of the fracture.

Open fractures

Classification

Gustilo’s classification of open fracture 1990

Type I The wound is usually a small, clean puncture through which a bone spike has protruded. There is little soft-tissue damage with no crushing and the fracture is not comminuted.

Open fractures

Type II The wound is more than 1 cm long, but there is no skin flap. There is not much soft- tissue damage, and no more than moderate crushing or comminution of the fracture.

Open fractures

Type III There is extensive damage to skin, soft tissue and neurovascular structures, with considerable contamination of the wound. There are three grades of severity

Type IIIA the fractured bone can be adequately covered by soft tissue.

Open fractures

Type IIIB there is also periosteal stripping, as well as' severe comminution of the fracture;

Open fractures

Type III C if there is an arterial injury which needs to be repaired, regardless of the amount of other soft-tissue damage. High-velocity injuries are classified as IIIB or C; although the wound is small, internal damage is severe.

Open fractures

The incidence of wound infection correlates directly with the extent of soft-tissue damage, rising from less than 2% in type I to over 10% in type II fractures.

Open fractures

Early management

The wound should be kept covered until the patient reaches the operating theatre. Antibiotics are given as soon as possible. no matter how small the laceration and are continued until the danger of infection has passed. In most cases a combination of benzyl penicillin and flucloxacillin given 6 hourly for 48 hours will suffice;

Open fractures

if the wound is heavily contaminated, it is prudent to cover also for Gram- negative organisms by adding gentamicin or metronidazole and to continue treatment for 4 or 5 days. Tetanus prophylaxis is equally important: toxoid for those previously immunized, human antiserum if not.

Open fractures

Debridement

The operation aims to render the wound devoid of foreign material and of dead tissue, leaving a good blood supply throughout. Under general anesthesia the patient’s clothing is removed, while an assistant maintains traction on the injured limb and holds it still.

Open fractures

The dressing previously applied to the wound is replaced by a sterile pad and the surrounding skin is cleaned and shaved. The pad is then taken off and the wound is irrigated thoroughly with copious amounts of physiological saline; the final irrigation may be with an antibacterial agent such as bacitracin.

Open fractures

A tourniquet is not used because it would endanger the circulation still further and make it difficult to recognize which structures are devitalized. The tissues are then dealt with as follows.

Open fractures

Skin Only small strip from the skin edge is excised from the wound (much skin as possible is spared). The wound often needs to be extended by planned incisions to obtain adequate exposure: .once it is enlarged clothing and other foreign material may be picked out.

Open fractures

Fascia is divided extensively so that the circulation is not impeded.

Muscle Dead muscle is dangerous; it provides food for bacteria. It can usually be recognized by its purplish discoloration. Its mushy consistency, its failure to contract when stimulated and its failure to bleed when cut. All dead and doubtfully viable muscle is excised.

Open fractures

Blood vessels large bleeding vessels are tied meticulously.

Nerves it is usual best to leave a cut nerve undisturbed. It should be left for secondary suture.

Tendons as a rule, cut tendon also should left for secondary suture

Open fractures

Bone the fracture surfaces are gently cleaned and replaced in the correct position. Bone like skin, should be spared and fragments removed only if they are small and totally detached.

Open fractures

Joint Open joint injury are best treated by wound toilet, closure of synovium and capsule and systemic antibiotics; drainage or suction irrigation is used only if contamination is severe.

Open fractures

Wound closure

To close or not to close the skin - this can be a difficult decision. A small, uncontaminated type I wound, operated on within a few hours of injury may after debridement, be sutured (provided this can be done without tension) or skin grafted. All other wounds must be left open until the dangers of tension and infection have passed. The wound is packed with sterile gauze and is inspected after 5 days: if it is clean, it is sutured or skin grafted (delayed primary closure).

Open fractures

Stabilization of the fracture

It is now recognized that stability of the fracture is important in reducing the likelihood of infection. For type I or small type II wound with a stable fracture a widely split plaster is permissible or, for the femur, traction on a splint but more severe wounds (and gunshot wounds) need to have the fracture fixed more securely.

Open fractures

The safest method is external fixation. Intramedullary nailing (with locking if the fracture is comminuted) can be used for the femur or tibia. Plates and screws can be used for metaphyseal or articular fractures, but only if the surgeon is experienced in their use and the circumstances are ideal.

 

Open fractures