Open Fractures Management and Classification

Presented by Dr Atif LabbanSupervised by Dr M.Abbas

DEFINITION: An open fracture is one in which a break in the skin and underlying soft tissues leads directly into or communicates with the fracture and its hematoma.

Gustilo Open Fx ClassJBJS, 72A: 299-303, 1990

2%

7%

7%10-50%25-50%

Open Fractures

Type II Type IIIA

Type IIIB Type IIIB

Negative Biology of Open Fx

ContaminationCrushingStripping

DevascularizationComminution

Type I wound

is caused by a low-energy injury that is usually less than 1 cm long . It is usually caused by the bone piercing from the inside outward rather than by a penetrating injury.

Type II wound

is greater than 1 cm in length and has a moderate amount of soft tissue damage owing to a higher-energy injury . These are usually outside-to-inside injuries.

Type III wound

a high-energy, outside-to-inside injury and is usually longer than 10 cm with extensive muscle devitalization.

Extensive wound contamination also increases the likelihood of infection and subsequent complications.

A type IIIA open fracture

There is limited stripping of the periosteum and

soft tissues from bone .There may be loss of skin, There is adequate muscle and soft tissue coverage over bone

A type IIIB open fracture

there is extensive stripping of soft tissues and periosteum from bone. Devitalization or loss of soft tissues usually requires a local flap or free tissue transfer for coverage of exposed bone.

A type IIIC open fracture

is one in which there is a major vascular injury requiring repair for salvage of the extremity. A tibia fracture with disruption of the anterior tibial artery but preservation of the posterior tibial artery is not a type IIIC

injury.

MANAGEMENT OF OPEN FRACTURESGoals of management:

Early return to the function avoid complications

ER management: OR management:Assesment I&DReduction&splinting SK. Stabilization

Wound care Wound managmentTetanous prophylaxisAntibiotics

EXAMINATION OF THE WOUND AND INITIAL EMERGENCY MANAGEMENT

START BY APPLYING THE PRINCIPLES OF ATLS

Tetanus ToxoidTetanus Toxoid 2.5 cc to all poly-trauma patients, otherwise:

IMMUNIZATION HISTORY

NON-TETANUS

PRONE

TETANUS PRONE*

UNKNOWN YES YES

>3 IMMUNIZATIONS<(5 YEARS)

NO NO

*Tetanus Prone: >6 hours old, complex soft tissue injury, wound >1 cm deep, missile, crush, burn, frostbite, devitalized tissues, soil contaminants, denervated, ischemic, early infection.

Tetanus Immune Globulin250-500 units IM:

IMMUNIZATION HISTORY

NON-TETANUS

PRONE

TETANUS PRONE*

UNKNOWN NO YES

>3 IMMUNIZATIONS

<(5 YEARS)

NO NO

ANTIBIOTICSIs therapeutic not prophylactic.

role :kill residual organisms ,inhibit their growth to the point where host protective mechanisms can eradicate them .

Irrigation and debridement :most important measures in preventing infection in open #,antibiotics certainly cannot be relied on to prevent infection in an inadequately debrided

wound. Early administration of antibiotics during initial phases of within 3 hrs of injury decreases incidence of infection in open fracturescommon organism :Staphylococcus aureus

Duration :48 to 72 hours after initial and any subsequent debridements, & after wound closure, bone graft & major surgical procedure

1 Gen Ceph Gent PCNGrade I (G+ve)

Grade II (G+ve

Grade III (G+ve&

-ve) -/+

Farm & Ischemic Wounds

(anaerobic)

Recommended Antibiotic Treatment

Local Antibiotics• Numerous antibiotics can be

incorporated in polymethylmethacrylate (PMMA) without losing their bactericidal activity.

• Should prepared by surgeon• Useful for type II & III

1)Decrease infection rates2)High local antibiotic

levels(10-20times)3)Useful for dead space

management4)Decrease systemic effect of IV

antibiotics

PREPARATION FOR SURGICAL DEBRIDEMENT

All open fractures need to be formally treated in operating room on an urgent basis with meticulous irrigation&debridement.

A 2-phase surgical preparation of the limb may be advisable for severely contaminated wounds

IRRIGATION AND DEBRIDEMENT

“The solution to pollution is dilution.”

The more important is copious irrigation of the wound

advantages of irrigation

1) Clear blood and other debris for inspection.2)Lavage floats contaminated blood clots ,

loose tissue , debris from unseen places .3)Lavage of tissue restores its normal color

and facilitates determination of viability .4) reduces the bacterial population .