Open Fractures

Open Fractures Principles of Management

Prof. Mamoun Kremli

Objectives

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

Definition of Open Fracture

• A fracture where the skin coverage overlying the fracture is breached even if a small puncture wound
  • (Another name: Compound fracture)
  • All open fractures, no matter how trivial they seem, must be assumed to be contaminated

Causes (Types) of Injury

• Assault & firearms: severe
• Crushing under heavy object falling. More soft tissue damage
• Fall: height is important
• Road traffic accident (RTA): severe: Car (MVA), motorcycle, pedestrian
• Sport: stronger impact

Mechanism of Injury

Determine if Injury was Caused By:

• Crushing under objects
• Low velocity / High velocity

Penetrating Missiles

• Low velocity < 300 m/s -
  • Damage along the tract
  • Comminution
• High velocity: >300m/s -
  • Wide soft tissue damage & sever comminution
  • Some fragment inside
  • Some flip inside
  • Vacuum phenomena - cavitation

Field of Injury

• Relatively clean
• Contaminated soil

Open Injury From:

• In-out: usually cleaner
• Out-in: more contamination and dirt

Signs of High Energy Injury

• Extensive de-gloving
• Compartment syndrome
• Crush syndrome
• Bone loss
• Segmental fracture

Examples

Low Energy vs. High Energy

Low Energy	High Energy

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

Higher Infection Rate

• More contamination if:
  • Delay > 12 hours
  • Exposure to fecal material
  • Exposure to oral material
  • Exposure to soil or water
  • Animal bites

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

Management of Open Fractures

• Initial management
• Classifying the injury
• Definitive treatment

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!
  • (ABC) ATLS protocol
  • Exclude shock and brain injury
  • Vital signs
    • must be observed and followed up

Approach - Clinical Exam

• Examination of the viscera

  • Rib fractures: Injuries to lungs, liver, spleen
  • Pelvic fractures: Injury to urinary bladder, urethra
  • Head and spinal injury: Neurological examination

• Look:

  • Special attention is to be paid to wounds

• Feel:

  • Sensory /motor deficits
  • Pulse distal to injury
  • Tense Compartment syndrome

• Move:

  • With care, if necessary! (should splint first)

• When the fracture is ready to be dealt with:
  • Inspect the wound
  • Remove gross contamination
  • Photograph the wound
  • Cover with a saline-soaked dressing
  • Check limb circulation & distal neurological status
  • Splint

Principles of Treatment

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

Primary Surgical Debridement

Demands meticulous excision of all dead and devitalized tissues

• Remove all foreign material
• Trim skin edges
• Remove all dead muscles & lacerated tissues & fully detached small bone pieces
• Preserve N/V !
• Saline wash: 3-6-9 Liters (wash–wash–wash)

Primary Surgery - Debridement

“Dilution is the Solution to Pollution”

Alois Karlbauer

Wound Closure / Bone Fixation

• Both depend on extent of soft tissue damage and contamination
  • Primary skin closure and internal fixation
    • In small wounds / good soft tissue condition / minimal contamination
  • Delayed secondary closure / External fixation
    • In larger wounds / bad soft tissue condition / more contamination

Summary

• Definition of open fracture
• Important points in history of an open fracture
• Example of types of energy in open fractures
• Management:
  • Importance of early surgical debridement
  • Soft tissue management
  • Bone treatment initial & definitive