OPEN FRACTURES DEBRIDEMENT

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

Classification
Gustillo Anderson (1976)

 Type 1
The wound is < 1 cm long. It is usually a moderately clean puncture through which a spike of bone pierces the skin. There is little soft tissue damage and no sign of crushing injury. The fracture is usually simple, transverse, or short oblique with minimal comminution.

Classification
Gustillo Anderson (1976)

 Type 2
The wound is > 1 cm long. It has no flaps, avulsions, or extensive soft tissue damage. There is a minimal to moderate degree of crushing injury and moderate fracture comminution. There is moderate contamination.

Classification
Gustillo Anderson (1976)

 Type 3
It is characterized by extensive soft-tissue damage to the muscles, skin, and neurovascular structures. There is high degree of contamination. It is often the result of high velocity injury; considerable comminution and instability are commonly seen.

Classification
Gustillo Mendoza Williams (1984) Type 3A
There is adequate soft tissue coverage of the fractured bone despite 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 periosteal stripping and bone exposure, massive contamination, and severe fracture comminution from high-velocity injury. Since there is exposed bone segment, it usually requires local flaps or free flaps for coverage.

Type 3C
It is associated with arterial injury requiring repair, regardless of the degree of soft tissue injury.

Classification

EVALUATION
 Mechanism of injury
Open fractures result from the application of a violent 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

Treatment
 Pre-hospital
Pressure over the wound Splinting of fractures Placement of sterile dressings Rapid transport to appropriate medical center

TREATMENT
 Emergency Department Management  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 removed should be manually removed with sterile forceps. irrigate the wound with 1 to 2 L of saline fluid (*) Wound hemorrhage should be addressed with direct pressure 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

Treatment
 Debridement and Irrigation  The objectives of debridement (and

irrigation) 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 residual bacterial contamination and heal without infection.

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 and distally to examine the zone of injury Debridement of tissue begin at the skin and proceed in an orderly fashion Remove devitalized skin until bleeding is visible in the skin edge

An elliptical excision of the fracture wound permits proper inspection of the area of injury as well as better closure if the wound is sutured

 Methods for extending a

traumatic transverse or oblique wound.  A. The Z-plasty technique produces two large flaps, and risks necrosis of the tips of the flaps.  B,C. Both of these methods also produce large skin flaps that risk necrosis of the distal portion of the flap.  D. Incision bisecting the wound results in the smallest flaps. This reduces the risk of flap necrosis and is the preferred incision in most instances

technique
 Remove the subcutaneous tissue, including

all contaminated tissue  Remove devitalized fat beneath the flaps down to clean, bleeding, subcutaneous tissue  Open the fascia to allow exposure of the muscle tendon  Removal of all devitalized muscle,

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 a saw or rongeur Avoid curettage of the medullary canal

Technique
 Irrigate with normal saline  A number of irrigation additives have been examined

concurrent to the focus on method of irrigation delivery. Antisep tics investigated include hydrogen peroxide, povidone-iodine, chlorhexidine, and various alcohol solutions . These agents inhibit pathogens by damaging cell walls. Host toxicity through this same mechanism, to include impaired osteoblast function, has been demonstrated as well

 The benefit of adding antibiotics to irrigation solutions has

not been fully demonstrated either. Rosenstein et al (79) noted a decrease in positive cultures following instillation of bacitracin P.405

Irrigation variables
Variable Volume Effect Increasing volume removes more particulate matter and bacteria, but the effect plateaus at a level dependent of the system Increased pressure removes more debris and bacteria; the highest pressure settings damage bone, delay fracture healing, and may increase risk of infection by damaging soft tissues In theory, improves removal of surface debris by means of tissue elasticity Recommendation Grade 1, 3 L Grade 2, 6 L Grade 3, 9 L Use a power irrigation system that provides a variety of settings, select a low or middle range setting Not established

Pressure

Pulsation

Anglen JO. Wound irrigation in musculoskeletal injury. J Am Acad Orthop Surg 9:219, 2001

 Suture the surgically created wound first  Loosely close the remaining wound over adrain if    

necessary 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 of necrotic soft tissue or bone.

Complication
 Infection: Open fractures may result in cellulitis

or osteomyelitis, despite aggressive, serial debridements, copious lavage, appropriate antibiosis, 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 avoided by a high index of suspicion with serial neurovascular examinations

Thank you

Case

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 unknown mechanism, unconscious (-), Helmet (+). After the accident patient felt pain on his left thigh and leg and couldnt move it. Patient also felt pain on his right upper arm. active bleeding(+) on left leg. Vomiting (-). Patient got transfered to a nearby clinic, then was transfered to CM Hospital.

 Primary Survey
A: Clear B: spontaneous, RR 18x/mnt, C: Warm, PR 100x/mnt BP130/70 D: GCS 15

General Condition
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
     

Local State
Cruris Sinistra  Look: Deformity: Angulation (-), shortening Swelling (-); open wound (+), in poplitea 10x 3 x3 cm , base subcuticular. And in mid cruris anterior 5x 3x3, base subcuticular.  Feel: tenderness (+), a dorsalis pedis -, a tibialis post -, a poplitea -.  Move: not performed

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

DIAGNOSIS
 Multiple Trauma  Closed Fracture Right Humerus + Post U-Slab + Suspect

Right Radialis Nerve Injury  Closed Fracture Left Femur  Open Fracture Left Tibia-Fibula Gr. IIIC  Rupture Left A. V. Femoralis + Post Repair