Management of Open Fractures
Open Fracture
Definition
Communication of bone with the exterior
Open Fractures
Is an emergency in orthopaedics
Associated with multiple injuries
Significant morbidity
Open fractures:
Classification
Gustilo & Anderson
Grade I
Grade II
Grade III - III A
III B
III C
Grade I open fracture
Low velocity injury
Small puncture wound
Minimal soft tissue trauma
Prognosis is similar to a closed fracture
Grade I open fracture
Grade II open fracture
Moderate velocity injury
1 - 5 cm wound ( only a guide )
Moderate soft tissue injury
Grade II open fracture
Grade III open fracture
High velocity injury
Soft tissue damage extensive
May need secondary skin cover
Grade III A open fracture
Large wound
Bone comminution & Contamination
Skin graft usually possible because
periosteum is often not disrupted
Grade III B open fracture
Large wound
Bone comminution & contamination
Skin graft alone often not adequate
Local & free flaps necessary
Secondary bone procedures
Grade III A open fracture
Grade III C open fracture
Large wound with significant skin
disruption
Loss of bone & soft tissue
Significant bone comminution &
contamination
NEUROVASCULAR injury is present
Grade III C open fracture
Infection in open fractures
Grade I
less than 1%
Grade II
1-10 %
Grade III
10-50%
Principles of management
General
Recognise an open fracture
General survey ABCs
Intravenous line & Fluids
Pain relief & analgesia
Cover the wound with moist gauze
Temporary immobilzation & splinting
Principles of management
General
Intravenous broad spectrum antibiotic
Appropriate X-rays
Blood for GXM, FBC, U/E, CXR, ECG
Instruction for no oral intake
Arrange for emergency operation
Angiogram if indicated
Obtain informed consent for surgery
Principles of management
Specific
General anaesthesia
Apply the torniquet (use with caution)
Irrigate the wound with saline or
chlorhexidine
Mechanical cleansing with a soft brush
Surgical preparation & draping
Principles of management
Specific
Wound debridement - skin
subcutaneous fat
fascia
muscle & tendon
bone
blood vessels & nerves left intact
Debridement
Remove all devitalised tissue, including
bone
Necrotic tissue increases the incidence
of complication especially infection
Principles of management
Specific
Assess vascularity of tissue
Stabilization of the fracture
Stabilization of the fracture
Stability is important for healing of bone
& soft tissue
External fixator commonly used
Other implants
- plates
intramedullary nails
Principles of management
Wound coverage - never close the
wound
primarily in open
fractures
Only exception is open joint injuries
Principles of management
Wound coverage
Dress with Tulle-grass dressing
Split skin graft rarely done on day one
Principles of management
Re-inspect the wound at 24-48 Hrs
If necessary further debridement
Consider wound cover within the first 5
days to one week
Start interim limb physiotherapy
Observe for fracture complication
Open fracture : Problems
General
ARDS
Atelectasis
Open fracture : Problems
Specific
Skin necrosis
Fat embolism
Compartment syndrome
Infection
Chronic osteomyelitis
Open fracture : Problems
Non-union
Delayed-union
Mal-union
Ischemic contractures
Reflex sympathetic dystrophy
Joint contractures
Principles of management
SUMMARY
Resuscitation
Primary management
Prevent infection
Soft tissue healing
Bone healing
Rehabilitation of the limb and the patient
Principles of management
SUMMARY
Resuscitation
Primary management
Prevent infection
Soft tissue healing
Bone healing
Rehabilitation of the limb and the patient
Principles of management
SUMMARY
Resuscitation
Primary management
Prevent infection
Soft tissue healing
Bone healing
Rehabilitation of the limb and the patient
Principles of management
SUMMARY
Resuscitation
Primary management
Prevent infection
Soft tissue healing
Bone healing
Rehabilitation of the limb and the patient
Principles of management
SUMMARY
Resuscitation
Primary management
Prevent infection
Soft tissue healing
Bone healing
Rehabilitation of the limb and the patient
Principles of management
SUMMARY
Resuscitation
Primary management
Prevent infection
Soft tissue healing
Bone healing
Rehabilitation of the limb and the patient
Knee
