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Department of surgery

Principles and problems


of treatment

FRACTURES
Mulya Gunawan

FRACTURE

A fracture is a complete or
incomplete break (discontinue) in a
bone or cartilage resulting from the
application of excessive force.

Incidence

UK 21,1 per 1000 populasi (2,1%)


pertahun (Buckley , 2000
26,7 % of the cases in emergency

Problem

Problem

Fracture disease
Pneumonia
Abdominal distended
UTI
Disused Atrophy
Osteoporotic
Stiff joint
Decubitus

Social and Economic

Fracture is not as complicated as you


think
Fracture can healing perfectly
Most Soft tissue will heal by fibrotic
tissue

Principle of fracture treatment

Recognize
Reduction
Resistance
Rehabilitation

Life is movement

YOU MAY HAVE CASES LIKE THIS

A fracture where a wound leads to a


communication between the fracture
haematoma and the outside
environment

Open fracture

Smith, Gopal. Current Orthopaedics 1999

WOUND LAVAGE, DEDRIBEMENT,


Contamination and potential infection
ANTIBIOTICS
SKELETAL
STABILIZATION
Bony
Principles
ofstability
Management
Soft tissue
loss
HEALTHY
SOFT injury,
TISSUE
COVER

ADVANCE TRAUMA LIFE SUPPORT1


OTHER THAN CONTROLLING
HAEMORHAGE, # ASSESSMENT
LEFT FOR 2 SURVEY2

INJURY ASSESSMENT

MINOR, MODERATE OR SEVERE


1. Advance Trauma Life Support programme for Doctors 6th Ed. 1997
2. Chapman, Olson. Rockwood and Green 1996

HISTORY

VELOCITY OF IMPACT

Energy absorbed by bone and soft tissue


causes vacuum and sucks foreign material1

INJURY
ASSESSMENT
ENVIRONMENTAL
EXPOSURE

Farmyard (Clostridium perfringens)


Drain (Pseudomonas aeruginosa or
Aeromonas hydrophilia)2
1.

Advance Trauma Life Support programme for Doctors 6th Ed. 1997
2.
2. Gustilo et al. JBJS (Am) 1990

DISTAL NEUROVASCULAR STATUS


DIGITAL / POLOROID PHOTO
REMOVE
GROSS
CONTAMINATION
INJURY
ASSESSMENT
COVER WITH STERILE DRESSING
SPLINTAGE
APPROPRIATE REFERRAL

Classification

TYPE I

A type I wound caused by a lowenergy injury that is less than 1 cm


long. Usually caused by the bone
piercing from the inside outward
rather than by a penetrating injury

TYPE II

A 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.
Usually outside-to-inside
injuries

TYPE III

Type IIIA open fracture


is limited stripping of
the periosteum. There is
adequate muscle and
soft tissue coverage
over bone, tendon, and
neurovascular bundles.

WITHIN 6 HOURS1
PREVENT CONTAMINATION
SURGICAL MANAGEMENT
INFECTION
With in GOLDEN PERIOD

Principle of Treatment
1.
2.

3.

4.
5.
6.
7.

All open fracture treated as an emergency


Through initial evaluation to diagnose
other life-threatening injuries
Appropriate and adequate antibiotic
therapy
Adequate debridement and irrigation
Stabilization of the open fracture
Appropriate wound coverage
Rehabilitation of the involved extremity

GOAL

Early closure
Avoidance of sepsis
Establishing durable soft tissue
coverage
Facilitating future reconstruction
surgery
Containing cost

Treatment

OF Type 1
Debridement + ORIF or Ex Fix, primary
closure the wound is accepted

OF Type 2
Debridement + ORIF or Ex Fix, closure
the wound at second look

Treatment

Type 3
A
Debridement +external fixation
ORIF depend on operator

B
Debridement +external fixation
Second look soft tissue coverage

C
Debridement +external fixation
Repair vascular

WHICH ONE?

ANTIBIOTICS USE IN OPEN


FRACTURES

the use of combinations to cover both gram-positive and


gram-negative infections is recommended, regardless of its
duration of use1
THEREFORE FIRST GENERATION CEPHALOSPORIN, GRADE I
AND II 24 TO 72 HOURS
GRADE III ADD AMINOGLYCOSIDE
IF FARMYARD EXPOSURE ADD PENICILLIN
1. Patzakis, Wilkins. Clin Orthop 1983

WHEN SHOULD THEY BE GIVEN?

ANTIBIOTICS USE IN OPEN


FRACTURES

THE EARLIER THE DELIVERY, THE MORE EFFECTIVE IN


PREVENTING INFECTION1

1 Patzakis, Wilkins. Clin Orthop 1989.

HOW OFTEN AND FOR HOW LONG?

ANTIBIOTICS USE IN OPEN


FRACTURES

OPEN GRADE I,II 3 DAYS OF CEPHALOSPORIN


GRADE III 5 DAYS OF CEPHALOSPORIN +
AMINOGLYCOSIDE
ADDITIONAL 72 hrs IF 2ND PROCEDURE DONE

1. Patzakis, Wilkins. Clin Orthop 1983

HOW OFTEN AND FOR HOW LONG?

ANTIBIOTICS USE IN OPEN


FRACTURES

SINGLE DOSE AMINOGLYCOSIDE IS JUST AS EFFECTIVE AS


TWICE DAILY DOSE1
DURATION NO DIFFERENCE BETWEEN SINGLE DAY AND 5
DAY COURSE2
1. Sorger et al. Clin Orthop 1999
2. Dellinger et al. Arch Surg 1988

SHOULD CULTURES BE TAKEN ON PRESENTATION IN A/E?

ANTIBIOTICS USE IN OPEN


FRACTURES

CULTURES OBTAINED ON PRESENTATION HAVE A LOW


PROBABILITY OF PRODUCING INFECTION.
THEY ARE CONTAMINANT OF THE INJURY RATHER THAN
PREDICTORS OF INFECTION.
THEREFORE NO RECOMMENDED
1. Merritt. J Trauma. 1988
2. Patzakis et al. J Orthop Trauma 2001
3. Robinson et al. JBJS (Am) 2000.

Adjunctive antibiotic use???

ANTIBIOTICS USE IN OPEN


high levels of tobramycin
locally but not systemically
FRACTURES
the bead pouch technique + systemic antibiotics

decreased incidence of acute inf and OM in grade IIIb/c


1. Eckman et al. Clin Orthop 1988
2. Keating et al. J Orthop Trauma. 1996
3. Moehring K. Clin Orthop. 2000

CAN BE HEAL WITH NORMAL


PROGNOSIS
FUCTION
EMERGANCY
CASE
OPEN
FRACTURE
Take
Home
Message
TIME
GOLDEN
PERIODE

CASE 1
OPEN GRADE IIIa LEFT TIBIAL
PLAFOND

CASE 2
OPEN GRADE IIIa RIGHT TIBIAL
PLAFOND

CASE 3
OPEN GRADE IIIa RIGHT TIBIA

CASE 4
OPEN GRADE IIIb RIGHT TIBIA

CASE 5
OPEN GRADE IIIb RIGHT TIBIA

THANK YOU