Management of Lower

Limb Trauma
OPEN WOUNDS AND
FRACTURES

Dr Suryasmi Duski
Musculoskeletal Oncology Unit
Department of Orthopaedic & Traumatology
Kuala Lumpur Hospital
Kuala Lumpur
Malaysia
 Fracture
Open Fracture
Break
Closed in the continuity of the bone
Fracture

Overlying skin intact Break in the skin and

underlying soft tissue
leading directly into or
communicating with the
fracture and its
hematoma
High chance of
infection

“A fracture where a wound leads to a communication between the fracture haematoma and
the outside environment”
 Smith, Gopal. Current Orthopaedics 1999
INJURY ASSESSMENT PERTAINING ORTHOPAEDIC

 HISTORY
• VELOCITY OF IMPACT
• Energy absorbed by bone and soft tissue
• Causes vacuum and sucks foreign material1

• 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
PRINCIPLE OF MANAGEMENT

• PROBLEMS • SOLUTION
• Contamination & potential • Wound lavage, debridement,
infection antibiotics

• Bony stability • Skeletal stabilization

• Soft tissue injury / loss • Healthy soft tissue cover

INJURY ASSESSMENT

 DISTAL NEUROVASCULAR STATUS

 DIGITAL / POLOROID PHOTO
 REMOVE GROSS CONTAMINATION
 COVER WITH STERILE DRESSING
 SPLINTAGE
 APPROPRIATE REFERRAL
Early Intervention
Important aspect of managing
musculoskeletal injuries
Decreases the pain


Reduces the bleeding



Decreases the damage to soft tissue,

nerves and blood vessels
Transportation

 Principles Of Splinting

Apply dry sterile

compression dressing to
all open wounds
 Principles Of Splinting
Incorporate one joint
above and one joint
below the fracture
Types of Splints

 Wooden Splints
 Metal Wire/Frame
Splints
 Air Splints
 Vacuum Splints
 Post-Splinting Care
Monitor:
Circulation
-Capillary Refill
-Pulse
Sensation
Motor function
 Classification of
open fracture
Gustilo – Anderson Classification, JBJS 1976

Treatment of 1025 open fractures

Modified 1984

Important in directing treating surgeon to plan and

manage

Only classify during surgery – exploration and debridement

1. GUSTILO, ANDERSON JBJS 1976

2. GUSTILO, et al. J Trauma 1984
Grade Wound Description

I < 1cm Low Energy Low contamination, Clean wound

Minimal tissue injury
II 1-10cm Moderate Energy Moderate contamination
Moderate tissue injury

IIIa > 10cm High Energy Trauma regardless of size of wound

Contaminated Extensive soft tissue laceratiosn or
flaps, but maintain adequate soft tissue coverage
of bone
IIIb Needs flap/ graft for closure
IIIc Needs vascular repair to save limb
Automatic Grade III Shotgun wound High-velocity
gunshot wound Segmental fracture with
displacement Diaphyseal segmental loss Wound
occurring in a farmyard/ highly contaminated
environment Crushing force from a fast-moving
vehicle

Modified Gustilo & Anderson Classification of Open Fractures

Objectives of Surgical Treatment
cc

• preserve life
• preserve limb
• preserve function

 Prevent infection
 Fracture stabilization
 Soft tissue coverage
How To Achieve these goals?

 1st – Absolute cleanliness

 2nd – stabilization of fracture
3rd – provision of free
drainage when necessary
We need to keep in mind…..

• All open fractures wounds are contaminated

• Bacterial colonization
• Presence of dead space and devitalised
tissues
• Soft tissue damage
ANTIBIOTICS USE IN OPEN FRACTURES
WHICH ONE ?
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

Contamination and bacterial colonization

Timing of Antibiotics
 Antibiotic therapy should be initiated as soon as possible
 Patzakis and Wilkins – Corr 1989
Studied 1104 open fractures
Given <3 hours from time of injury – 4.7% infection
Given >3 hours from time of injury – 7.4% infection

THE EARLIER THE DELIVERY, THE MORE

EFFECTIVE IN PREVENTING INFECTION1

1 Patzakis, Wilkins. Clin Orthop 1989

HOW OFTEN AND FOR HOW LONG?
 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

SHOULD CULTURES BE TAKEN ON
PRESENTATION IN A/E
• 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???
• “the bead pouch technique” + systemic antibiotics
• high levels of tobramycin locally but not systemically
• 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
Tetanus
Patient previously fully immunised

Wound not Tetanus-prone

If < 10 years since TT: nothing
If > 10 years since TT: single TT

Wound Tetanus-prone
If < 5 years since TT: nothing
If > 5 years since TT: single TT
Tetanus
Patient not adequately immunised or unknown

Wound not Tetanus-prone

Give 0.5ml TT
Wound Tetanus-prone
Give 250-500 units TIG
+ 0.5ml TT in other arm ± penicillin
 Treatment of a Developed
Case of Tetanus

• Human tetanus
immunoglobulin (min 500
units)
• Antibiotics to fight organism
–penicillin tetra,
• Respiratory management
• benzodiazepine
WOUND DEBRIDEMENT
Pierre-Joseph Desault (1738 – 1795)
• Coined the term ‘debridement’
• Deepening of incisions to explore wounds, remove non viable
tissues, allow path for drainage
• The sooner debridement performed, less likely for infection to
develop
WOUND
DEBRIDEMENT

Goals
• Remove debris and non viable tissue
• Irrigate
• 3C’s

Remove loose fragment except where they

WOUND DEBRIDEMENT

• Trauma scrub
– Soap and saline to remove gross debris

• “Zone of injury”
– Skin wound is the window through which the true wound
communicates with the exterior

• Extend the traumatic wound

– Excise margins
– Resect muscle and skin to healthy tissue
• color, consistency, capacity to bleed and contractility
WOUND DEBRIDEMENT

• Bone ends are exposed and debrided

• Irrigate
• Serial debridements?
– If needed, 2nd or 3rd debridement after 24-48 hours should be
planned
RECOMMENDATIONS

• 1st washout, highly contaminated

 Soap solution
• Repeat washout of clean wounds
 Saline
• Infected wounds
 Soap, then antibiotic
Wound Irrigation
Volume
• Ideal volume not well defined
• Gustilo – Anderson – described use of 10 – 15 L of
irrigation of all wounds

Anglen guide
• Type 1 : 3 – 6 L
• Type 2 : 6 – 9 L
• Type 3 : 9 L
*Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS 2001. 9: 219-226.
TO CLOSE OR NOT TO CLOSE?

Recently, renewed interest in primary closure

• Improved abx management
• Better stabilization

Infection risk increases if wound open > 7 days

1999 Delong et al: 119 open fractures
• Immediate closure is a “viable option”
• No significant difference
• delayed/nonunion and infection rates between immediate and delayed
closure
WHEN TO COVER THE WOUND?

Patzakis MJ, Bains RS, Lee J, et al. “Prospective, randomized,

double-blind study comparing single-agent antibiotic therapy,
ciprofloxacin, to combination antibiotic therapy in open
fracture wounds.” JOT 2000. 14: 529-533

• As soon as possible
• Suggests hospital acquired etiology of infection
in delayed closure
CONTRAINDICATIONS TO PRIMARY
CLOSURE

• Inadequate debridement
• Gross contamination
• Farm related or freshwater immersion injuries
• Delay in treatment >12 hours
• Delay in giving antibiotics
• Compromised host or tissue viability
 WHEN CLOSURE IS
POSSIBLE,
WHAT ARE THE OPTIONS?
Vacuum assisted wound closure
Webb LX: New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002 Sep-Oct;10(5):303-11.
-Dedmond BT, Kortesis B, Punger K, Simpson J, Argenta A, Kulp B, Morykwas M, Webb L. “The use of Negative Pressure Wound Therapy in
the Temporary Treatment of Soft Tissue Injuries associated with High Energy Open Tibial Shaft Fractures.” JOT. 2007
Dressings

• Semi-permeable membranes

• Antibiotic bead pouch

• VAC
Complications

o Infection, sepsis
o Chronic osteomyelitis
o Loss of function
Conclusions
• Treatment should be prompt
• antibiotics given therapeutically and aimed at
appropriate contaminants
• All open fractures should be thoroughly irrigated
and debrided
• Wound closure and coverage should be completed
as soon as possible to prevent nosocomial
infection
 Infection, sepsis, chronic osteomyelitis Nonunion, malunion
Loss of function (muscle loss, nerve injury, unrecognized
compartment syndrome) SIRS, ARDS, multi-system organ
failure
 Infection, sepsis, chronic osteomyelitis Nonunion, malunion
Loss of function (muscle loss, nerve injury, unrecognized
compartment syndrome) SIRS, ARDS, multi-system organ
failure