Department of surgery

FRACTURES

Principles and problems

of treatment
Zulkarnaini
 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
 Open fracture

“A fracture where a wound leads to a

communication between the fracture
haematoma and the outside
environment”

Smith, Gopal. Current Orthopaedics 1999

 Principles of Management

WOUND LAVAGE, DEDRIBEMENT,

Contamination and potential infection
ANTIBIOTICS

SKELETAL STABILIZATION
Bony stability

Soft tissue
HEALTHY SOFT injury,
TISSUEloss
COVER
 INJURY ASSESSMENT
 ADVANCE TRAUMA LIFE SUPPORT1

 OTHER THAN CONTROLLING

HAEMORHAGE, # ASSESSMENT
LEFT FOR 2° SURVEY2

 MINOR, MODERATE OR SEVERE

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

 DISTAL NEUROVASCULAR STATUS

 DIGITAL / POLOROID PHOTO
 REMOVE GROSS CONTAMINATION
 COVER WITH STERILE DRESSING
 SPLINTAGE
 APPROPRIATE REFERRAL
Classification
 TYPE I
 A type I wound caused by a low-
energy 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.
 SURGICAL MANAGEMENT

 WITHIN 6 HOURS1
 PREVENT CONTAMINATION

INFECTION
 With in “GOLDEN PERIOD”
 Principle of Treatment
1. All open fracture treated as an
emergency
2. Through initial evaluation to diagnose
other life-threatening injuries
3. Appropriate and adequate antibiotic
therapy
4. Adequate debridement and irrigation
5. Stabilization of the open fracture
6. Appropriate wound coverage
7. 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
 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

 ANTIBIOTICS USE IN OPEN
FRACTURES
• WHEN SHOULD THEY BE GIVEN?

THE EARLIER THE DELIVERY, THE MORE EFFECTIVE IN

PREVENTING INFECTION1

1 Patzakis, Wilkins. Clin Orthop 1989.

 ANTIBIOTICS USE IN OPEN
FRACTURES
• 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

 ANTIBIOTICS USE IN OPEN
FRACTURES
• HOW OFTEN AND FOR HOW LONG?

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
 ANTIBIOTICS USE IN OPEN
FRACTURES
• 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.
 ANTIBIOTICS USE IN OPEN
FRACTURES
• 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
 Take Home Message

CAN BE HEAL WITH NORMAL

PROGNOSIS
FUCTION

EMERGANCY CASE
OPEN FRACTURE

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