Open fractures

Open fractures
Fractures communicating to the outside
through a rent in the skin, however small the
break in the skin.
More often, open fractures are associated with
multiple injuries and shock

Open fracture - tibia Open fracture - forearm

 Open fractures
4 questions to be answered
1. What is the nature of the wound
2. What is the state of the skin around the wound
3. Is the circulation intact
4. Are the nerves intact
Helps classify the fracture & decide management
 Open fractures
Gustilo - Anderson classification
Type I : wound small < 1cm long, (inside out wound),
little soft tissue damage, minimal
contamination, fracture not comminuted
Type II: wound 1-5 cm long, mod. soft tissue
damage, moderate contamination,
fracture may be comminuted
Type III: extensive damage to skin, soft tissue &
neuro-vascular structures, wound
contaminated, fracture comminuted
IIIA - loss of skin and muscles
IIIB - loss of periosteum
IIIC - associated neuro-vascular injury
Open fractures : GUSTILO CLASSIFICATION
Type I Type lll A

Type IIIC
Type II
Type III B
 Wound S.Tissue Soft tissue Fracture
Size contamination damage

< I cm
Type I Minimal Not
Puncture Minimal comminuted
wound

Mod. No ST May be
Type II 1-5 cm long Moderate. loss comminuted

Skin, Sc
Type III A tissue, +/- Usually
> 5 cms Extensive
muscle comminuted

Loss of Usually
Type III B > 5 cms Extensive periosteum comminuted

Neuro-
Type III C vascular Usually
> 5 cms Extensive
damage comminuted
 Open fractures
Most important complication of open fracture: infection
Incidence correlates directly with the extent of soft tissue
damage :
Type I : < 2%, Type III : > 10%
To prevent this the following are essential
1. Antibiotic prophylaxis
2. Early wound debridement
3. Stabilization of the fracture
4. Wound coverage
“Golden period” Open fractures

Golden period More than 6 hours

Wound Considered uninfected Considered infected even
(unless there is if it appears clean
obvious
contamination)
Antibiotic Usual broad spectrum Potent broad spectrum
used antibiotics used for 5-7 antibiotic to be used -
days parenteral and oral - for
longer periods
Method of Usual intervention can Care in intervention
stabilization be planned as per required as per
protocol. Results indications. Infection rate
better higher
 Open fractures

“Golden period”
 When patient comes “early” : mandatory to start
definitive treatment in this period
 Once an infection .... always an infection
 Hence wound debridement has to be considered as
an emergency especially when a patient comes in the
“golden period”
 Open fractures
Tetanus prophylaxis ASSESS WOUND

Clean minor wound Contaminated wound

Primary Tetanus diphtheria series taken? Primary Tetanus diphtheria series taken?

No Unknown Yes No Unknown Yes

Administer today Was the most Administer vaccine Was most recent
Instruct to recent dose and tetanus immune dose within last 5
complete series within last 10 globulin (TIG) years?
as per age- years?
appropriate No Administer No
Yes Yes
schedule vaccine today
Pt. should next
Vaccine not needed : next dose to dose as per age- Vaccine not needed :
be given 10 yrs after last dose appropriate next dose to be given
schedule 10 yrs after last dose
 Open fractures
Tetanus Prophylaxis
History of
adsorbed tetanus Clean minor wounds All other wounds
toxoid immunisaton

Td (tetanus- TIG (Human Td (tetanus- TIG (Human

diphtheria – tetanus diphtheria – tetanus
Adult type: Immunoglobulin: Adult type: Immunoglobulin:
0.5ml IM) 250-500 IU IM) 0.5ml IM) 250-500 IU IM)
Unknown or less Yes No Yes Yes
than 3 doses
3 doses or more No* No No** No

For children < 7 years : DPT or DPaT (DT if pertusis vaccine is contraindicated)
For people > 7 years: Td preferred to tetanus toxoid alone
*Yes: if last dose is more than 10 yrs ago
** Yes: if last dose more than 5 years ago
Td and TIG are given with separate syringes to different sites
 Open fractures
Tetanus Prophylaxis : important points
• Primary series : minimum 3 doses of T and D containing vaccine
• Vaccines available: DTaP (safer version of old DTP vaccine),
DTP, Tdap (tetanus, diphtheria, acellular
pertusis), DT/Td
• No vaccine or TIG is recommended for infants <6 weeks of age
with clean, minor wounds. TIG is recommended for infants in
case of contaminated (dirty) wounds

• TIG 250 IU IM can be given for all ages - can and should be
given simultaneously with the tetanus-containing vaccine
• All HIV patients immunized regardless of previous status
• Td and TIG are given with separate syringes to different sites
• Adsorbed TT product preferred to fluid TT
 Open fractures
 Antibiotic prophylaxis
 As soon as possible
 Till danger of infection passes
 Broad spectrum : based on contamination
 Wound debridement
 Should be thorough
 Use plenty of saline for washing the wound clean
 How long? How much?
 Debride the wound till the wound is
rendered absolutely clean and devoid of all
foreign particles
 Open fractures
Early wound debridement
Aim
 Wound: devoid : foreign material & dead tissue
Procedure
 Tourniquet not used : kept ready
 Preparation of part
 Sample for culture taken before starting the
debridement & after completion
 Irrigate wound with saline : minimum 5 liters
 Final irrigation with antibacterial solution
 Open fractures
Tissue debridement
Skin
 Wound is extended
 Skin margins : trimmed till bleeding edges seen
 Skin retained as much as possible
 Once debrided, the extended portion may be
closed
 Exposed bone is covered with muscle
 Skin closure decided based on contamination :
preferably closed as delayed primary procedure
 Open fractures
Tissue debridement
Fascia
 Fasciae divided extensively so that circulation
is not impeded
 Fascia need not be closed

Muscle
 All dead muscle should be removed : nidus for
infection
Recognised based on
 Colour
 Bleeding
 Contractility
 Open fractures
Tissue debridement
Blood vessels
 Large bleeding vessels : tied meticulously
 Small vessels : clamped or cauterised : cauterisation :
minimal
Nerves & tendons
 Cut nerves : left undisturbed
 Sheath of cut ends tagged : non- absorbable suture
material : for identification later
 Repair of nerve usually done at a later date
 Primary repair done only when wound is clean &
further dissection is not necessary for repair
 Open fractures
Bone debridement & stabilization
Bone debridement
 Fracture ends : cleaned & reduced
 Small fragments totally devoid of
blood supply : removed
 Limited excision- as in skin
Stabilization of bone
 Reduces infection rate especially in type II & III
fractures
 Type I may be stabilised by POP casts
 Type II & III stabilised by external fixation
 Open fractures
Bone debridement & stabilization
• Stabilization of bone
• Primary internal fixation not
advised : infection rate is high
• Minimum internal fixation is
advisable and acceptable
• When wound is clean:
unreamed intramedullary
nailing done
Joints
• Debrided & closed : closure of synovium & capsule
• Drainage or suction irrigation : contamination is
severe
 Open fractures
Wound closure
 All Open fractures should be treated open….
 Bone coverage : as soon as possible
 Wound inspected:48 hrs & SOS: redebridement done
or wound closure achieved

Wound closure :
Delayed primary : by
 Releasing incisions
 Skin grafting
 Plastic surgery - flaps:
rotation, vascularised, free
 Open fractures
Aftercare
 Limb kept elevated
 Continue antibiotic prophylaxis
 Re-debridement as necessary

Complications of fracture
• General complications
• Local complications
 Early
 Late
 Open fractures

Complications
General
 Crush syndrome
 DVT and PE
 Tetanus
 Gas gangrene
 Fat embolism
Local (bone, joints & soft tissues)
 Early
 Late
 Early Delayed Late
- Infection - AVN
Bone - Delayed - Malunion
union - Nonunion

- Haemartrosis - Infection - Instability

Joints - Ligament - Sudeck’s - Stiffness

injury Osteodystrophy - Sudeck’s
Osteodystrophy

- Blisters - Bed sores - Myositis

- Injury to - Tendinitis ossificans
Soft tissue - Tendon rupture
muscles
- Nerve
Tendons
entrapment
Nerves - Volkmann’s
Vessels – contracture
Volkmann’s ish.