Open Fracture

A presentation by
Muhammad Ihsan Bin Khalib Jaafar
PEGAWAI PERUBATAN SISWAZAH HOSPITAL KEMAMAN

Based on guidelines from :

AADO scientific
meeting 2009 MYNAG 2008 Orthobullet 2018
Jabatan Ortopedik HKM 2018
 Overview on Fractures
• Fracture : a break in the structural continuity
of bone.
- If skin is intact , it is a closed fracture.
- If skin / cavities is breached, it is an open
fracture.
- If joint are involved it may strain ligaments and
cause subluxation of joint
 Type of fracture
• Complete fracture
- Complete broke of bone into two or more fragments.
- Can be transverse, oblique spiral,
- transverse tend to remain in place after reduction
- oblique and spiral tend to slip and redisplaced.

• Comminuted fracture
– More than two fragments
– Often unstable due to poor interlocking of fragments
– Butterfly fracture : two oblique fracture lines meeting to
create a large triangular or wedge-shaped fragment
• Incomplete fracture
*periosteum remain some form of continuity
– Greenstick fracture : in children where bone is
buckled or bent
• Reduction is easy , healing is quick

– Stress fracture : break appear in part of cortex

• Healing is the same as complete fracture

– Compression fracture
Fracture & Displacements
 Fracture healing
• Two types, with callus or without callus
 Fracture healing time
STAGES UPPER LIMB LOWER LIMB
Callus visible 2-3 weeks 2-3 weeks
Union 4-6 weeks 8-12 weeks
Consolidation 6-8 weeks 12-16 weeks

*healing is about twice time faster in children

 Definition
• A fracture with direct communication to the
external environment
• historically called a "compound" fracture
• a soft tissue wound in proximity to a
fracture should be treated as an open fracture
until proven otherwise
 Significance
• Usually caused by High energy trauma
• Often associated with additional injuries
(tendon, nerve, articular cartilage)
• contamination of the wound with
microorganisms increased risk of infection,
<2% type I to >10% type III
 Type I

Type II
 Type IIIb
Type IIIa

***All gunshot wounds are treated as

Gustillo type III wound
 Type IIIc

Vascular
Injury
Oestern and Tscherne classification
 Approach to Open Fracture at ED
“Save the patient first, then the limb”
• Airway
• Breathing
• Circulation
• Disability
• Exposure
 Assessment
• Soft tissue
• Neurovascular examination
• if suspicious of vascular insult,
- ankle brachial index (ABI) should be obtained
- normal ratio is >0.9, vascular surgery consult if ABI
<0.9
• If suspicious of traumatic arthrotomy + inspection
/palpation is inconclusive, do saline load test
• Check Tetanus status
 Saline load test
• Saline injected was related to the size of the joint;
- 60 ml for the knee,
- 20 ml for the ankle and elbow,
- 5 ml for the wrist
- 1 to 2 ml for finger joints.
• Procedure done under aseptic technique
• Leakage of fluid indicated a positive test.
• Test is negative if there is a joint distention without leakage
• sensitivity (94%) and specificity (91%) of the SLT in the ED
setting
 Bleeding management
• Apply direct pressure to control bleeding

• Avoid blind application of clamp or torniquet

 Irrigation and dressing
• Remove debris, not bones.
• Irrigation
- 2016 studies shows irrigation lowers
incidence of infection
- normal saline is the best solution
• Place sterile soaked dressing on wound
 Stabilize
• Stabilization at ED can be done using splint,
brace, or traction for temporary stabilization
- decreases pain, minimizes soft tissue trauma, and
prevents disruption of clots

• Plating, internal fixation and external fixation

done for proper stabilization
- Improves wound care, allow early motion of
adjacent joint and early mobilization of patient
 Antibiotics
• Gustillo I & II
- 1st generation cephalosporin

• Gustilo III
- 1st generation cephalosporin + aminoglycosides

- * commonest organism is staph aureus & staph epididermidis

 Antibiotics
• Should be initiate as soon as possible
• Increase rate of infection if delayed > 3 hours
• To continue for 24 hour after onset of injury of
injury closed primarily (within 12 hours of
injury)
• To continue for 24 hour after time of closure if
closure is delayed ( ~72 hour after injury)
 Approach to surgical intervention
• Mangled Extremity
Severity Score (MESS
Score)
-Estimates viability of an
extremity after trauma, to
determine need for
salvage vs empiric
amputation.
- Score 3-6 : viable
- score 7-12 : may
require amputation
 Irrigation
• Low pressure irrigation better than high
pressure pulse lavage
• Use normal saline
• 3,6,9 L
• May require staged debridement every 24 to
48 hours
 Debridement
• Remove bony fragment without soft tissue
attachment
• Assess muscle viability based on 4C : colour,
consistency, contractility, capacity to bleed
• Wound is extended & ragged margin excised
leaving healthy tissue
• Leave cut nerves and tendon alone
 Wound closure
• Ideal time is controversial
• Early closure is ideal
• Increased risk of infection if closed > 7 days post incidence
• Gustillo I & II can be closed within hours after injury,
provide closure done without tension
• > Gustillo > 3 may require serial debridement before
closure & may require skin grafting
• Bone graft can be done once wound is cleaned and closed
• If wound coverage cannot be achieved, vacuum dressing
can be done
• Open dirty wound can also be treated with antibiotic
beads
Stabilization
 Post operative management
• Look out for complications :
- Visceral injury
- Compartment syndrome
- Fat embolism syndrome
- Neurovascular injury
- Infection

Delayed complications :
- Delayed union
- Non-union
- Malunion
- Avascular necrosis
- Growth disturbance
- Joint instability
 Delayed union
• Causes
– Poor blood supply
– Severe soft tissue damage
– Periosteal stripping
– Imperfect splint
– Rigid fixation
– infection
Non union
Malunion
Avascular Necrosis
 Reference
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AADO scientific meeting 2009 (2018). [online] Available at:

http://www.aado.org/file/open-fracture-ws_mar09/LFTse.pdf [Accessed 27 Aug. 2018].

Malaysian National Antibiotiic guidelines (2018). [online] Available at:

https://www.pharmacy.gov.my/v2/sites/default/files/document-upload/national-antibiotic-guideline-2014-full-versionjun2015_1.pdf
[Accessed 27 Aug. 2018].

Pdfs.semanticscholar.org. (2018). [online] Available at: https://pdfs.semanticscholar.org/888a/21b96fa04227e290fbb943cb45a5d9f04f97.pdf

[Accessed 27 Aug. 2018].

Researchgate, (2018). [online] Available at:

https://www.researchgate.net/publication/234050385_The_Saline_Load_Test_of_the_Knee_Redefined_A_Test_to_Detect_Traumatic_Arthrotomi
es_and_Rule_Out_Periarticular_Wounds_Not_Requiring_Surgical_Intervention [
[Accessed 27 Aug. 2018].

Orthopaper.com. (2018). [online] Available at: http://www.orthopaper.com/archives/2016/vol2issue4/PartA/2-3-44-846.pdf

[Accessed 27 Aug. 2018].

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[Accessed 27 Aug. 2018].

Orthopaedic Dept. of Faculty of Medicine of Chulalongkorn University(2018). [online] Available at:

http://ortho.md.chula.ac.th/student/SHEET/srihatach/Open%20fracture%20MSV%20Handout.pdf [Accessed 27 Aug. 2018].