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LOWER LIMB FRACTURES Identifying problems early

Specialists Without Borders Seminar in Surgery Rwanda, September 2010. LOWER LIMB FRACTURES Identifying problems early. Professor Jegan Krishnan Flinders University Adelaide, South Australia. Specialists Without Borders Seminar in Surgery Rwanda, September 2010.

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LOWER LIMB FRACTURES Identifying problems early

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  1. Specialists Without Borders Seminar in Surgery Rwanda, September 2010 LOWER LIMB FRACTURES Identifying problems early Professor Jegan Krishnan Flinders University Adelaide, South Australia

  2. Specialists Without Borders Seminar in Surgery Rwanda, September 2010

  3. www.specialistswithoutborders.org Learning Objectives • Emergency care of traumatised patient • Acute care of compound fractures • Assessment and Management of Neurovascular Injury • Recognition and Management of Compartment Syndrome

  4. www.specialistswithoutborders.org Emergency Care of Traumatised Limb • General assessment of patient – Emergency Medical and Surgical Trauma (EMST) • Clinical assessment • Neurovascular assessment • Limb stabilisation • Wound inspection dressings • Preliminary radiology

  5. www.specialistswithoutborders.org Compound Fractures Goals of open fracture management include: • Prevention of infection • Achievement of bony union • Restoration of function

  6. www.specialistswithoutborders.org Compound Fractures Compound fractures according to Gustilo and Anderson: • Grade I: skin wound < 1 cm, clean no contamination • Grade II: skin wound > 1 cm no major soft tissue damage • Grade III: high energy, major soft tissue injury or crush injury

  7. www.specialistswithoutborders.org Compound Fractures Grade I compound #

  8. www.specialistswithoutborders.org Compound Fractures Grade IIIc compound #

  9. www.specialistswithoutborders.org Compound Fractures • Grade III A: adequate soft tissue coverage of bone, although major soft tissue damage B: major soft tissue damage with periostal stripping and no coverage of bone C: arterial damage requiring reconstruction

  10. www.specialistswithoutborders.org Management Principles • Antibiotic utilisation • Timing of initial surgery • Type of wound closure • Antibiotic delivery methods • Tetanus coverage • Wound irrigation • Adjunctive therapies

  11. www.specialistswithoutborders.org Compound Fractures Need immediately: • Bandage and splint • Antibiotics (Cephazolin 1gram IV) • Immediate referral Follows: • Arteriography? • Surgery (<6 hrs) • At least 5 days of IV antibiotics

  12. www.specialistswithoutborders.org Compound Fractures Surgery Grade I and II: - no plates - intramedullary nail possible Grade III: - external fixator - plastic surgeon – flap - intramedullary nail possible

  13. www.specialistswithoutborders.org External Fixation All over ………………………

  14. www.specialistswithoutborders.org Compound Fractures • Standard treatment for open tibial fractures undergone changes over the last 20 years • Prompt assessment in emergency room required • Early aggressive soft tissue and bone debridement • High volume pulsatile lavage • Administration of IV antibiotics

  15. www.specialistswithoutborders.org Compound Fractures – current concepts • Delayed wound closure or soft tissue coverage with local or distant flaps proven highly effective • Minimise the risk of late deep infection, overall infection rate between 3 and 5% for all open fractures • Risk of infection related to severity of associated soft tissue injury; Gustilo-Anderson Grade II fractures reported incidence as high as 10%, with Grade III reporting as high as 20%

  16. www.specialistswithoutborders.org Compound Fractures – current concepts • Heitmann et al and Faisham et al have both reported 60-64% of all open tibial fractures are contaminated on presentation in emergency room • Robson et al demonstrated nearly all open fractures are contaminated to some degree, introduced the concept of “Golden Period of Opportunity” – initial 4 to 12 hr period following injury.

  17. www.specialistswithoutborders.org Compound Fractures – current concepts • Early soft tissue coverage generally believed to limit risk of subsequent deep infection after open fracture • Very early wound closure is not a radical or new concept in trauma surgery • No universal agreement regarding the potential advantages of primary wound closure

  18. www.specialistswithoutborders.org SUMMARY • Early EMST wound dressing and splintage • Wound debridement • Appropriate antibiotics • Tetanus prophylaxis • Wounds coverage • Amputation

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