OPEN FRACTURES

1. OPEN FRACTURES Joseph J. Ruzbarsky, MD Trauma Conference September 22, 2014

2. Open Fracture • A fracture in which a break in the skin and underlying soft tissues leads directly into or communicates with the fracture and its underlying hematoma • “Compound fracture”

3. Goals of Treatment • Prevent infection • Achieve bony union • Restore soft-tissue envelope • Early motion and rehabilitation

4. Classification • Gustilo and Anderson, JBJS, 58A, No.4, 1976 • Reported on 1,025 open fractures of long bones and offered a classification system based largely, though not entirely, on the size of the wound

5. Type-I • < 1 cm wound • low-energy injuries • 'inside-out’ • minimal soft tissue damage • minimal comminution • minimal contamination

6. Type-I

7. Type-II • > 1 cm wound • mild-mod. energy • 'outside-in' moderate soft tissue injury • moderate comminution • moderate contamination

8. Type-II

9. Type-III • large wounds (> 10cm) • high energy injury • extensive soft-tissue injury • marked comminution • marked contamination

10. Type-III

11. Gustilo et al., J Trauma, Vol.24, No 8, 1984 • Type-IIIa • adequate soft-tissue coverage remains • Type-IIIb • soft-tissue coverage procedure necessary • Type-IIIc • vascular injury that requires repair

12. Automatic Type III’s • shotgun wounds • high velocity GSW (> 2000 ft./sec.) • displaced segmental fractures • diaphyseal segmental bone loss • farmyard injuries • highly contaminated injury • severe crush injuries • any open fracture seen after 8 hrs

13. Infection • Incidence correlates directly with extent of soft-tissue injury, NOT the length of the wound. • Gustilo et al., JBJS, 72A; 1990

14. Infection Rates • Type-I: 0-2 % • Type-II: 2-7 % • Type-III: 10 - 25 % (overall) • Type-IIIa: 7 % • Type-IIIb: 10-50 % • Type-IIIc: 25-50 %

15. Initial Treatment • ABC's according to the ATLS protocols • Life-threatening injuries take precedence over limb threatening injuries • Thorough neurovascular exam

16. Tetanus Prophylaxis • Clostridium tetani • Immunized w/in 5 yrs - No treatment • Immunized > 5 yrs - tetanus toxoid • Status unknown - tetanus toxoid and tetanus immune globulin

17. Value of ER or Pre-debridement Cultures? • organisms seen on initial culture rarely the same organisms cultured from infected wounds • costly • Lee, Chapman, et al., Orthop Trans, 15; 1991

18. Initial treatment • Cover the wound • sterile dressing • Repeated evaluation leads to increased incidence of infection • Reduce and splint fracture • for comfort • to prevent further soft tissue damage

19. Antibiotic Treatment • should begin as soon as possible • > 70 % of open fxs. are contaminated with bacteria at the time of injury

20. Which antibiotic? • Type-I and Type-II • cephazolin • Type-III • cephazolin plus aminoglycoside • Farm or sewage related injury • cephazolin, aminoglycoside and penicillin

21. Irrigation and Debridement • The most important intervention! • Repeat every 24-48 hours until wound appears clean and devoid of non-viable tissue.

22. Irrigation • 9-10 liters of normal saline should be used during irrigation of open fx • Gustilo et al., 1986; Sanders et al.,JBJS 1994. • Pulsatile lavage may impede bone healing • Bhandari, JOT, 1998 • Dirschl, JOT, 1998

23. Skin Debridement • avoid tourniquet • excise margins (saucerize) • enlarge wound with extensile incisions • obtain meticulous hemostasis as needed • skin is not the major source of infection

24. Fascia • excise any non-viable, damaged or contaminated fascia • limited vs. formal fasciotomy for high-energy injuries • Open fractures do NOT necessarily decompress compartment

25. Indications for Fasciotomy • after arterial repair with re-perfusion edema • after sustained hypotension • severe polytrauma • patient is unable to communicate (i.e. closed head injury) • open fxs. with a crushing component

26. Muscle Debridement • nonviable muscle is themajor nidus for infection • the Four C's • color • consistency • contractility • capacity to bleed

27. Tendon Debridement • unless severely damaged or contaminated, may be preserved • preserve peritenon if possible • cover tendons with local muscle

28. Bone Debridement "Our most common judgement error has been the delayed excision of nonviable bone” Chapman and Olson, Fractures, Ed 4, 1996.

29. Bone Debridement • Remove small-moderate sized avascular segments • Retain major articular fragments • large cortical segments can often be retained initially, but must be debrided if infection intervenes.

30. Open Joints • explore any open joint injury • arthroscopy may play a helpful role during I & D

31. Limb Salvage vs. Amputation "Unfortunately it requires more judgement and courage to do a primary amputation that it does to salvage the limb of a patient with a severe open tibia fracture. Heatley, BMJ, 1988

32. Primary Amputation • Lange's absolute indications: • warm ischemia time > 6 hours • anatomic division of the tibial nerve

33. Fracture Stabilization • Begins after vascular repair (when needed) and adequate irrigation and debridement. • Based on: • fracture configuration • soft-tissue injury, associated injuries • patient's general condition.

34. Cast Immobilization • Some Type-I and Type-II fractures • Difficult to observe wound

35. External Fixation • Advantages • good stability to fracture site • good wound access • easily and rapidly applied • minimal trauma to soft tissues

36. External Fixation • Disadvantages • pin tract problems (irritation, loosening, infection) • limited life span • may limit soft-tissue procedures

37. Plate and Screw Fixation • Advantages • anatomic reduction possible • improved soft-tissue access • rigid stabilization • early mobilization well tolerated • The role of early internal fixation in the management of open fractures. Chapman MW, Mahoney M:CORR: 138: 120-131, 1979

38. Plate and Screw Fixation • Disadvantages • need for further exposure • devascularization of tenuous bone fragments

39. Plate and Screw Fixation • Indications • Type-I and some Type-II open fractures • intra-articular fractures • metaphyseal fractures • Forearm

40. Intramedullary Fixation • Advantages • provides excellent stability • improved soft-tissue access • early motion and rehabilitation well-tolerated

41. Intramedullary Fixation • Disadvantages • impairs endosteal circulation (reamed> unreamed) • often longer OR time than external fixation

42. Intra-articular Fractures • Goals • anatomic reduction of the articular surface • stabilization of the shaft to achieve a well-aligned congruous joint • Often accomplished with limited internal fixation and a 'spanning' ex-fix (hybrid).

43. Wound Management • Operative wounds may be closed primarily • Traumatic wounds left open • Every 24-48 hrs, debridements to achieve a clean, stable wound.

44. Closure and Coverage • GOAL: healthy soft tissue envelope with adequate muscle coverage over the fracture • delayed primary closure • split thickness skin grafting (STSG) • Exposed tendon or bone necessitates flap coverage

45. Rehabilitation • Early, aggressive rehab has the following benefits: • prevention of "fracture disease” • prevention of muscle disuse atrophy • prevention of joint stiffness and contracture • improved circulation

46. Type-III open tibial fractures • Averages: • 6 operations! • 2 mos of hospitalization! • > 1 year of rehabilitation! • 3 mos until complete soft tissue healing! • 12 mos for complete fracture healing!

47. THANK YOU