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OPEN FRACTURES. Joseph J. Ruzbarsky , MD Trauma Conference September 22, 2014. 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”. Goals of Treatment.
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OPEN FRACTURES Joseph J. Ruzbarsky, MD Trauma Conference September 22, 2014
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”
Goals of Treatment • Prevent infection • Achieve bony union • Restore soft-tissue envelope • Early motion and rehabilitation
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
Type-I • < 1 cm wound • low-energy injuries • 'inside-out’ • minimal soft tissue damage • minimal comminution • minimal contamination
Type-II • > 1 cm wound • mild-mod. energy • 'outside-in' moderate soft tissue injury • moderate comminution • moderate contamination
Type-III • large wounds (> 10cm) • high energy injury • extensive soft-tissue injury • marked comminution • marked contamination
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
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
Infection • Incidence correlates directly with extent of soft-tissue injury, NOT the length of the wound. • Gustilo et al., JBJS, 72A; 1990
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 %
Initial Treatment • ABC's according to the ATLS protocols • Life-threatening injuries take precedence over limb threatening injuries • Thorough neurovascular exam
Tetanus Prophylaxis • Clostridium tetani • Immunized w/in 5 yrs - No treatment • Immunized > 5 yrs - tetanus toxoid • Status unknown - tetanus toxoid and tetanus immune globulin
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
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
Antibiotic Treatment • should begin as soon as possible • > 70 % of open fxs. are contaminated with bacteria at the time of injury
Which antibiotic? • Type-I and Type-II • cephazolin • Type-III • cephazolin plus aminoglycoside • Farm or sewage related injury • cephazolin, aminoglycoside and penicillin
Irrigation and Debridement • The most important intervention! • Repeat every 24-48 hours until wound appears clean and devoid of non-viable tissue.
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
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
Fascia • excise any non-viable, damaged or contaminated fascia • limited vs. formal fasciotomy for high-energy injuries • Open fractures do NOT necessarily decompress compartment
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
Muscle Debridement • nonviable muscle is themajor nidus for infection • the Four C's • color • consistency • contractility • capacity to bleed
Tendon Debridement • unless severely damaged or contaminated, may be preserved • preserve peritenon if possible • cover tendons with local muscle
Bone Debridement "Our most common judgement error has been the delayed excision of nonviable bone” Chapman and Olson, Fractures, Ed 4, 1996.
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.
Open Joints • explore any open joint injury • arthroscopy may play a helpful role during I & D
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
Primary Amputation • Lange's absolute indications: • warm ischemia time > 6 hours • anatomic division of the tibial nerve
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.
Cast Immobilization • Some Type-I and Type-II fractures • Difficult to observe wound
External Fixation • Advantages • good stability to fracture site • good wound access • easily and rapidly applied • minimal trauma to soft tissues
External Fixation • Disadvantages • pin tract problems (irritation, loosening, infection) • limited life span • may limit soft-tissue procedures
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
Plate and Screw Fixation • Disadvantages • need for further exposure • devascularization of tenuous bone fragments
Plate and Screw Fixation • Indications • Type-I and some Type-II open fractures • intra-articular fractures • metaphyseal fractures • Forearm
Intramedullary Fixation • Advantages • provides excellent stability • improved soft-tissue access • early motion and rehabilitation well-tolerated
Intramedullary Fixation • Disadvantages • impairs endosteal circulation (reamed> unreamed) • often longer OR time than external fixation
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).
Wound Management • Operative wounds may be closed primarily • Traumatic wounds left open • Every 24-48 hrs, debridements to achieve a clean, stable wound.
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
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
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!