Management of compund fractures

MANAGEMENT OF COMPOUND FRACTURES

DR.JAYANT SHARMAM.S. D.N.B. M.N.A.M.S.

CONSULTING ORTHOPAEDIC SURGEON

ARIHANT HOSPITAL AND RESEARCH CENTRE. INDORE

Nearly two centuries ago Percival Pott was thrown from his horse in the Old Kent Road and sustained an open fracture of tibia, he bought a backyard door, to which he nailed two poles to make a stretcher not only did he survive the injury but escaped an amputation.

High Velocity of vehicles

Competitive sports

Increased Terrorism.

PATHOPHYSIOLOGY

The limb absorbs the energy on contact Releases the energy in an explosion Comminutes the bone Creates a soft tissue shock wave Strips the periosteum, tears apart the skin causing a momentary vacuum Sucks the adjacent foreign material in the depth of the limb

GUSTILO ANDERSON CLASSIFICTION

Grade I- Open fracture clean wound , less than 1 cm long.Grade II- More than 1 cm long, extensive soft tissue damage, skin flaps or avulsion includes segmental, and comminuted fracture.Grade III - A - Extensive soft tissue damage, but bone covered. B - Bones periosteum also stripped and bone exposed. C - Open fractures with Arterial injuries.

DRAWBACKS OF GUSTILO

Highly case dependent Needs experience of the Surgeon Changes with debridement Not an adequate basis for the treatment decision. Not comparable.

A.O. CLASSIFICATION IC1 - No skin lesionIC2 - No laceration but contusionIC3 - Circumscribed deglovingIC4 - Extensive closed deglovingIC5 - Necrosis from contusionAnd with Fracture,IO1 - Skin breakage from inside outIO2 - Skin breakage from outside less than 5 cms.IO3 - Skin breakage from outside more than 5 cms with devitalized edges.IO4 - Full thickness contusion with degloving.

DRAWBACKS OF A.O.CLASSIFICATION

Score is biased on the size and nature of the wound.

Equal emphasis is not provided to the damage of the functional structures, and severity to the bony injury.

Poor predictor of the outcome.

M.E.S.S.– MANGLED EXTREMITY SEVERITY SCORING

It is good to decide the amputation but , Does not provide the guidelines for the treatment. Does not prognosticate the outcome.

GANGA HOSPITAL SCORECOVERING STRUCTURES 

1. WOUND- NOT OVER THE BONE 0                                               i. No skin loss 1

                                              ii. With skin loss 2

2.  WOUND OVER THE BONE

                                              i. No skin loss 3 3.  With skin loss/ friction burns/ degloving 4

4.  Circumferential wound 5

GANGA HOSPITAL SCOREFUNCTIONAL TISSUE

Exposed musculotendinous unit without injury 1

Reparable injury to MT unit 2

Crushing with loss of MT unit with reparable Nerve 3 

Loss of one compartment with irreparable nerve 4

Loss of 2 or more compartment 5

GANGA HOSPITAL SCORE

SKELETAL TISSUE 

Transverse/oblique # with periosteal stripping 1

Butterfly fragment/ unicortical injury Comminution/ segmental/without bone loss 2

Periarticular comminution with joint disorganized 3 

Circumferential comminution bone loss less than 4cm. 4

Comminuted with bone loss more than 4 cm 5

GANGA HOSPITAL SCORE

COMORBID CONDITION (2 POINTS FOR EACH)

Open injuries more than 12 hrs.Sewage contaminationMore than 65 yrs. Of ageDebilitating diseaseFat embolismAssociated systemic injuryOther injury in the same limb/compartment syndrome.

TREATMENT OPTIONS

The philosophy of the treatment requires, reduction of the risk of complication : a) By urgent treatment, b) Removal of foreign body, c) Sharp debridement and d) Reduction of bacterial load.

GOLDEN HOUR CONCEPT

, “Every person has right to the best medical care, if you are critically injured, you have less than 60 mins to survive.You may not die right then, it may be 3 days to 2 weeks later, but something has happened in your body that is irreparable.”

R. Adams Cowley

SILVER DAY CONCEPTThe first day is of great significance. It involves ,

a) Quick reaction of the medical teamb) Documentationc) Investigationd) Transportation to an appropiate trauma center.e) Splintage - movements allow material contamination to be buried deeper in the

wound and suction of infected material in the joint

DEBRIDEMENT

It is a term applied to the, Exploration of the wound Excision of devitalized tissue. Removal of the foreign material.

EXPLORATION

The greatest of all antiseptics is a living tissue”- Sir, Alexander Fleming.

Superficial wound opening must be extended sufficiently to expose all deep structures.

EXPLORATION

For the debridement of the Muscles we should take under consideration of the 4-

C ,are, COLOUR, CONSISTENCY, CONTRACTILITY, CAPACITY TO BLEED .

EXPLORATIONRemove all nonviable bone fragments without

adequate soft tissue attachment.

Clear the tract if wide excision of muscles is not required, with a gauze.

Irrigation with the Normal saline should be carried out using 10-14 lts. of Saline.

Installation of local antibiotics is no remedy for incomplete wound toilet.

EXPLORATION

Jeffery Anglen — Irrigation with a detergent solution is more effective then a solution

with antibiotic additives.

(JBJS Oct2005)

EXCISION

Beginning with skin,it includes excision of devitalized structures, till the fresh

bleeding is seen.

REMOVAL OF FOREIGN BODY

Fragments of clothing, wood, grass, or mud should be removed .

Shot gun pellets cause little devitalization and quick healing occurs.

Metallic foreign bodies should be lifted from the cavity, but there need not be exploration beyond the tissue limits.

 Bullets should be removed they donot get sterilized

by the heat, there is a suction effect which draws outside environment inside.

PROPHYLACTIC ANTIBIOTIC  The ATLS protocol(Advanced trauma life

support), must be administered for prophylactic Intravenous antibiotics, preferably III generation Cephalosporins, Aminoglycosides(Gentamicin), Entroquinolones(Metronidazole) is given, depending on the contamination.

PRIMARY CLOSURE Depending on the adequacy of the debridement, viability of the skin margins, and ability to approximate the skin, without tension, placed ¼ inch (6mm) apart, sometimes skin closure is possible by making releasing incisions.Do not drag the tissue to approximate.

DELAYED PRIMARY CLOSURE V/S FLAPS

The older concept of the delayed suture is still practiced but has taken a back seat over the flaps,due to decreased risk of –

Secondary infectionWound dessicationNeed for redebridement

Split Skin grafting is considered most effective means of delayed primary closure

Instability of scar from split skin grafting may not heal well during reconstructive procedures

This could be achieved by full thickness pedicle flaps and free flaps.

STABILIZATION OF BONE

Upto grade IIIA- Internal fixation after thorough debridement is the standard followed practice.

IIIB - A primary stabilization using external fixators followed by a definitive fixation and bone grafting.

COMPLICATIONS

• INFECTION

• NON UNION & DELAYED UNION

• COMPLICATIONS OF WOUND HEALING.

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