Trauma- Management of Open Fractur

8/19/2019 Trauma- Management of Open Fractur

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Management of

Open Fractures

Source: Bucholz, R; Heckman, J.; CourtBro!n, C.Rock!oo" # $reen%s Fractures &n '"ults(olume ), Sect&on One $eneral *r&nc&ples

Chapter )+ Olson, S.; &ll&s, M.


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-/RO01C/-O

• Fracturesthat are

e2pose" totheen3&ronment

through4reaks &n thesk&n


3/59

• Occur &n !&"espectrum ofcon"&t&ons !&thspec&5cconse6uences – Bacter&a ma7

contam&nate area of&n8ur7

– Force magn&tu"ere6u&re" to pro"ucethe fracture &s3ar&a4le


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• Mechan&sm of -n8ur7

result from the appl&cat&on of a3&olent force

appl&e" k&net&c energ79.? m(+


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6/59

– -n certa&n cases, "&agnos&s ma7 4e"&@cult as the !oun" ma7 appear

remote to the s&te of fracture. –M&sse" open &n8ur&es A

osteom7el&t&s, &nfecte" nonun&on

–

Fracture must 4e cons&"ere" openunt&l pro3en other!&se "&recte" 47surg&cal stag&ng


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• H&ppocrates 9D>E> BC< ar asmost appropr&ate tra&n&ng groun" forsurgeons. /he7 can fac&l&tate heal&ngan" cannot &mpose &t. '"3ocate" -#0for !oun"s that "&" not progress.

• $alen 9+n"< also recogn&ze"

purulence, cons&"ere" essent&al tothe repa&r process

History


8/59

• Brunsch!&g an" Botello 9)?th an" )Dth< remo3al of necrot&c t&ssue from !oun"sthat "&" not progress

• 'm4ro&se *are 9)th< Hot o&l as cauter7.1se" turpent&ne o3er !oun", enlarge"!oun"s; largel7 unrecogn&ze" "ur&ng h&s"a7

• 0esault 9)Gth< A reesta4l&she" e2plorat&onof !oun", a"opte" the term "e4r&"ement

History


9/59

• arre7 A 0esaultIs pup&l a""e" t&m&ng sooner the 4etter

• Math7sen A *O*, occlus&3e "ress&ngs!ere re&ntro"uce", onl7 to lapseaga&n 4ecause of unto!ar" eectsfrom m&sappl&cat&on, t&me !hen

"e4r&"ement !as a4an"one"• &ster Car4ol&c ac&" "ress&ngs

History


10/59


11/59

• orean ar I?>I?E A 'nt&4&ot&c use.*ol&c7 of rap&" e3acuat&on, !oun"

"e4r&"ement, an" "ela7e" closure.St&ll the stan"ar" to"a7

• '"3ances sh&fte" the focus – *reser3at&on of l&fe an" l&m4

preser3at&on of funct&on an" pre3ent&onof compl&cat&ons

History


12/59

• Operat&on n"ur&ng Free"omO/' AC*$ m&rror the m&l&tar7 mo"el: 'BCs,spl&nt an" "ress !oun", -(ant&4&ot&cs, urgent operat&3e"e4r&"ement an" &rr&gat&on, lea3e the

!oun" open, an" sta4&l&ze unsta4leskeletal &n8ur&es, repeate""e4r&"ements prn

History


13/59

0-'$OS-S

• Stra&ghtfor!ar" &n most

• H&stor7

•

* A !oun" "&mens&on, 3&s&4le 4one,(, compare to normal s&"e


14/59

'ssessment of the *at&ent

• '"3ance" trauma l&fe support'&r!a7

Breath&ng

C&rculat&on

0&sa4&l&t7

2posure

Sa3e the pat&ent, then the l&m4NN


15/59

'ssessment of the pat&ent

• ook for :&fe&m4 threaten&ng &n8ur&es

Other assoc&ate" &n8ur&es

Check "&stal c&rculat&on, neurolog7

Check compartment pressure


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/he Soft /&ssues

Fracture appears non complex onradiographs

The realinjury


17/59

*at&ent (ar&a4les

• 'ge

• $en"er

• 0&a4etes• -nfect&on

• Smok&ng

•

Me"&cat&ons• 1n"erl7&ng

ph7s&olog7


18/59

-n8ur7 (ar&a4les

• Se3er&t7

• nerg7 of -n8ur7

• Morpholog7 of thefracture

• Bone loss

•

Bloo" suppl7• ocat&on

• Other &n8ur&es


19/59

'ssessment of the !oun"

• hat &s the nature of the !oun"

• hat &s the state of the sk&n aroun" the

!oun"• -s the c&rculat&on sat&sfactor7

• 're the ner3es &ntact


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21/59

Open fracture class&5cat&on

• 'llo!s compar&son of results

• *ro3&"es gu&"el&nes on prognos&s an"treatment – Fracture heal&ng, &nfect&on an"

amputat&on rate correlate !&th the"egree of soft t&ssue &n8ur7

• $ust&lo upgra"e" to $ust&lo an"'n"erson

• 'O open fracture class&5cat&on


22/59

C'SS-F-C'/-O

• $ust&lo an" 'n"erson – Most 6uote" an" !&"el7 accepte"

– 0egree of softt&ssue &n8ur7 an"

contam&nat&on pre"&ct outcome – &"e 3ar&at&on, too much emphas&s on

!oun" s&ze•

0e3astat&ng crush &n8ur7 of the legnecess&tat&ng amputat&on ma7 4e assoc&ate"!&th onl7 a small sk&n !oun"; 3er7 large!oun" cause" 47 a sharp o48ect, such as akn&fe, ma7 ha3e m&n&mal assoc&ate" soft

t&ssue crush


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/7pe ) Open Fractures

• -ns&"eout &n8ur7

• Clean !oun"

• M&n&mal soft t&ssue

"amage• o s&gn&5cant

per&osteal str&pp&ng


24/59

/7pe + Open Fractures• Mo"erate soft

t&ssue "amage

• Outs&"e&n

• H&gher energ7

• Some necrot&cmuscle

• Some per&osteal

str&pp&ng


25/59

/7pe Ea Open Fractures

• H&gh energ7• Outs&"e&n

• 2tens&3e muscle"e3&tal&zat&on

• Bone co3erage!&th e2&st&ng softt&ssue


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/7pe E4 Open Fractures

• H&gh energ7• Outs&"e &n• 2tens&3e muscle

"e3&tal&zat&on• Re6u&res a Pap

for 4oneco3erage an"soft t&ssueclosure

• *er&osteal

str&pp&ng


27/59

/7pe Ec Open Fractures

• H&gh energ7

• -ncrease" r&sk ofamputat&on an"

&nfect&on• 'n7 gra"e E !&th

ma8or 3ascular&n8ur7 re6u&r&ngrepa&r


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• ' t7pe ---C open fracture &s one &n!h&ch there &s a major 3ascular&n8ur7 re6u&r&ng repa&r for sal3age of

the e2trem&t7. – ' t&4&a fracture !&th "&srupt&on of the

anter&or t&4&al arter7 4ut preser3at&on of

the poster&or t&4&al arter7 &s not a t7pe---C &n8ur7.

– 'n open fracture of the forearm !&th an&ntact ulnar or ra"&al arter7 an" well-

perfused han" &s not a t7pe ---C &n8ur7.


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h7 use th&sclass&5cat&on

• $ra"es of soft t&ssue &n8ur7 correlates !&th&nfect&on an" fracture heal&ng

Grade 1 2 3A 3B 3C

-nfect&onRates

>+Q +Q )>+?Q)>?>Q

+??>Q

FractureHeal&ng9!eeks<

+)+G +G+G E>E? E>E?

'mputat&on Rate

?>Q


32/59

AO classifcation (adapted

rom Tscherne)• /he

'O class&5cat&on of fracture !oun" se3er&t7 pro3&"es a gra"&ng s7stem for &n8ur&es of

each of the sk&n 9-


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34/59

/reatment

Current Treatment at the ER

• O43&ous "e4r&s that can 4e eas&l7remo3e" shoul" 4e taken !&th ster&le

forceps.• -f the pat&ent !&ll 4e at OR &n )+ hours

from &n8ur7, co3er !oun" !&th a ster&le

4an"age• -f not, &rr&gate the !oun" !&th )+

*SS 4efore plac&ng the ster&le "ress&ng


35/59

• Once the ster&le "ress&ng &s place", no further!oun" &nspect&on shoul" 4e "one unt&l thepat&ent &s &n the OR

• .EQ &nfect&on rate &n open !oun"s that !ereco3ere" &mme"&atel7 !&th a ster&le "ress&ng,compare" !&th an )GQ &nfect&on rate &n open!oun"s left e2pose" unt&l surger7.

• /o pre3ent su4se6uent ph7s&c&ans remo3&ng the"ress&ngs to 3&e! the !oun", a photograph can4e taken an" place" &n the chart for laterre3&e!.


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'nt&4&ot&cs

• /herapeut&c, notproph7lact&c

•

&ll res&"ualorgan&sms an" atleast &nh&4&t the&rgro!th to the po&nt

!here hostprotect&3emechan&sms canera"&cate them


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39/59

• . 'ssess sk&n an" soft t&ssue"amage; *lace a mo&st "ress&ng onthe !oun"

• ?. *erform pro3&s&onal re"uct&on offracture an" place &n a spl&nt, 4raceor tract&on

• D. Operat&3e -nter3ent&on


40/59

Operat&3e /reatment

*r&mar7 surger7

• O48ect&3es of &n&t&al

surg&cal management – *reser3at&on of l&fe an"

l&m4

– oun" "e4r&"ement

–

0e5n&t&3e &n8ur7assessment

– Fracture sta4&l&zat&on

Stages of open fracture management &n the


41/59

• Clean open - -- fractures !herepr&mar7 &nternal 52at&on &s carr&e"out, &mme"&ate cancellous 4one

graft&ng ma7 4e &n"&cate"• Remo3e R spl&nt an" "ress&ng

• Ma&nta&n tract&on

• *oss&4le tourn&6uet

• /!ophase surg&cal preparat&on


42/59

• /ourn&6uet shoul" not 4e &nPate" unless &t &snecessar7 4ecause ano2&a pro"uce"&nterferes !&th e3aluat&on of the 3&a4&l&t7 of

muscle an" ma7 a"" to pree2&st&ng&schem&c t&ssue &n8ur7.

• /rans&ent &nPat&on of the tourn&6uet for )>to +> m&nutes, follo!e" 47 release, results

&n cap&llar7 Push. /h&s ma7 4e a helpful&n"&cator of softt&ssue 3&a4&l&t7. ' tourn&6uetshoul" ne3er 4e &nPate" !h&le -M ream&ng.


43/59

• S7stemat&c: sk&n, fat, muscle,$regor7 Cs, 4one. Scull7: 9H&sto<cons&stenc7 an" capac&t7 to 4lee".

Olson: contract&l&t7 an" cons&stenc7• oun" shoul" 4e e6ual &n length to

the "&ameter of the l&m4 at that le3el

• 3en &f )>Q of a muscle 4ell7 an" &tsattache" ten"on &s preser3e",s&gn&5cant funct&on &s reta&ne"


44/59

• &thout a ma8or 4loo" 3esel, e2c&se

• Met&culous hemostas&s

• '3o&" "&stal Paps

• -t &s 4etter to "eal !&th the reconstruct&onof a large segmental "efect than to allo!chron&c &nfect&on to result &n chron&costeom7el&t&s, !h&ch ma7 lea" to e3en

more 4one loss A so "e4r&"e 4one. *apr&ka 4one e"ge 4lee"&ng &s the most rel&a4letechn&6ue a3a&la4le.


45/59

• Fasc&otom7 after 3essel repa&r often &snecessar7, surgeon &s urge" to "o &tproph7lact&call7 &n nearl7 e3er7 case. -f

there &s an7 "ou4t a4out &ts &n"&cat&on,&t pro4a4l7 shoul" 4e "one. Moreo3er,&t &s 4etter "one too earl7 than too late

•

)> &rr&gat&on. -f a l&ttle "oes somegoo", a lot !&ll "o a great "eal more. /he solut&on to pollut&on &s "&lut&on


46/59

• -n&t&al la3age Pushes a!a7 4loo" for&nspect&on, remo3es "e4r&s

• ecrot&c t&ssue Poats

• a3age restores &ts normal color an"fac&l&tates "eterm&nat&on of 3&a4&l&t7.

• -rr&gat&on re"uces the 4acter&al populat&on.

•

-rr&gat&on &nclu"es pulsat&le la3age, !aterp&c, cont&nuous &rr&gat&on, an" 4ul4s7r&nge. ach has an a"3ocate. '""&t&3es


47/59

• -rr&gat&on an"0e4r&"ement

a"e6uate&rr&gat&on an""e4r&"ement are themost &mportant steps

&n open fracturetreatment


48/59

Ho!e3er, after re3&e! of alll&terature..

• Ok&ke et al. states.• /horough operat&3e "e4r&"ement &s the

stan"ar" of care for all open fractures.T•

3en &f the 4ene5ts of formal -#0 !ere&ns&gn&5cant for lo! gra"e fractures,operat&3e "e4r&"ement &s st&ll re6u&re"for proper !oun" class&5cat&on.T

• Open fractures gra"e" on the 4as&s ofsuper5c&al character&st&cs are oftenm&sclass&5e".T

• Huge r&sk not to e2plore an" "e4r&"eNOk&ke , Bhattachar77a /: /ren"s &n the management of open fractures. ' cr&t&cal anal7s&s. J Bone Joint Surg Am.+>>D 0ec;GG9)+


49/59

O48ect&3es of 0e4r&"ementan" -rr&gat&on

• 2tens&on of the traumat&ze" !oun" to allo!&"ent&5cat&on of the zone of &n8ur7

• 0etect&on an" remo3al of fore&gn mater&al,

espec&all7 organ&c fore&gn mater&al• 0etect&on an" remo3al of non3&a4le t&ssues

• Re"uct&on of 4acter&al contam&nat&on

• Creat&on of a !oun" that can tolerate the

res&"ual 4acter&al contam&nat&on an" heal!&thout &nfect&on.

-#0 & th OR


50/59

-#0 &n the OR• /rauma scru4

– Soap an" sal&ne to remo3e gross"e4r&s

• Uone of &n8ur7T – Sk&n !oun" &s the !&n"o! through

!h&ch the true !oun" commun&cates!&th the e2ter&or

•2ten" the traumat&c !oun" – 2c&se marg&ns – Resect muscle an" sk&n to health7

t&ssue• color, cons&stenc7, capac&t7 to 4lee" an"

contract&l&t7

• Bone en"s are e2pose" an""e4r&"e"

• -rr&gate• Ser&al "e4r&"ements

– -f nee"e", +n" or Er" "e4r&"ement after+G hours shoul" 4e planne"


51/59

/he -rr&gat&on•

'mount – o goo" "ata, cop&ous &s

4etter

– 'nglen recommen"s:•

E for t7pe )• D for t7pe +

• L for t7pe E

'nglen JO. oun" -rr&gat&on &n Musculoskeletal -n8ur7.T JAAOS +>>). L: +)L++D.


52/59

S/' S/'B--U'/-O

• -f unsta4le follo!&ng "e4r&"ement

• Restore length an" al&gnment of long 4ones

• Re"uce art&cular surfaces "&splace" 47

fracture• 'llo! access to the traumat&c !oun"

• Fac&l&tate further reconstruct&on proce"ures

• 'llo! earl7 use of the l&m4

• Fac&l&tate fracture un&on an" return of funct&on


53/59

• Range from tract&on to plaster&mmo4&l&zat&on to &nternal 52at&on.

• /he more se3ere the open fracture, the

greater the nee" for "&rect skeletal52at&on to allo! &mpro3e" access to thetraumat&c !oun".

• Reesta4l&shment of al&gnment pro3&"esopt&mal c&rculat&on to the &n8ure"e2trem&t7 from neuro3ascular structures.


54/59

• Salter, M&tchell an" Shepar" A goo"&ntraart&cular re"uct&on ha3e goo"outcomes

•

Contra&n"&cat&ons: – Se3ere osteopen&a

– Se3ere comm&nut&on; nonreconstructa4leV

– M&n&mal soft t&ssue &n8ur7 !&th a non"&splace"

fracture 9&.e., &"eal for close" treatment< – Se3ere ongo&ng local &nfect&on

– Se3ere comor4&"&t&es preclu"&ng anesthes&a


55/59

• *laster cast use 4est &f un&3al3e"than 4&3al3e"

• Bu44le

• 2ternal 52at&on &s most often&n"&cate" for Open ---B ---C

*OS/O*R'/-( '/-B-O/-C


56/59

*OS/O*R'/-( '/-B-O/-C1S

• Os!ol": 'nt&4&ot&cs are g&3en for G hoursafter the &n&t&al an" an7 su4se6uent"e4r&"ements, as !ell as after !oun"

closure.• /h&s often translates &nto a pat&ent 4e&ng

on ant&4&ot&cs for + to "a7s follo!&ng&n&t&al presentat&on an" "e4r&"ement. -f

s&gns of &nfect&on or "ra&nage occur at an7t&me, the !oun" &s culture" an" treatment&s 4ase" on those cultures


57/59

• +. g /o4ram7c&n or )g (ancom7c&npo!"er !&th e3er7 >g of *MM' 4onecement. /he m&2ture &s place" &nto a 4ea"

mol" to create a ser&es of Dmm "&ameter4ea"s strung on mult&plestran" sta&nlesssteel !&re or nona4sor4a4le suture

• Ostermann et al: 4ea" pouch techn&6ue as

a supplement to -( ant&4&ot&cs. )? cases,.EQ (S ELQ Osteo4last to2&c&t7, nonun&on


58/59

• OC' $'/-(*RSS1R0RSS-$S)LL, 'rgenta an" Mor7k!as

• S/S$


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• /hank 7ouN

Documents

Trauma- Management of Open Fractur