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this is only about management of open fractures. Kindly give your valuable suggestions
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OPEN FRACTURES
By Dr Shahid Latheef
TREATMENT OF OPEN FRACTURES
HIPPOCRATES – “ SURGEONS CAN ONLY FACILITATE HEALING THEY CANNOT IMPOSE IT”.
EMERGENCY DEPARTMENT
A B C D E
Compressive bandages - Open, actively bleeding wounds.
Associated injuries. Spine , Chest & Pelvis
A careful examination of the extremities to diagnose fractures and dislocations
EMERGENCY DEPARTMENT.....
Assess neurovascular status
Documentation of wound
Photograph
IV antibiotics, Tetanus prophylaxis
Can I take pictures with my phone and send it to my senior?
EMERGENCY DEPARTMENT.....
Local irrigation with saline
Sterile compressive dressing and splint – Betadine soaked
Repeat wound examinations associated with higher infection rate
Do not culture wound in casualtyTscherne et al, Fractures with Soft Tissue
Injuries. 1984
DEBRIDEMENT
Pierre JosephTiming
At the earliest Within 6 hours from time of injury
Retrospective Study 47 Grade II/III open fractures Initial debridement
Less than 5 hours - 7% infection rateMore than 5 hours - 38% infection rate
Kindsfater et al, J Orth Trauma, Apr 1995,9(2) p121-7
Debridement Goals
Remove foreign material
Detection and removal of nonviable tissue
Reduction of bacterial contamination
Creation of wound that can heal without infection and promote fracture healing
Fasciotomy as indicated
HOW….. Not in CASUALTY but in THEATRE
5 to 10 liters of saline
Pulse lavage preferable
Iodine/Hydrogen peroxide not beneficial
Tourniquet used – may interfere with evaluation of muscle viability
Incision
Extensile incision
extend wound in longitudinal direction both proximally and distally
Expose: fracture, damaged tissue, and healthy tissue
“wound should be equal in length to the diameter of the limb at that level”
Evaluate muscle for:Color, Consistency, Contractility, and Capacity to
bleed
Necrotic muscle is culture medium for infection, especially anaerobic
“when in doubt, take it out”
Tendons Left if clean, and preserve blood supply Cover properly
Bone If devoid of soft tissue attachments, must
be removed Soft tissue attachments to remaining bone
must be preserved
ANTIBIOTICS
Minimal contamination 1st gen Cephalosporins
Moderate contamination, higher energy Amikacin (5mg/kg) IV Q 24
Soil contamination/severe contamination Penicillin Metrogyl
DURATION
Clinical decision Type I wounds 12 – 24 hours Type II and III wounds 2-3 days No role for prolonged use of antibiotics
Surgical Irrigation >10 Liters Normal Saline results in lower
incidence of infection
Pulse lavage is more effective than bulb syringe with NS resulting in 100 fold decrease in Staph Aureus in the wound
Anglen et al, J Ortho Trauma,2008 :390-396
Antibiotic Beads Provides high local concentration of
antibiotics in the wound
Prepared in the OR PMMA with Tobramycin made into bead
shapes, threaded on large non-absorbable suture, placed directly in the wound and covered with impervious dressing, creating “bead pouch”
STABILISATIONSplint Good option if operative fixation not required Synthetic splints preferred
External Fixation (Damage Control Orthopaedics in polytrauma patients)
Great option in contaminated wounds, or extensive soft tissue injury
Internal fixation Usually appropriate if wound clean, and soft tissue
coverage available
External Fixation
• Easily and rapidly applied• Excellent stability obtained• Damage Control Surgery• Reasonable anatomic reduction possible
Ex Fix…
Risk of infection minimized
Ability to convert to internal fixation when wound is clean with adequate soft tissue coverage available
Facilitates bone transport/acute shortening
Internal Vs External Fixation
Grade I to IIIA: Early –Internal fixation Late – External. Convert
to Internal fixation at the earliest
Grade IIIB: External fixation. Convert to Internal fixation when possible
Nail/ plate
Nail preferrable
Stable biological fixation – Plate or Nail
Supplement with bone grafts
Wound Closure
Delayed Primary Closure Local Soft Tissue Flap Free Tissue Transfer Best if wound is covered or closed within 5-7
days Decreases infection rate
Role of Amputation
“Saving a functional limb versus saving the patient”
Decision to be made early (48 – 72 hrs) Mangled Extremity Score Ganga Hospital Score
AO RECOMENDATIONS
1. Treat open fractures as emergencies.
2. Perform a thorough initial evaluation to diagnose life-threatening and limb-threatening injuries.
3. Begin appropriate antibiotic therapy in the emergency department or at the latest in the operating room, and continue treatment for 2 to 3 days only.
AO…4. Immediately debride the wound of
contaminated and devitalized tissue, copiously irrigate, and repeat debridement within 24 to 72 hours
5. Stabilize the fracture with the method determined at initial evaluation.
6. Leave the wound open (controversial).
AO…
7. Perform early autogenous cancellous bone grafting.
8. Rehabilitate the involved extremity aggressively.
SUMMARY Provide Airway and Urgent resuscitation
Immobilise injured extremity and cover wound with sterile dressing
Prophylactic IV antibiotics
Urgent optimum wound debridement
External fixation for damage control, definitive internal fixation at the earliest
Early bone grafting
Delayed wound closure with SSG/Flap
COMPLICATIONS GAS GANGRENE
TETANUS THROMBO EMBOLIC COMPLICATION
LATE COMPLICATION DELAYED UNION NON-UNION MAL-UNION CHRONIC INFECTION
REFERENCES
Rockwood and Green’s fractures in adults- 6th
Campbells Operative orthopaedis- 11th edn
Text book of orthopaedics – Kulkarni Anglen et al, J Ortho Trauma,2008 :390-
396
Dr Shahid Latheef+917795664142
Thank you…