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Open Fractures PowerPoint Presentation

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Description : Open fractures management

Tags : health,fractures,bones,bones break,fractures management

Published on : Mar 23, 2022 | Views : 4213 | Downloads : 33

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Slide 1-

Open Fractures Principles of Management Edwin Chege
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Historical fact … until WW I Treatment of open fractures was “Amputation” Mortality rate ~ 75% Function in “survivors” was poor Alois Karlbauer
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Objectives Definition of an open fracture Important points in history of an open fracture Classification Management: Initial treatment Importance of surgical debridement Bone treatment initial & definitive Soft tissue coverage Factors affecting outcome
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Definition Open fracture is a fracture where the skin coverage overlying is breached even a small puncture wound Another name: compound fracture www.merryshannon.com
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History in open fractures Mechanism of injury Date, time, type, method of impact, … Consciousness Size of wound Amount of bleeding Other injuries: often missed Anti-Tetanus status
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Type of injury Determines amount of energy and Extent of soft tissue injury
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Type of injury Fall: height is important Sport: stronger impact Heavy object falling: direct injury – soft tissue Road traffic accident (RTA): more severe Car (MVA) , motorcycle, pedestrian Assault & firearms: severe
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Mechanism of Injury Try to determine if injury was caused by: Low velocity High velocity Crushing under objects
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Mechanism of Injury Field of injury: Relatively clean Contaminated soil
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Mechanism of Injury Open injury from: In-out: usually cleaner Out-in: usually more contamination and dirt www.aofoundation.org
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Mechanism of Injury Penetrating Missiles Low velocity < 300 m/s - damage along the tract Comminution High velocity: >300m/s - sever comminution Comminution with wide soft tissue damage Some fragment inside Some flip inside Vacuum phenomena - cavitation
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Eye Witness
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Signs of high energy injury Segmental fracture Bone loss Compartment syndrome Crush syndrome Extensive de-gloving
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A. Karlbauer Examples Low energy High energy
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Approach – clinical exam General medical condition should be evaluated to exclude shock and brain injury Vital signs should be observed and followed up Look: special attention is to be paid to wounds
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Approach – clinical exam Feel: Sensory and motor deficits Pulse distal to injury Compartment syndrome Tense compartment Move: With care, if necessary! www.medicinabih.info
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Approach – clinical exam Examination of the viscera Rib fractures Lung, liver and spleen Pelvic fractures Urinary bladder and urethra Head and spinal injury Neurological examination
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Management of open fractures Initial management Classifying the injury Definitive treatment
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Initial management it is essential that the step-by-step approach in advanced trauma life support not be forgotten Treat the patient, not the fracture! (A B C)
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Initial management it is essential that the step-by-step approach in advanced trauma life support not be forgotten When the fracture is ready to be dealt with: The wound is carefully inspected Any gross contamination is removed The wound is photographed The area then covered with a saline-soaked dressing The patient is given antibiotics Tetanus prophylaxis is administered The limb circulation and distal neurological status checked repeatedly
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Grades of open fracture Important to grade severity of open injuries and soft tissue injuries To treat according to guidelines To have an idea about prognosis Several classifications Most widely used: Gustilo Classification
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Gustilo Classification Grade 1: Low-energy, minimal soft-tissue damage (wound < 1cm) Grade 2: Higher energy, no flaps needed / no crushing Moderate contamination (wound > 1cm) Grade 3: High-energy, flaps needed / crushing Significant contamination.
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Gustilo Classification Sub-Types of Grade III: Type 3A : Adequate soft-tissue cover Can cover skin primarily Type 3B: Inadequate cover Can not cover skin primarily May need skin graft or flap Type 3C: Vascular injury Requires vascular repair
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Gustilo Grade I Low energy Simple fracture Skin open by fragment pressure within – out Wound < 1 cm No / little contamination www.orthopaedicsone.com/
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Gustilo Grade II Higher energy Laceration > 1 cm No flap / No contusion Minimal contamination
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Gustilo Grade IIIA High-energy, Adequate soft-tissue cover Contamination Comminution or segmental fracture
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Gustilo Grade IIIB High-energy, Extensive soft-tissue stripping Inadequate cover, Massive contamination
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Gustilo Grade IIIA or IIIB An intra-operative decision
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Gustilo Grade IIIA or IIIB ? Adequate soft tissue coverage
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Gastilo Grade? IIIC
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Problem of open fractures Infection – skin is breached Primary: from the field Massive contamination Debris and foreign bodies Devitalized tissues Secondary infection after internal fixation Initial bacterial contamination Proper debridement not done Internal fixation is a foreign body
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Principles of treatment All open fractures, no matter how trivial they may seem, must be assumed to be contaminated The basic guidelines: Antibiotic prophylaxis Urgent and proper wound and fracture debridement Stabilization of the fracture – Early definitive wound cover
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Primary surgery The aims of primary surgery are: Preservation of life and limb Definitive injury assessment Staged wound debridement May need to repeat after 48-72 hours Fracture stabilization
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Primary surgery – Debridement Trim skin edges Remove foreign material Remove all dead muscles and lacerated tissues Remove fully detached small bone pieces Saline wash: 5 Liters (wash–wash–wash) ? Delayed secondary closure
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Primary surgery – Debridement www.us.elsevierhealth.com / Principles of Fracture Treatment
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Alois Karlbauer
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Alois Karlbauer
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Alois Karlbauer
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Alois Karlbauer
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Treatment guidelines Gustilo I and II: Can treat by primary internal fixation Rate of infection low – if follow guidelines Alois Karlbauer
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Treatment guidelines Gustilo IIIA Usually defer internal fixation until soft tissue condition allows Gustilo IIIB External fixation Later, internal fixation Gustilo IIIC Vascular repair is a priority External fixator
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Higher infection rate Increased contamination: Exposure to soil Exposure to water Exposure to fecal material Exposure to oral material Gross contamination Delay > 12 hours
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Role of Antibiotics About 60–70% of the open injuries are contaminated at the time of arrival to the emergency department and the organism may vary according to the ambience of injury. The antibiotic should have a broad spectrum of action and our first choice is either the first or second generation of cephalosporins. In open injuries involving proximal femur or pelvis or with associated abdominal or perineal injuries, it is prudent to add an aminoglycoside and metronidazole as there is an increased chance of fecal contamination