Identifying Problems Early / Fractures des Membres Inférieurs
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Transcript Identifying Problems Early / Fractures des Membres Inférieurs
Specialists Without Borders
Seminar in Surgery
Rwanda, September 2010
LOWER LIMB FRACTURES
Identifying problems early
Professor Jegan Krishnan
Flinders University
Adelaide, South Australia
Specialists Without Borders
Seminar in Surgery
Rwanda, September 2010
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Learning Objectives
Emergency care of traumatised patient
Acute care of compound fractures
Assessment and Management of Neurovascular
Injury
Recognition and Management of Compartment
Syndrome
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Emergency Care of Traumatised Limb
General assessment of patient – Emergency
Medical and Surgical Trauma (EMST)
Clinical assessment
Neurovascular assessment
Limb stabilisation
Wound inspection dressings
Preliminary radiology
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Compound Fractures
Goals of open fracture management include:
Prevention of infection
Achievement of bony union
Restoration of function
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Compound Fractures
Compound fractures according to Gustilo and
Anderson:
Grade I: skin wound < 1 cm, clean
no contamination
Grade II: skin wound > 1 cm
no major soft tissue damage
Grade III: high energy, major soft tissue injury
or crush injury
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Compound Fractures
Grade I compound #
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Compound Fractures
Grade IIIc compound #
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Compound Fractures
Grade III A: adequate soft tissue coverage
of bone, although major soft
tissue damage
B: major soft tissue damage with
periostal stripping and no
coverage of bone
C: arterial damage requiring
reconstruction
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Management Principles
Antibiotic utilisation
Timing of initial surgery
Type of wound closure
Antibiotic delivery methods
Tetanus coverage
Wound irrigation
Adjunctive therapies
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Compound Fractures
Need immediately:
Bandage and splint
Antibiotics (Cephazolin 1gram IV)
Immediate referral
Follows:
Arteriography?
Surgery (<6 hrs)
At least 5 days of IV antibiotics
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Compound Fractures
Surgery
Grade I and II: - no plates
- intramedullary nail possible
Grade III:
- external fixator
- plastic surgeon – flap
- intramedullary nail possible
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External Fixation
All over ………………………
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Compound Fractures
Standard treatment for open tibial fractures
undergone changes over the last 20 years
Prompt assessment in emergency room
required
Early aggressive soft tissue and bone
debridement
High volume pulsatile lavage
Administration of IV antibiotics
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Compound Fractures – current concepts
Delayed wound closure or soft tissue coverage with
local or distant flaps proven highly effective
Minimise the risk of late deep infection, overall
infection rate between 3 and 5% for all open
fractures
Risk of infection related to severity of associated
soft tissue injury; Gustilo-Anderson Grade II
fractures reported incidence as high as 10%, with
Grade III reporting as high as 20%
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Compound Fractures – current concepts
Heitmann et al and Faisham et al have both
reported 60-64% of all open tibial fractures are
contaminated on presentation in emergency room
Robson et al demonstrated nearly all open fractures
are contaminated to some degree, introduced the
concept of “Golden Period of Opportunity” – initial
4 to 12 hr period following injury.
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Compound Fractures – current concepts
Early soft tissue coverage generally believed
to limit risk of subsequent deep infection
after open fracture
Very early wound closure is not a radical or
new concept in trauma surgery
No universal agreement regarding the
potential advantages of primary wound
closure
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SUMMARY
Early EMST wound dressing and splintage
Wound debridement
Appropriate antibiotics
Tetanus prophylaxis
Wounds coverage
Amputation