Transcript Document

OPEN (compound)
FRACTURES
Prof. M. Ngcelwane
1
2013
OBJECTIVES
MUST BE ABLE TO DIAGNOSE
OPEN FRACTURES
RECOGNIZE THAT THERE MAY
BE ASSOCIATED INJURIES
BE ABLE TO CLASSIFY OPEN
FRACTURE
PRINCIPLES OF EARLY
MANAGEMENT
DEFINITIVE MANAGEMENT
COMPLICATIONS
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WHAT IS A FRACTURE
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OPEN (COMPOUND)
FRACTURE
FRACTURE
XR: A break in the continuity of bone
Clinically: swollen, deformed, tender, loss of fx
COMPOUND
FRACTURE
Fracture where there is a skin wound
communicating with the fracture
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Examples of open
fractures
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IMPORTANCE OF SOFT
TISSUES
 An open fracture is a severe soft
tissue injury in which bone is also
broken.
 Extent of damage to soft tissue
determine the prognosis
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Gustilo and Anderson
classification of open
fractures
I < 1cm clean wound, simple fracture
pattern
II > 1cm, no extensive soft tissue
damage, no flaps/avulsion, simple
fracture fracture
III (A) Extensive wound, bone
adequately covered.
(B) Bone exposed, usually
contaminated.
(C) Arterial injury.
NB
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Causes
High energy trauma
Look for other injuries
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Anatomic considerations
Commonest long bone open fracture is
tibia
Most studied bone
Poor soft tissue cover
Cf. femur
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CLINICAL APPROACH TO
PATIENT WITH OPEN
FRACTURE
1.
2.
Assess life threatening injuries
• ABC of resuscitation
• Physical and neurologic exam
• Emergency Surgery (decision)
Assess limb
(a) Vasculature
pulse
doppler
angiogram
(b) Soft tissues
Skin - site - bruising
contamination
muscles
periosteum
(c) Neurology
Plantar skin sensation
3.
NB
Fracture pattern XR
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Neurovascular
assessment (tibia)
Vascular:
- Dorsalis pedis
- Posterior tibial
Motor:
- all compartments of the leg:
toe flexures, toe dorsiflexors, ankle evertors, plantar
flexors
Sensory:
- Tibial n: plantar surface of foot
- Deep peroneal n: dorsal web space 1st and 2nd toe
- Superficial peroneal n: dorsolateral
- Saphenous n: medial
REMEMBER - NOT POSSIBLE IN ALL PATIENTS
NB
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Treatment
MAIN COMPLICATION OF OPEN
FRACTURES IS INFECTION
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Open Tibial
Fractures
A
Open Fractures: Challenges
1.
Management of traumatic wound
2.
Achieving bony stability
3.
Decision making -limb salvage
vs. amputation
4.
Achieving soft tissue coverage
5.
Achieving fracture union
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PRINCIPLES
OF
TREATMENT
B
1.
2.
3.
4.
5.
NB
Wound debridement
Antibiotic therapy
Bony stabilization
Wound coverage
Maintain vascularization
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Emergency
Room
Treatment
C
1.
2.
3.
4.
5.
6.
7.
8.
9.
Reduce and splint the limb
Document neurologic and vascular
status
(Lavage wound)
Sterile compression dressing,
do not open again
(photograph)
Start I/V antibiotics
Tetanus prophylaxis
X-ray evaluation
To surgery as soon as possible
< 6 hours
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INTRAVENOUS
ANTIBIOTICS
Type open fracture
Cefazolin
Aminoglycoside
Penicillin
I
*
II
*
IIIA
*
*
#
IIIB
*
*
#
IIIC
*
*
#
# Soil contamination (clostridia)
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MANAGEMENT
Limb - specific treatment
(a) debride/decontaminate
• No tornique
• Remove all dead tissue
• Save bone
(b)
(c)
(d)
(e)
Skeletal stabilization
Soft tissue cover
Bone reconstruction
Rehabilitation
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Sepsis cannot occur
if good bleeding tissue
is present
“The solution to pollution is dilution”
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Principles
of
Debridement
D.
1.
2.
3.
4.
5.
6.
7.
NB
Classification determined at time
of debridement of future surgeries
Extend wound
a.
Visualise entire zone of
injury and where hematoma
traveled
Debride wound in a systematic way
a.
Skin edges subcutaneous
muscle bone
Remove foreign material
Debride necrotic skin, fat, muscle, bone
a.
Skin: conservative
b.
Fat and fascia: radical
Prophylactic fasciotomy of
compartment exposure
Muscle: debride non-viable tissue
a.
Color
b.
Consistency
c.
Contractility
d.
Capacity to bleed
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e.
Response to hemostasis
MUSCLE
DEBRIDEMENT
Colour: red/brown
Consistency: feels like
muscle/soft
Capillary circulation: does it
bleed?
Contractility: does it contract
with cautery or pinching
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COVER EXPOSED
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a
b
c
d
Neurovascular structures
Tendon
Bone
Articular surface
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BONE STABILIZATION
EXTERNAL FIXATOR
Reason: be able to clean/dress
wound; difficult to eradicate
infection with internal
fixation/plate
NB
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COMPLICATIONS
Neurovascular
Compartment syndrome
INFECTION (prophylaxis NB!!)
Loss of limb
NB
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Mangled Extremity Severity
Score
“MESS”
Skeleton Soft Tissue
Points
Low energy, simple fx, low velocity GSW
Medium, moderate comminution
High energy (close range shot gun, etc)
Massive crush
1
2
3
4
Shock
Normotensive (SBP>90)
Transient hypotension
Persistent hypotension
0
1
2
Ischemia
None
0
Decreased pulses
1*
No pulse, slow cap refill, paresthias
2*
Cool pulseless, insentiate
3*
Points double if ischemia > 6 hrs
Age
< 30 Yr
30-50
>50
0
1
2
MESS > 6 Amputation
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Not for studying purposes
MANAGEMENT
1.
2.
General supportive measures
(a) cover wounds
(b) fluid resuscitation/blood
(c) Antibiotics
- Cephosporin (2nd generation)
Limb - specific treatment
(a) debride/decontaminate
• No tornique
• Remove all dead tissue
• Save bone
(b)
(c)
(d)
(e)
Skeletal stabilization
Soft tissue cover
Bone reconstruction
Rehabilitation
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End
Thank you
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