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Open Fractures TTB

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26 views45 pages

Open Fractures TTB

Uploaded by

cromwellopoku42
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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OPEN FRACTURES

PRESENTED BY:
DR AKUA YEBOAH SENYAH
TRAUMA TEAM B
OUTLINE
 INTRODUCTION
 ETIOLOGY AND PATHOPHYSIOLOGY
 CLASSIFICATION
 PRINCIPLES OF MANAGEMENT
 EMERGENCY MANAGEMENT
 INVESTIGATION
 DEFINITIVE MANAGEMENT
 COMPLICATIONS
 CASES
 CONCLUSION
 REFERENCES
INTRODUCTION

DEFINITION - A fracture communicating with the


external environment through a break
in the skin and underlying soft tissue or other viscus.
MECHANISM OF INJURY
 The kinetic energy imparted to the tissues produces varying
degrees of damage depending upon the amount of force
applied.
 Open fractures are usually caused by the following
mechanisms:
i. Road traffic accidents (COMMONEST)
ii. Gunshot wounds
iii. Farming accidents
iv. Falls
v. Industrial injuries
CLASSIFICATION

Various classifications had been in existence but the


most widely accepted and prognostically significant is
the Gustilo-Anderson classification
This was based on the size of wound, energy level, level
of contamination and the duration of injury.
GUSTILO-ANDERSON CLASSIFICATION

 Type I: an open fracture with a wound less than 1 cm in


length, and clean. Fracture pattern is simple (low energy)
and inside-out injury.
 Type II: an open fracture with a laceration more than 1 cm in
length, without extensive soft tissue damage, flaps, or
avulsions. Fracture pattern may be simple or complex
(moderate energy) and it’s an outside-in injury.
 Type III: either an open multifragmentary fracture, an open
simple fracture with extensive soft tissue damage, or a
traumatic amputation.
 The description of type III fractures was subsequently further
refined and described by Gustilo et al in 1984, as follows:

Type IIIa: severe comminution or segmental fractures, but with


adequate coverage of bone and a wound that is closeable by
simple means
Type IIIb: extensive soft tissue damage in association with the
open fracture, with significant bone exposure and periosteal
stripping, typically requiring tissue rotation or free tissue transfer
for closure
Type IIIc: any open fracture with a neurovascular injury that
requires repair. And all gunshot injuries.
Fig. 2.3 Sixteen year old male who sustained a Type IIIB open tibia fracture. The fracture was
stabilized with an external fi xation system, enabling access to the skin wound created by the open
Mangled Extremity Severity Score
• An attempt to help guide between primary amputation vs. limb salvage
• In one study a score of 7 or higher was predictive of amputation*Jahasen et al Trauma 1991

*Johansen et al. J Trauma 1991


DIAGNOSIS

 The diagnosis of an open fracture is often obvious.


 It must be remembered that any fracture associated
with a wound in its vicinity should be technically
regarded as open unless proven otherwise.
NB

 Open fractures may be associated with significant


nerve and vessel damage.
 A thorough examination of the peripheral nerves and
vessels should be performed.
 The possibility of the development of a
‘compartment syndrome’ should
always be borne in mind.
• PRINCIPLES OF MANAGEMENT
Goals of treatment
1. Preserve life
2. preserve limb
3. preserve function

Also,
- prevent infection
- fracture stabilization
- soft tissue coverage
EMERGENCY MANAGEMENT
NB: Principles of management of a traumatised patient
remain the same.
Primary assessment:
 Never forget A, B, C,D,E
 Control bleeding
 IV antibiotic
 ATS and TT (if immunity has waned)
 adequate analgesia
 Wash (high or low pressure) and dress the wound
 Realign fracture, splint, elevate and apply ice
 Recheck pulse, motor and sensation.
 Secondary assessment:
 Can now take a detailed history and assess thoroughly for
other injuries
 Radiographs to confirm diagnosis
 Other investigations (urgent
 FBC
 BUE, Cr
 GXM
EMERGENCY (CONT.)

 Okike et al states:
“Thorough operative debridement is the standard of care for all
open fracture”
“ Even if the benefits of formal I&D were insignificant for low grade
fractures, operative debridement is still required”
 In theatre,
 Adequate debridement
 Thorough irrigation
 Can mount an external fixator for Grades II and III open fractures to
maintain reduction and at the same time allow for soft tissue recovery.
 Grade I: Can do primary closure and treat like a closed fracture
Definitive management
 Will depend on the location and type of fracture.
IM nailing
Plating
Screws
Ex Fix
Cast
COMPLICATIONS
IMMEDIATE
- Shock
- Nerve injury
EARLY
 Infections
 Compartment syndrome
 Joint stiffness
 DVT
 Thromboembolism
 PE
LATE
Delayed union
Mal-union
Non-union
Avascular necrosis
SOME GOOD WORKS
LACK OF EDUCATION
IN CONCLUSION:
 We must always remember:
 Our goals:
-Preserve life
- Preserve limb
- Preserve function
 Operative debridement is the gold standard of care
 In stabilization, restore length, alignment, rotation and
stability
 Soft tissue care
NB: Size of wound does not necessarily correlate with the
extent of soft tissue damage.
 Involve all the necessary departments in your management.
You cannot do it all alone.
References:
• Classification and diagnosis in Orthopaedics,
 RAHIJ ANWAR
 M.S. (Orth.); M.Sc. (Trauma); M.R.C.S. (Ed.)
 Specialist Registrar (Trauma & Orthopaedic
 UK
 KENNETH W. R. TUSON
M. B., Ch. B, F.R.C.S. Orth, Edinburgh, F.R.C.S. Eng.
Consultant Orthopaedic Surgeon
 SHAH ALAM KHAN
M.S. (Orth), Dip National Boards (Ortho.), M.R.C.S. (Ed.), M.Ch. Ortho.
Asistant Professor, Department of Orthopaedic Surgery

• Wheeless textbook of Orthopaedics

• www.medscape.com
THANK YOU

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