Mangment & Out come

Dr. Hassanzadeh.Z Orthopaedic surgeon

POTA 2013

open Fx and classification New

concept of “C”

Antibiotic?

Solution Irrigation?

Debridement time and severity?

Bead and biodegradable Ab?

Wound closuer (vac)?

Management and fallow up?

Principles of tscherne in open Fx Life preservation Limb preservation Infection avoidance Functional preservation Rapid and High – value trauma care

Biomechanic properties "basic Engineerig"

Ultimate strength tensil (mpa) (maximum force in tension)

U.S

0/2 Musle

4 Cartilage

8 Skin

10 Facia

70 Tendon

100 Bone (C)

• incidence 2.6% of 5271 case •Adult male highest incidence 15-19 Y •Adult male females highest incidence 80-89 Y •Finger phalanges, tibia and fibula, distal radius and ankle •Crush, Fall , Cut , Rta Charles.M. injury. Int.43(2012)-891

Type 1 Open Fractures

Inside-out injury

Clean wound

Minimal soft tissue damage

No significant periosteal stripping

Moderate soft tissue damage

Outside-in

Higher energy

Some necrotic muscle

Some periosteal stripping

High energy

Outside-in

Extensive muscle devitalization

Bone coverage with existing soft tissue

Type 3b Open Fractures

High energy

Outside in

Extensive muscle devitalization

Requires a flap for bone coverage and soft tissue closure Periosteal stripping

High energy

Increased risk of amputation and infection

Any grade 3 with

major vascular injury requiring repair

Pacce.James Lee MD. Journal of pediatric orthopaedics

Volume 32-PS 123.septambe 2012

Most level I and II recommendation come from studies involving open Fx in adult. Pediatric open Fx have better outcome than Adult…

pubmed, EBM, web of science -Assessment of Gustilo – Anderson (tibia , laceration length, plan) classification -New concept and new classification 1- skin inj (closure), 2-muscle inj (function), 3-artarial (ischemia) , 4- contamination (dept and nature-infection), 5-bone (loss)

Orthop Trauma. Volume 24 No 8 Aug 2010

Open Fx IIIA and IIIB

Sensitivity 98%

Specifity 100%

Superior to MESS

- Specifity

- Negative predictive 50%

Timing issue in open Fx debridement a review article:

1- open Fx asses after ATLS

2-Time figures including 6h rule should be re-evaluated

3-Recognize the presence of infection and adequate assessment of the grad of injury will allow us to identify those Fx at increased risk for nonunion

Alberto Jorge. Mora Eur J orthop surg Trauma – 2013 (23:125-129)

Relationship between time to surgical detriment and infection incidence in open Fx III

Conclusion: Our study shows that the risk of developing an infection was not increased if the primary surgical management was delayed more than 6hour after injury.

Jag wan Singh – Rohit Rambani

Trauma. 2012- 7(33-37)

Does timing to operative debridement affect infectious complications in open Fx? - A systematice Review:

Schenrer ML. JBJS Am 2012 Jun 20, 94 C (2)1057

Conclusion 1- The data not indicate an association between delaly debridement and higher infection Rate . When all infection were considered When only deep infection consider 2-on the basis this analysis historical 3-”Six – hour “ has littele support.

Time to OR is probably less important than:* Adequacy of debridement

Time to soft tissue coverage

Timing depends on….** Is patient stable?

Is the OR prepared?

Is appropriate assistance available? Ortho trained scrub techs, assistant surgeons, xray techs, and other OR staff

2005 Skaggs et al:*** If after 10pm, keep until the morning! Or at least within 24 hours.

Unless…. neurovasc compromise

horrible soft tissue contamination

compartment syndrome

*Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg. 2006 Dec;88(12):2739-48.

Within 24

hours

Within 6 hours

Trauma scrub Soap and saline to remove gross debris

“Zone of injury” Skin wound is the window through which the true wound communicates with the exterior

Extend the traumatic wound Excise margins Resect muscle and skin to healthy tissue

color, consistency, capacity to bleed and contractility

Bone ends are exposed and debrided Irrigate Serial debridements?

If needed, 2nd or 3rd debridement after 24-48 hours should be planned

Bacitracin and Normal salin same effect on Colony count

Anglen-J.O soap and antibiotic solution for Irrigation of Low –Limb open Fx

JBJS Am-2005-87 1415-1422

But: Age , Duration of fallow. up prevalence of hypotension, duration of Ab Treatment.

-Various Irrigation solutions? - High or Low pressure? -Amount of Fluid ? 3L 6L 9L

1- Large volume salin steril to reduce the bacterial count 2- No difference salin and Ab solution

James Lee pace. J Pediatric. Orthop volume 32 –N2. sep 2012

In animal model (Rat): Salin+soap>salin on pseudomonas Salin+soap=salin on staphylococcus aurous

Conroy Bp, Anglen Jo, cmpraison of castile soap and J. orthop Trauma

2009:13-332-337

Contraindications to primary closure

Inadequate debridement

Gross contamination

Farm related or freshwater immersion injuries

Delay in treatment >12 hours

Delay in giving abx

Compromised host or tissue viability

Dressings

Temporary closures – rubber bands Wet to dry dressings Semi-permeable membranes Antibiotic bead pouch VAC

Vacuum assisted wound closure Recommended for temporary management

Mechanically induced negative pressure in a closed system

Removes fluid from extravascular space

Reduced edema

Improves microcirculation

Enhances proliferation of reparative granulation tissue

Open cell polyurethane foam dressing ensures an even distribution of negative pressure

-Webb LX: New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002 Sep-Oct;10(5):303-11. -Dedmond BT, Kortesis B, Punger K, Simpson J, Argenta A, Kulp B, Morykwas M, Webb L. “The use of Negative Pressure Wound Therapy in the Temporary Treatment of Soft Tissue Injuries associated with High Energy Open Tibial Shaft Fractures.” JOT. 2007

Do these early!

1994 Osterman et al.* Retrospective 1085 fractures, 115 G2 and 239 G3

All treated with appropriate IV Abx and I&D

No infection if wounds closed at 7.6 days

Yes infection if wounds closed at 17.9 days

Infection risk increases if wound

open > 7 days

Primary closure

Secondary intention

Skin graft

Local flap

Regional flap

Distant flap

Free flap

Tissue expansion

Type 1 open fx

Type 3B open fx

Type 2/3A open fx