open fracture management p. blachut division of ortho trauma vancouver general hospital university...

Open Fracture Open Fracture ManagementManagement

P. BlachutDivision of Ortho Trauma

Vancouver General Hospital

University of British Columbia

•Introduction•Assessment•Classification•Management

Open fracturesOpen fractures

Goals of Fracture Management

1 Fracture healing with satisfactory length and alignment

2 Avoidance of complications•infection•nonunion•malunion•stiffness

3 Early restoration of function

Fracture Healing

•Biologic factors•Biomechanical factor

•No necrotic tissue•No dead space•No contamination•Well vascularized tissue

Avoidance of Complications (Infection)

•Early mobilization–Stable fixation–Early wound healing

•Avoid excessive scarring–Early wound coverage with quality tissue

•Preservation of “critical tissues”

–Nerves–Tendons

Early Restoration of Function

•The soft tissues are paramount to the successful management of fractures

Therefore:

•A bone healing complication with good soft tissues is easier to deal

with than a complication with poor soft tissues

• healing potential• resistance to infection

•contamination

Consequences of an Associated Soft Tissue Injury

•Look for associated life threatening injuries!!!

•Carefully assess and document neurovascular status

Assessment

•Primary SurveyA irwayB reathingC irculationD isabilityE xposure

•Secondary Survey

ATLS (Advanced Trauma Life Support)

Compartment SyndromeCompartment Syndrome

• Always look for in fractures with soft tissue injuries

• Open fractures - up to 10% have compartment syndrome

Amputation vs. Salvage

• Multidisciplinary decision

• Based on the assessment of likely ultimate function of limb compared to function with amputation

Factors Favoring Amputation

1 Warm ischemia time > 8 hrs2 Severe crush

• minimal remaining functional tissue

3 Chronic debilitating disease4 Severe polytrauma5 Mass casualty6 complexity of

reconstruction

Classification

•Reflection of amount of energy imparted and consequently, the prognosis1Skin wound size2Level of contamination3Extent of soft tissue

injury/ periosteal stripping

4Fracture configuration

Classification - Open Fractures

•Classification can really only be done at the completion of debridement


•Open injuries

–Gustilo & Anderson

–AO


•Type I–Small wound– Inside out–No/minimal contamination

–Minimal soft tissue trauma

–Low energy fracture pattern

Open Fracture - Gustilo Classification

•Type II–Moderate wound–Some contamination–Some muscle damage–Moderate energy fracture pattern


•Type III–Large wound–Significant comtamination

–Major soft tissue trauma•crushing•periosteal stripping

–High energy fracture pattern


• IIIA–enough soft tissue to cover

bone

• IIIB– insufficient soft tissue–need flap (local, free)

• IIIC– vascular injury requiring

repair


•Type III - Additional Factors–Barnyard–Shotgun–High velocity gunshot–Displaced segmental

fracture–Neglected open fracture (>

8 hrs)–Bone loss


•First aid•Emergency Room

•Definitive•Rehabilitation

Management

•Control bleeding–direct pressure

•Realign– further soft tissue

damage/ compromise

•Splint–comfort– further damage

First Aid

•First aid if not already given

•Remove gross debris/irrigate/dress/ splint

•Tetanus prophylaxis - if necessary

•Antibiotics

Emergency

•The open wound should be assessed and documented only once

Emergency

Antibiotics

• ? Prophylactic vs. treatmentClosed with operative RxCephalosporinGrade I

Grade II / III Add aminoglycoside

High Risk Add penicillin

Antibiotics

• Antibiotics can not compensate for an inadequate surgical management

Timing of Administration of Antibiotics

• The Prevention of Infection in Open Fractures An Experimental Study of

the Effect of Antibiotic TherapyWorlock, et al JBJS 1988

No antibiotics

1-4 hrs post-inoculation

1 hr. pre-inoculation

91% infection

51% infection

30% infection

Antibiotics

• The Role of Antibiotics in the Management of Open Fractures

Patzakis, et al JBJS, 1974

Control

Pen./Streptomycin

Cephalothin

13.9% infection

9.7% infection

2.3% infection

Definitive Treatment

1 Wound excision2 Wound extension3 Debridement4 Irrigation5 Bone stabilization6 Wound dressing7 +/- re-debridement8 Early wound

closure/coverage

Timing of Operative Intervention

• General standard - within 6-8 hours

• Not evidence based!!

Operating Room

• Scrub/remove gross debris/ irrigate

• Double setup1 debridement/irrigation2 bone stabilization if

internal fixation planned

• Tourniquet• apply/not inflated• in case of bleeding

Wound Excision

• Excise crushed/ contaminated skin edge

Wound Extension

• Sufficient extension to fully evaluate and treat soft tissue injury (approximately 1 diameter of limb)

• Anticipate incisions for bony stablization/soft tissue reconstruction

• Avoid incision that will compromise skin further

Wound Extension

Debridement

• Layer by layer• Remove all

devitalized and contaminated tissue (including bone)

Debridement - Objective:

• To leave a wound with:1 No/minimal

contamination2 Well vascularized

tissue for healing and to resist infection

Debridement

• “When in doubt, take it out”

Irrigation

• 10 litres for significant wounds– saline

• ? antibiotics• ? pulsed lavage• ? detergent

Irrigation

1 Improves visualization

2 Float out necrotic tissue

3 Flush out debris4 Reduce bacterial

population

Irrigation

• The solution to pollution is dilution

Stabilization

The Prevention of Infection in Open Fractures: An

Experimental Study of the Effect of Fracture Stability

Worlock, et al Injury 1994

Bony Stabilization

• Second prep if internal fixation

• Principles1 Minimize further trauma2 Sufficient stability to allow

early rehab3 Should not impede subsequent

soft tissue management4 Restoration of anatomy

Bony Stabilization

• Diaphyseal Fractures

• Humerus• Forearm

• Femur• Tibia

ORIF

IM nail

Bony Stabilization

• Articular Fractures• primary ORIF• spanning external fixator

+ / - articular ORIF delayed ORIF

• external fixation

Open Wound Management

• Can close extensions• Occasionally close open wound

primarily1 No crush2 No contamination3 Small wound4 No dead space5 Closure without tension

• Keep wound moist - ? bead pouch

Price of Primary Open Wound Closure

Gas Gangrene

Limb Loss Limb Loss DeathDeath


leave open


Antibiotic beads

• Depo of local antibiotics

• ? efficacy• ? toxicity

Antibiotic Bead Pouch VGH Experience

85 open tibial shaft fractures

• 59 antibiotic bead pouch• 26 no bead pouch

• No statistical difference in:– age, sex, ISS, time to

wound coverage

Keating, et al

Antibiotic Bead Pouch VGH Experience

• Infection

Keating, et al

No Bead Pouch

Bead Pouch

p value

Type II Type III TOTAL

16%

0%

<0.03

11%

3%

0.35

15%

2%

<0.06

Redebridement

• High grade injury• Severe contamination• Questionable tissue viability

– ? adequacy of debridement

• Q 24-48 hours until wound is Q 24-48 hours until wound is viableviable

Wound Closure/Coverage

• ? Immediate• Optimally by 3-7 days• Principles

1 Durable coverage2 Well vascularized

soft tissue envelope for bone

3 Fill dead space


1 Secondary intent2 Delayed primary

closure3 Skin graft4 Flap

– local– distant - free


Role of VAC yet to be delineated

Rehabilitation

1 Splint joints in functional position pending soft tissue healing

2 Swelling control3 ROM/Muscle rehabilitation as

soon as wound healing permits

4 Wound management to minimize scarring

Summary

• The soft tissues are critical to the successful management of all fractures

Summary

• Aggressive, systematic management is required for fractures with significant soft tissue injuries

THANK THANK YOU !!YOU !!


ARS31 yr old man•Ped struck•Isolated injury

The most critical componentof this man’s treatment is:

1. Antibiotics2. Tibial fixation3. Avoidance of reaming4. Soft tissue management5. Early fracture stabilization



After management of the softtissues the bone is best stabilized by:

1. Cast2. External fixator3. Plate4. Reamed IM nail5. Unreamed IM nail



How would you grade this injury?

1. I2. II3. III A4. III B5. III C



The most critical componentof this man’s treatment is:

1. Antibiotics2. Tibial fixation3. Avoidance of reaming4. Soft tissue management5. Early fracture stabilization



After management of the softtissues the bone is best stabilized by:

1. Cast2. External fixator3. Plate4. Reamed IM nail5. Unreamed IM nail

open fracture management p. blachut division of ortho trauma vancouver general hospital university...

Documents

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poor soft tissues

energy imparted

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freeiiicvascular injury

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