OPEN FRACTURES

OPEN FRACTURES ARE ALSO KNOWN AS COMPOUND

FRACTURES

OPEN FRACTURES INTRODUCTION

Definition
Open fracture implies communication
between external environment and
the fracture.
A soft tissue injury complicated by a
broken bone.

Components of open fracture

Fracture
Soft-tissue damage
Neurovascular compromise
Contamination

Extent of each component must be assessed

individually
in
order
to
achieve
a
comprehensive understanding of the injury,
upon which the treatment plan can be based.

History
A century ago, the high mortality of
patients with open fractures led to early
amputations to prevent death.
Trueta
recommended
open
wound
treatment and subsequent enclosure of
extremity in a cast
In 1943, the use of Penicillin reduced the
rate of wound sepsis
Hampton recommended closure between
4th-7th day after injury

Mechanism of injury
Open fractures occur as a result of
direct high energy trauma either
from Road traffic collisions or falls
from height.

Epidemiology
Diaphyseal fractures
were more common
than
metaphyseal
fractures.
Highest
rate of diaphyseal
fractures were seen
in
tibia(21.6%)
followed
by
femur(12.1%), radius
and ulna(9.3%), and
humerus(5.7%)

Microbiology
Poor tissue oxygenation and devitalization of the
surrounding tissues including the bone provide a
perfect
medium
for
infection
and
bacterial
multiplication.
When left open >2weeks prone to nosocomial
infection such as pseudomonas species and gram
negative bacteria.
This phenomenon of hospital acquired infection
emphasizes the importance of a strict protocol for inhospital management and early wound coverage.

WHY OPEN FRACTURES CAN BE DANGEROUS

OPEN FRACTURES COMPLICATIONS

Early Complications

Infection
Hypovolemic shock
Compartment syndrome
Fat embolism
Ards
Neurovascular injuries

Hypovolemic shock

Hypovolemic shock management

Two large-bore IV lines should be
started.
Once IV access is obtained, initial
fluid resuscitation is performed with
an isotonic crystalloid, such as Ringer
lactate solution or normal saline. An
initial bolus of 1-2 L is given in an
adult (20 mL/kg in a pediatric
patient), and the patient's response
is assessed.

Hypovolemic shock

Type of fluidColloid albumin, dextran, plasma

Crystalloid NS, D5, RL
Blood uncrossed O ve

Based on 3:1 rule when using crystalloids

Eg. If blood loss is 100cc the patient should
receive 300cc of normal saline or Ringer
lactate
1:1 rule for colloids

Compartment syndrome

Compartment syndrome
Classically 5 "Ps" associated with
compartment syndrome
Painout of proportion to what is
expected
Paresthesia
Pallor
Paralysis
Palpable pulse

Measurement of compartment syndrome

-gauging pressure by introducing needle into
compartments

Stryker 295 quick-pressure

monitor set

Compartment syndrome
Treatment - Fasciotomy

Fat embolism
Definition - Occlusion of small vessels
by fat globules
Types 1. cerebral drowsy, restless and
disoriented
2.pulmonary tachypnea,
tachycardia, petechial rash(in front of
neck, ant axillary fold, chest and
conjuctiva)

Fat embolism
Diagnosis
signs of retinal artery emboli(striate
hemorrhages and exudate) may be
present.
Sputum and urine may reveal
presence of fat globules.
X-ray of chest shows patchy
pulmonary infarcts.
Blood Po2 <50mm

Fat embolism

TreatmentRespiratory support
Heparinization
Intravenous low-molecular weight
dextran and corticosteriods

ARDS
Is caused by release of inflammatory
mediators which cause disruption of
pulmonary vasculature.
Signs and symptoms Tachypnea,
low BP, Cyanosis
Treatment 100% oxygen

Injury to blood vessels

Absent peripheral pulses in an injured
limb should be considered to be due to
vascular damage unless proved
otherwise.
hard signs of arterial injury
(a) absent pulses
(b) active hemorrhage
(c) expanding hematoma, and
(d) bruit or thrill.

Vascular injury
Investigations Colour doppler study
Arteriography
Treatment Arterial reconstruction
Bypass grafts
Timing- loss of total blood
supply to the limb for > 8
hours nearly always
results in amputation.

Nerve injury
Nerve repair should be done within 3
weeks of injury for better results

TO ACCURATELY DESCRIBE SIMILAR INJURIES IN ORDER TO

PROVIDE A BASIS FOR TREATMENT, TO ESTIMATE
PROGNOSIS AND TO ENABLE COMPARISON BETWEEN
CENTERS.

OPEN FRACTURES
GRADING AND
CLASSIFICATION

Gustilo and Anderson

Gustilo and Anderson

Tscherne
Grade I small puncture without associated
contusion, negligible contamination, low-energy
mechanism of fracture.
Grade II- small laceration, skin and soft tissue
contusions, moderate bacterial contamination
Grade III- large laceration with heavy bacterial
contamination, extensive soft tissue damage
Grade IV- incomplete or complete amputation
with variable

Hannover fracture scale

Total score -

This considers every detail of

the injury to the involved extremity and is made
up as a checklist. The fracture type according to
the AO classification, the skin laceration, the
underlying soft tissues, the vascularity, the
neurological status, the level of contamination, a
compartment syndrome, the time interval
between injury and treatment, and the overall
severity of the injury to the patient are added up
to prove the total score.

Hannover fracture scale

Interpretation
minimum score: 0
maximum score: 22
The higher the score the worse the
injury.
A score 11 indicates significant
trauma, with amputation
recommended.

AO classification

AO classification

Io 1 skin breakage from inside out

Io 2- skin breakage from outside in

<5cm, contused edges

Io3 skin breakage from outside in >5cm,

increased contusion, devitaised edges

IO 4 Considerable, full thickness contusion,

abrasion, extensive open degloving, skin loss

IO5 extensive degloving

Neurovascular injury - AO

Muscle/tendon injury AO

Ganga hospital score

Interpretation:
The total score was used to address
the question of salvage and the
outcome was measured by dividing
the injuries into four groups (Group I
- < 5; II - 6-10; III - 11-15 and IV - 16
and above of the total score)
All limbs in Group IV and one in
Group III underwent amputation

Mangled extremity severity index

Mangled extremity severity

score(MESS)

LSI- limb salvage index

Interpretationminimum score: 0
maximum score: 14
The higher the score the more severe the injury.

Limb Salvage Index

Outcome

05

limb salvage successful (51 of 51)

614

amputation (19 of 19)

Predictive salvage index

Interpretation
minimum score: 3 (based on the point
assignments; if no vascular, bone or muscle injury
then the score could reach 1, but then it would
not be a seriously injured limb)
maximum score: 13
The higher the score the worse the chances for a
PSI
successfulOutcome
limb salvage.
7

good (12 of
14 limbs
salvaged

poor (7 of 7
amputated)

NISSSA
Parameters
N = nerve injury
I = ischemia
S = soft tissue contamination
S = skeletal injury
S = shock
A = age of the patient

NISSSA

NISSSA

NISSSA
Interpretation
minimum score: 0
maximum score: 19
The higher the score, the more severe
the injury.
A score 7 was 100% sensitive for
amputation, but with specificity of 46%.
A score 11 had a 100% specificity and
positive predictive value for amputation.

THE TREATMENT OF HIGH ENERGY INJURIES AIM TO

PRESERVE LIFE, LIMB AND FUNCTION.

OPEN FRACTURES MANAGEMENT

Goals of treatment
The intermediate objectives are Prevention of infection
Fracture stabilization
Soft-tissue coverage

Stages of care

Initial assessment
Important
components
in
assessing
traumatized extremity
1. History and mechanism of injury
2. Neurovascular status
3. Size of skin wound
4. Muscle crush or loss
5. Periosteal stripping or bone loss
6. Fracture pattern, fragmentation
7. Contamination
8. Compartment syndrome

Primary surgery

Irrigation
Supplements systemic debridement
in removing foreign material and
decreasing bacterial load.
Fracture type

Vol of fluid used for

irrigation

Type I

3L

Type 2

6L

Type 3

9L

Irrigation
2 adages.
If a little does some good, a lot will
do a great deal more
solution to pollution is dilution

Irrigation
NS normally used for
irrigation.
Antibiotic solution is no
better than soap for open
fracture irrigation
Antiseptic solutions have
been not shown to
decrease infection rates.
Surfactant(non sterile
soap) same effectiveness,
less tissue damage n more
economical.

Timing of debridement and

irrigation
Most guidelines recommend
debridement within 6 hrs.
Serial debridement may be
necessary every 24-48hrs until the
wound viability is ensured

Antibiotics
Systemic administration:

Antibiotics
Local antibiotics:
In gustilo type III fractures additional
use
of
local
aminoglycoside
impregnated
polymethylmethacrylate(PMMA)
beads reduces overall infection rate.

Tetanus prophylaxis
Tetanus Toxoid(TT), dose is 0.5ml i.m.
regardless of age
Immunoglobulin
75IU <5yrs of age
125IU 5-10yrs
250IU >10yrs

Primary surgery
Timing :
Surgical emergency
Operating room with 6-8hrs of injury
contaminated wounds not treated
within this time will have sustained
bacterial multiplication to result in
early infection.

Primary surgery
Fracture stabilization:
As soon as primary wound care is
completed, treatment should
proceed to fracture reduction and
fixation.
Surgeon should rescrub, regown and
reglow. Different set of instruments
than those used for debridement is
necessary.

Relative Indications for Type of

Skeletal Fixation in Open Fractures
External fixation
Severe contamination any site
Periarticular fractures
Definitive
Distal radius
Elbow dislocation
Selected other sites
Temporizing
Knee
Ankle
Elbow
Wrist
Pelvis
Distraction osteogenesis
In combination with screw fixation for severe soft tissue injury

Relative Indications for Type of

Skeletal Fixation in Open Fractures
Internal fixation
Periarticular fractures
Distal/proximal tibia
Distal/proximal femur
Distal/proximal humerus
Proximal ulnar radius
Selected distal radius/ulna
Acetabulum/pelvis
Diaphyseal fractures
Femur
Tibia
Humerus
Radius/ulna

Plates
Open diaphyseal fractures of the
radius and ulna as well as the
humerus are best managed with
plate fixation.
The plate fixation of lower extremity
diaphyseal fractures is generally not
recommended due to higher rate of
infections.

Intramedullary nailing
Locked intramedullary nailing has been
established as the treatment of choice for
most diaphyseal fractures in lower
extremity.
The technique has particular value for
open fractures. Intramedullary nails can be
inserted with no further disruption of the
already injured soft-tissue envelope and
preserves the remaining extra osseous
blood supply to cortical bone.

IM nailing
Data showing that solid intramedullary
nails inserted without reaming have a
lower risk of infection.
On the other hand reamed intramedullary
nails can reliably maintain fracture
reduction with regards to angulation,
rotation, displacement, and length.
Prospective randomised trails that
compared reamed with unreamed
interlocked IM nails did not show any
significant difference concerning outcome
and risk of complication.

External fixation
Advantages of ext Fixation Can be applied relatively easily and
quickly
It provides relatively stable fracture
fixation
There is no further damage done if
applied correctly
It avoids implantation of hardware in
open wound.

Ext fixator
Major problems with external fixation are
related to pin tract infection, malalignment ,
delayed union, poor patients compliance.
External fixators are particularly useful in
fractures with severe damage and
contamination, where metallic implants
with risk of bacterial adherence are best
avoided.
Ring fixators may be an option in
diaphyseal fractures

 Types
Ring fixators
Joint spanning external fixator

Open wound coverage after primary

surgery

Primary Closure
If it is to be done, the following criteria must be met:
1. The original wound must have been fairly clean, and not
have occurred in a highly contaminated environment.
2. All necrotic tissue and foreign material have been debrided.
3. Circulation to the limb is essentially normal.
4. Nerve supply to the limb is intact.
5. The patient's general condition is satisfactory and allows
careful postoperative assessment.
6. The wound can be closed without tension.
7. Closure will not create a dead space.
8. The patient does not have multisystem injuries.

Delayed primary closure

closure before the fifth day is termed delayed
primary closure
As long as closure is achieved before the fifth
day, wound strengths at 14 days are
comparable with those in wounds closed on the
first day
leaving the wound open minimizes the risk of
anaerobic infection, and the delay allows the
host to mount local wound defensive
mechanisms that permit safer closure than is
possible on the first day.

 Current standard of care for all open

fracture wounds is to be left open
initially.
Delayed closure is accomplished
within 2-7days
VAC assisted wound closure is
presently recommended for
temporary management of open
fracture wounds.

VAC
The wound bed is exposed to mechanically
induced negative pressure in a closed
system .
The system removes fluid from extravascular
space, reduces edema, improves micro
circulation and enhances the proliferation of
preparative granulation tissue.
Polyurethane foam dressing is placed in
wound and ensures an even distribution of
negative pressure.

VAC

Antibiotic bead pouch

technique

References
AO principles of fracture
management 2nd Ed
Rockwood and green fractures in
adults 7th Ed
Campbell - operative orthopedics 11th
Ed.
Management of open fractures by Dr.
TSE Lung Fung
Various sources on Internet

THANK YOU