open fractures

HOSPITALFORSPECIALSURGERY

OPEN FRACTURESOPEN FRACTURES

Joseph J. Ruzbarsky, MDJoseph J. Ruzbarsky, MD

Trauma ConferenceTrauma Conference

September 22, 2014September 22, 2014


Open FractureOpen Fracture

• A fracture in which a break in the skin A fracture in which a break in the skin and underlying soft tissues leads and underlying soft tissues leads directly into or communicates with the directly into or communicates with the fracture and its underlying hematomafracture and its underlying hematoma

• ““Compound fracture”Compound fracture”


Goals of TreatmentGoals of Treatment

• Prevent infectionPrevent infection

• Achieve bony unionAchieve bony union

• Restore soft-tissue envelopeRestore soft-tissue envelope

• Early motion and rehabilitationEarly motion and rehabilitation


ClassificationClassification

• Gustilo and AndersonGustilo and Anderson, JBJS, 58A, , JBJS, 58A, No.4, 1976No.4, 1976

• Reported on 1,025 open fractures of Reported on 1,025 open fractures of long bones and offered a classification long bones and offered a classification system based largely, though not system based largely, though not entirely, on the entirely, on the size of the woundsize of the wound


Type-IType-I

• < 1 cm wound < 1 cm wound

• low-energy injurieslow-energy injuries

• 'inside-out’'inside-out’

• minimal soft tissue damageminimal soft tissue damage

• minimal comminutionminimal comminution

• minimal contaminationminimal contamination


Type-IType-I


Type-IIType-II

• > 1 cm wound> 1 cm wound

• mild-mod. energy mild-mod. energy

• 'outside-in' moderate soft tissue injury'outside-in' moderate soft tissue injury

• moderate comminutionmoderate comminution

• moderate contaminationmoderate contamination


Type-IIType-II


Type-IIIType-III

• large wounds (> 10cm)large wounds (> 10cm)

• high energy injuryhigh energy injury

• extensive soft-tissue injuryextensive soft-tissue injury

• marked comminutionmarked comminution

• marked contaminationmarked contamination


Type-IIIType-III


Gustilo et al., J Trauma, Vol.24, No 8, 1984Gustilo et al., J Trauma, Vol.24, No 8, 1984

• Type-IIIa Type-IIIa – adequate soft-tissue adequate soft-tissue

coverage remainscoverage remains

• Type-IIIb Type-IIIb – soft-tissue coverage soft-tissue coverage

procedure necessaryprocedure necessary

• Type-IIIc Type-IIIc – vascular injury that vascular injury that

requires repairrequires repair


Automatic Type III’sAutomatic Type III’s

• shotgun woundsshotgun wounds

• high velocity GSW (> 2000 ft./sec.)high velocity GSW (> 2000 ft./sec.)

• displaced segmental fracturesdisplaced segmental fractures

• diaphyseal segmental bone lossdiaphyseal segmental bone loss

• farmyard injuries farmyard injuries

• highly contaminated injuryhighly contaminated injury

• severe crush injuriessevere crush injuries

• any open fracture seen after 8 hrsany open fracture seen after 8 hrs


InfectionInfection

• Incidence correlates directly with Incidence correlates directly with extent of soft-tissue injury, NOT the extent of soft-tissue injury, NOT the length of the wound. length of the wound.

• Gustilo et al., JBJS, 72A; 1990Gustilo et al., JBJS, 72A; 1990


Infection RatesInfection Rates

• Type-I: Type-I: 0-2 %0-2 %

• Type-II: Type-II: 2-7 %2-7 %

• Type-III: Type-III: 10 - 25 % (overall)10 - 25 % (overall)– Type-IIIa: Type-IIIa: 7 %7 %– Type-IIIb: Type-IIIb: 10-50 %10-50 %– Type-IIIc: Type-IIIc: 25-50 %25-50 %


Initial TreatmentInitial Treatment

• ABC's according to the ATLS ABC's according to the ATLS protocolsprotocols

• Life-threatening injuries take Life-threatening injuries take precedence over limb threatening precedence over limb threatening injuriesinjuries

• Thorough neurovascular examThorough neurovascular exam


Tetanus ProphylaxisTetanus Prophylaxis

– Clostridium tetaniClostridium tetani

– Immunized w/in 5 yrs - No treatmentImmunized w/in 5 yrs - No treatment– Immunized > 5 yrs - tetanus toxoidImmunized > 5 yrs - tetanus toxoid– Status unknown - tetanus toxoid and Status unknown - tetanus toxoid and

tetanus immune globulintetanus immune globulin


Value of ER or Pre-Value of ER or Pre-debridement Cultures?debridement Cultures?

• organisms seen on initial culture rarely organisms seen on initial culture rarely the same organisms cultured from the same organisms cultured from infected woundsinfected wounds

• costlycostly– Lee, Chapman, et al., Orthop Trans, 15; 1991Lee, Chapman, et al., Orthop Trans, 15; 1991


Initial treatmentInitial treatment

• Cover the woundCover the wound– sterile dressingsterile dressing– Repeated evaluation leads to increased Repeated evaluation leads to increased

incidence of infectionincidence of infection

• Reduce and splint fractureReduce and splint fracture• for comfortfor comfort

• to prevent further soft tissue damageto prevent further soft tissue damage


Antibiotic Treatment Antibiotic Treatment

• should begin as soon as possibleshould begin as soon as possible

• > 70 % of open fxs. are contaminated > 70 % of open fxs. are contaminated with bacteria at the time of injurywith bacteria at the time of injury


Which antibiotic?Which antibiotic?

– Type-I and Type-IIType-I and Type-II• cephazolincephazolin

– Type-IIIType-III• cephazolin plus aminoglycosidecephazolin plus aminoglycoside

– Farm or sewage related injuryFarm or sewage related injury• cephazolin, aminoglycoside and penicillincephazolin, aminoglycoside and penicillin


Irrigation and DebridementIrrigation and Debridement

• The most important intervention!The most important intervention!

• Repeat every 24-48 hours until wound Repeat every 24-48 hours until wound appears clean and devoid of non-appears clean and devoid of non-viable tissue.viable tissue.


IrrigationIrrigation

– 9-10 liters of normal saline should be 9-10 liters of normal saline should be used during irrigation of open fxused during irrigation of open fx

• Gustilo et al., 1986; Sanders et al.,JBJS 1994.Gustilo et al., 1986; Sanders et al.,JBJS 1994.

– Pulsatile lavage may impede bone Pulsatile lavage may impede bone healinghealing

– Bhandari, JOT, 1998Bhandari, JOT, 1998

– Dirschl, JOT, 1998Dirschl, JOT, 1998


Skin DebridementSkin Debridement

– avoid tourniquetavoid tourniquet– excise margins (saucerize)excise margins (saucerize)– enlarge wound with extensile incisionsenlarge wound with extensile incisions– obtain meticulous hemostasis as neededobtain meticulous hemostasis as needed– skin is not the major source of infection skin is not the major source of infection


FasciaFascia

– excise any non-viable, damaged or excise any non-viable, damaged or contaminated fasciacontaminated fascia

– limited vs. formal fasciotomy for high-limited vs. formal fasciotomy for high-energy injuriesenergy injuries

– Open fractures do NOT necessarily Open fractures do NOT necessarily decompress compartmentdecompress compartment


Indications for FasciotomyIndications for Fasciotomy

• after arterial repair with re-perfusion after arterial repair with re-perfusion edemaedema

• after sustained hypotensionafter sustained hypotension

• severe polytrauma severe polytrauma

• patient is unable to communicate (i.e. patient is unable to communicate (i.e. closed head injury)closed head injury)

• open fxs. with a crushing componentopen fxs. with a crushing component


Muscle DebridementMuscle Debridement

• nonviable muscle is nonviable muscle is thethe majormajor nidus for nidus for infectioninfection

• the Four C'sthe Four C's– colorcolor– consistencyconsistency– contractility contractility – capacity to bleedcapacity to bleed


Tendon DebridementTendon Debridement

• unless severely damaged or unless severely damaged or contaminated, may be preserved contaminated, may be preserved

– preserve peritenon if possiblepreserve peritenon if possible– cover tendons with local musclecover tendons with local muscle


Bone DebridementBone Debridement

"Our most common judgement error has "Our most common judgement error has been the delayed excision of nonviable been the delayed excision of nonviable bone”bone”

Chapman and Olson, Fractures, Ed 4, 1996.Chapman and Olson, Fractures, Ed 4, 1996.


Bone DebridementBone Debridement

• Remove small-moderate sized Remove small-moderate sized avascular segmentsavascular segments

• Retain major articular fragmentsRetain major articular fragments

• large cortical segments can often be large cortical segments can often be retained initially, but must be debrided retained initially, but must be debrided if infection intervenes.if infection intervenes.


Open JointsOpen Joints

• explore any open joint injuryexplore any open joint injury

• arthroscopy may play a helpful role arthroscopy may play a helpful role during I & Dduring I & D


Limb Salvage vs. Limb Salvage vs. AmputationAmputation

"Unfortunately it requires more judgement and "Unfortunately it requires more judgement and courage to do a primary amputation that it does to courage to do a primary amputation that it does to salvage the limb of a patient with a severe open salvage the limb of a patient with a severe open tibia fracturetibia fracture..

Heatley, BMJ, 1988Heatley, BMJ, 1988


Primary AmputationPrimary Amputation

• Lange's absolute indications:Lange's absolute indications:– warm ischemia time > 6 hourswarm ischemia time > 6 hours– anatomic division of the tibial nerveanatomic division of the tibial nerve


Fracture StabilizationFracture Stabilization

• Begins after vascular repair (when Begins after vascular repair (when needed) and adequate irrigation and needed) and adequate irrigation and debridement.debridement.

• Based on: Based on: – fracture configurationfracture configuration– soft-tissue injury, associated injuries soft-tissue injury, associated injuries – patient's general condition.patient's general condition.


Cast ImmobilizationCast Immobilization

– Some Type-I and Type-II fracturesSome Type-I and Type-II fractures– Difficult to observe woundDifficult to observe wound


External FixationExternal Fixation

• AdvantagesAdvantages– good stability to good stability to

fracture sitefracture site

– good wound accessgood wound access

– easily and rapidly easily and rapidly appliedapplied

– minimal trauma to minimal trauma to soft tissuessoft tissues


External FixationExternal Fixation

• DisadvantagesDisadvantages– pin tract problems pin tract problems

(irritation, (irritation, loosening, loosening, infection)infection)

– limited life spanlimited life span

– may limit soft-may limit soft-tissue procedurestissue procedures


Plate and Screw FixationPlate and Screw Fixation

• AdvantagesAdvantages– anatomic reduction possibleanatomic reduction possible– improved soft-tissue accessimproved soft-tissue access– rigid stabilizationrigid stabilization– early mobilization well toleratedearly mobilization well tolerated

• The role of early internal fixation in the management of open fractures. Chapman MW, The role of early internal fixation in the management of open fractures. Chapman MW, Mahoney M:CORR: 138: 120-131, 1979Mahoney M:CORR: 138: 120-131, 1979



• DisadvantagesDisadvantages– need for further need for further

exposureexposure

– devascularization devascularization of tenuous bone of tenuous bone fragmentsfragments



• IndicationsIndications– Type-I and some Type-I and some

Type-II open Type-II open fracturesfractures

– intra-articular intra-articular fracturesfractures

– metaphyseal metaphyseal fracturesfractures

– Forearm Forearm


Intramedullary FixationIntramedullary Fixation

• AdvantagesAdvantages– provides excellent provides excellent

stabilitystability

– improved soft-improved soft-tissue accesstissue access

– early motion and early motion and rehabilitation well-rehabilitation well-toleratedtolerated


Intramedullary FixationIntramedullary Fixation

• DisadvantagesDisadvantages– impairs endosteal impairs endosteal

circulation circulation (reamed> (reamed> unreamed)unreamed)

– often longer OR often longer OR time than external time than external fixationfixation


Intra-articular FracturesIntra-articular Fractures

• GoalsGoals– anatomic reduction of the articular anatomic reduction of the articular

surfacesurface– stabilization of the shaft to achieve a stabilization of the shaft to achieve a

well-aligned congruous jointwell-aligned congruous joint– Often accomplished with limited internal Often accomplished with limited internal

fixation and a 'spanning' ex-fix (hybrid).fixation and a 'spanning' ex-fix (hybrid).


Wound ManagementWound Management

– Operative wounds may be closed Operative wounds may be closed primarilyprimarily

– Traumatic wounds left openTraumatic wounds left open

– Every 24-48 hrs, debridements to achieve Every 24-48 hrs, debridements to achieve a clean, stable wound.a clean, stable wound.


Closure and CoverageClosure and Coverage

• GOAL: healthy soft tissue envelope with GOAL: healthy soft tissue envelope with

adequate muscle coverage over the fractureadequate muscle coverage over the fracture • delayed primary closure delayed primary closure

• split thickness skin grafting (STSG)split thickness skin grafting (STSG)

• Exposed tendon or bone necessitates flap Exposed tendon or bone necessitates flap coveragecoverage


RehabilitationRehabilitation

• Early, aggressive rehab has the Early, aggressive rehab has the following benefits:following benefits:– prevention of "fracture disease”prevention of "fracture disease”– prevention of muscle disuse atrophyprevention of muscle disuse atrophy– prevention of joint stiffness and prevention of joint stiffness and

contracturecontracture– improved circulationimproved circulation


Type-III open tibial Type-III open tibial fracturesfractures

• Averages:Averages:– 6 operations!6 operations!– 2 mos of hospitalization!2 mos of hospitalization!– > 1 year of rehabilitation!> 1 year of rehabilitation!– 3 mos until complete soft tissue healing!3 mos until complete soft tissue healing!– 12 mos for complete fracture healing!12 mos for complete fracture healing!


THANK YOUTHANK YOU

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