Open Fractures

Goals of Open Fracture

ManagementPrevent InfectionAntibioticsDebridementIrrigation

Salvage LimbFixationSoft Tissue

CoverageRestore Function

Soft Tissue InjuryAll Fractures Have Some Degree

Of Soft Tissue InjuryPrognosis Determined By:

Amount Of Energy Transferred To The Soft Tissue And Bone

Degree Of Contamination & Type Of Bacteria

Patient Factors

Energy AbsorbedKE = ½ mv2

Energy TransferFall from curb

100 ft-lbsSkiing

300-500 ft-lbsHigh-Velocity GSW

2000 ft-lbsAutomobile Bumper @ 20 MPH

100,000 ft-lbs

Classification

Attempt To Quantify The Amount Of Energy Imparted And Therefore, The Prognosis

• Skin Wound Size• Extent Of

Contamination• Extent Of Deep Soft

Tissue Injury/ Periosteal Stripping

• Fracture Configuration

• Gustilo & Anderson; J Trauma, 24(8): 742-6., 1984

Type I< 1cm, clean,

inside to outside, minimal contusion, simple transverse or short oblique

Type II> 1cm Without

Extensive Soft Tissue Damage, Minimal To Moderate Crush, Simple Transverse Or Short Oblique With Minimal Comminution

Type IIIAExtensive Soft

Tissue Injury With Adequate Bone Coverage, Segmental Fractures, High-energy Gunshot Injuries; High Energy Trauma Despite Size Of WoundPrimary Closure Or

STSG

Type IIIBExtensive Soft-

tissue Loss, Periosteal Stripping And Bone Exposure, Usually Associated With Massive ContaminationRequires Flap

Coverage

Type IIICIncludes Arterial

Injury That Needs Arterial Repair For Limb Salvage

Initial TreatmentExamine Wound

OnceRemove Gross

ContaminationApply Sterile

DressingDocument Wounds

PhotographAssess &

Document N/V Status

Reduce Fx / DxParental

AntibioticsTetanus

AntibioticsEarly Parenteral Administration

1st Gen Cephalosporin+/- Aminoglycoside+/- PCN

Continue IV ATB 24 – 48 Hours After Wound Closure Coverage

Excisional Debridement

Surgical Urgency

? EmergencyClinical

Studies Have Not Demonstrated Significant Negative Outcome In Delay To OR

Depends On Severity Of Injury

Treatment Principles

All Open Fractures Goes To The OR In A

Timely Manner

Excisional Debridement

Convert Traumatic Wound Into Surgical WoundExcise

Nonviable & Contaminated Tissue

SkinSQFascia MuscleBone

Excisional Debridement

TechniqueExtend

WoundsDeliver Bone

EndsExcise &

Debride All Devitalized & Contaminated TissueIncluding Bone

Preserve Neurovascular

Structures!

IrrigationCopious

Lavage? High

Pressure Vs Low Pressure

? ATB Vs Soap Vs No Additives

Wash It Until It Is Clean

Irrigation No Substitute For Debridement

FixationRestoration Of

Length & Alignment

Minimizes Inflammation And Repetitive InjuryReduces Risk

Of InfectionStabilizing

Fracture Treats The Soft Tissue

Wound Management

Early Coverage BeneficialHowever,

Unclear How Early?

Wound ClosureTraditionally

3 Debridements

RealityWhen Healthy

Wound Bead Obtained

Wound ManagementDead Space

VACAssist In

Wound Management

TemporizingPossible VAC

To ClosureATB Bead

PouchMaintains

Sterile ? Environment

High Concentration Local ATB

Lessons Learned from LEAP Study

No one does really well

Scoring systems do not predict outcome (MESS)

Psycho-social issues play important role in long term outcomes

Outcomes continue to worsen with time

Absent plantar sensation not an indication for amputation

Avoid complications regardless of treatment path

Short term-Amp cheaperLong term-Limb salvage cheaper

Open Fracture - Summary

Aggressive RxEarly IV

AntibioticsComplete

Excisional Debridement

Early Bone / Soft Tissue Stablization

Early (???) Soft Tissue Coverage

Case Discussion

• 48 yo woman in MVC