AO-SEC Principles in Operative Fracture Management

for Operating Room Personnel

Oct 1-2, 2010 | RDEC Bhaban, Dhaka, Bangladesh

Prof. Muhammad Shahiduzzaman

Head, Department of Orthopaedics & TraumatologyDhaka Medical College

Open Fractures

Objectives

► Open fracture classification► Patient evaluation► Surgical management

► In the emergency department► First visit to the OT► Definitive management

►Soft tissue►Fracture

Definition“An open fracture is one that communicates with the outside environment.”

Classification

Gustilo type I Wound less than 1cm Minimal soft tissue injury

Minimal contamination

Fracture usually simple transverse, short oblique fracture

Low energy injury

Gustilo type II Wound greater than 1 cm Moderate soft tissue

injury Slight or moderate crush No extensive soft tissue

damage, flaps or avulsions

Simple transverse short oblique fracture with moderate comminution

Gustilo type IIIA

Adequate soft tissue coverage of the bone

Includes segmental and severely comminuted fractures

Gustilo type IIIB Extensive periosteal

stripping and bone exposure

Massive contamination

Severe comminution with high energy injury

Requires free or local flap for bone coverage

Gustilo type IIIC

Any open fracture that is associated with an arterial injury that must be repaired regardless of the degree of soft tissue injury

ManagementAim Problem

Prevent Infection

Soft tissue and bone healing without

complications

Restoration of function

Infection

Delayed and Non union

Loss of extremity

Emergency assessment Assessment of patient

ATLS guidelines Manage life threatening injuries first.

Examination of the injury Wound (photos) Neurological status Vascular status Compartments :Open fractures can still

develop compartment syndrome

Emergency assessment…

Emergency Management Bleeding – control with

direct pressure Remove gross

debride, gentle small volume irrigation, sterile dressing (normal saline)

Reduce bone or joint Splint limb Intravenous antibiotics

Principle of treatment Treat any open fracture as an emergency. Evaluate the patient to diagnose other life

threatening injury. Institute appropriate and adequate antibiotic. Adequate wound excision. Stabilize the fracture. Perform delayed closure of the wound within 3-7

days. Decide on early amputation. Rehabilitate the involved extremity.

This is a surgical emergency Treatment of open fracture is second only to life

threatening and arterial injury.

It is imperative to immediately treat open fracture in order to reduce or prevent wound sepsis.

All open fractures of more than 8 hours should be considered infected.

Antibiotic therapy

Prevention of wound sepsis is the primary objectives in the treatment of open fracture

Tetanus prophylaxis is indicated.

Both gram-negative and aerobic gram positive are major pathogens in open #

Penicillin is added for Agriclutural injuries.

Common pathogen

Blunt Trauma, Low Energy GSW Staph, Strept

Farm Wounds Clostridia

Fresh Water Pseudomonas, Aeromonas

Sea Water Aeromonas, Vibrios

War Wounds, High Energy GSW Gram Negative

Wound excisionWound excision to be under taken under strict

aseptic condition, must be systematic and complete.

Lavage is done with normal saline or distilled water. For final irrigation mixture of bacitracin and polymyxin solution is preferable.

Wound incision must be large enough to facilitate exposure and inspection.

The following structures are debrided : skin, fascia and tendons,muscles, and bones.

Debridement Prior to irrigation Requires extension of the

wound Longitudinal

Systematic fashion Skin Subcutaneous fat Fascia Muscle Bone

Debridement-skin Prior to irrigation Requires extension of the

wound Longitudinal

Systematic fashion Skin Subcutaneous fat Fascia Muscle Bone

Debridement-muscle Open the fascial

compartments to see the extent of injury

Remove muscle that is dead or necrotic

Based on colour and turgor of muscle (bleeding not as good)

If in doubt can leave and relook in 24 to 48 hours

Debridement-bones

Remove bone that has no soft tissue attachment

Keep large articular fragments consider fixing at the initial

debridement

Irrigation After the

debridement

Options: Low pressure versus

high pressure (pulse lavage)

Saline alone versus additives (antiseptics, antibiotics, or soap/detergents)

Wound management “If there is the slightest doubt in the surgeon’s

mind as to whether there has been adequate debridement of the wound after an open fracture, the wound should not be closed regardless of the type of open fracture. For the surgeon who manages only an occasional open fracture, the safe rule is not to close the wound”

Gustilo and Anderson JBJS 1974

VAC system Provides closed

suction system Reduces oedema and

bacterial counts Enhances

granulation tissue

Carefully does not prevent primary wound closure

Not a substitute for early definitive coverage Plastics &

Reconstructive Surgery 2008

Antibiotic bead pouch Antibiotic cement

beads Fill dead space High local antibiotic

concentration Seal wound from

further contamination Infection rates

decreased from 12.0% to 3.7% in 1085 fractures (Ostermann JBJS 1995)

Repeat Debridement High grade injury

Severe contamination

Questionable tissue viability

Repeat 24-48 hours until wound viable

Can include opening a wound that was primarily closed (eg subcutaneous border of the tibia)

Remember that this does interfere with fracture healing to some degree

Wound Coverage and closure For type I and type II open fracture delayed

primary closure or skin graft can be accomplished in 3 to 5 days.

For type III B and III C open fracture with significant soft tissue loss and exposed bone often require two or three debridement before flap coverage.

Early soft tissue converge is key to minimize wound sepsis.

Soft tissue Coverage

Primary closure Delayed primary

closure Skin graft Local flaps

Fasciocutaneous flaps Muscle pedicle

Free flaps Standard (eg lat dorsi) Fasciocutaneous (eg

lateral thigh flap)

Stabilization of open fracture Plaster immobilization Skeletal traction Internal fixation with implant External fixation

Stabilization of open fracture…• Achieving fracture stability is just as

important as wound excision.

• Stable fracture fixation preserves the integrity of the remaining soft tissues, muscles and neurovascular structures.

• Facilitates care of the wound and contributes to the well-being of the whole patient.

• Allows joint motion and muscle exercise program.

Fixation Important to protect

the soft tissues from additional injury by fracture fragments

Aids in wound care Allows early

mobilisation and rehabilitation of the patient

Skeletal traction Skeletal traction is

indicated for type I and type II open fracture of femoral shaft.

Wound is allowed to heal followed by internal fixation in 10 to 14 days.

External Fixation

Safe and reliable method of achieving bony stability in open fracture.

Major disadvantage is pin tract infection, but can be considerably reduced with proper pin insertion and care.

Can a functional,viable extremity be achieved ? Can the the time and expense of saving the

extremity be justified ?

Absolute indication of amputation :

Type III C injury with posterior tibial nerve disruption.

Type III C injury with soft tissue loss, massive contamination with severely comminuted segmented fracture or massive bone loss.

Amputation

Rehabilitation Immediate objectives of rehabilitation are to

prevent muscle atrophy, prevent joint stiffness and improve circulation in the extremity.

The ultimate objective, of course, is to restore the extremity to the greatest degree of function of which it is capable.

A well-organized rehabilitation program initiated early will help return the patient to a functional status.