Open Fractures

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Introduction

  • Open fracture is a fracture that communicates with an overlying break in the skin.
  • Goal of treatment is : 

     

    • Prevention of infection

    • Healing of the fracture

    • Restoration of function


Clinical Evaluation : 

  • ATLS ( read more )
  • Neurovascular Examination
  • Four Exterimities Evaluation
  • If surgical intervention is planned then no need for surgical exploration in the emergency room. It could even worsen the case by making more contamination. But, If surgery is sxpected to be delayed then irrigation of the emergency room with Sterile Normal Saline
  • Compartment syndrome must be expected to occur and should be ruled out. Charcter of compartment syndrome:

     

    • Pain out of proportion to injury
    • Pain to passive tretch of fingers or toes
    • Decreased sensation
    • Tense limb

Compartment pressure of 30 mmHg indicates emergent fasciotomy.


Investigations : 

Imaging: 

  • X-ray : 

     

    Trauma survey: 

    • Pelvis AP
    • Abdomen 
    • Chest AP 
    • Cervical Spine ( Lateral & AP )
    • Exterimity radiograph as indicated clinically.
  • Ultrasound : Abdomen
  • Duplex: If vascular injury is suspected.
  • Additional Imaging : As clinically required 

     

    • CT 
    • cystography
    • Angiography : 

       

      • Knee dislocations or lower limb injury with ABI < 0.9
      • cool pale foot with poor distal capillary refilling
      • High energy trauma to a vulenrable area (  popliteal region )

Classification:

Gustilo and Anderson: Based on the size of the open wound, amount of muscle contusion and soft-tissue crush, fracture pattern, amount of periosteal stripping, and vascular status of the limb.
This classification has been shown to have poor interobserver reproducibility.

Type I

Wound less than 1cm long

Moderately clean puncture, where spike of bone has pierced the skin

Little soft tissue damage

No crushing

Fracture usually simple transverse or oblique with little comminution

Type II

Laceration more than 1cm long

No extensive soft tissue damage, flap or contusion

Slight to moderate crushing injury

Moderate comminution

Moderate contamination

Type III

Extensive damage to soft tissues

High degree of contamination

Type III A

Fracture caused by high velocity trauma

Includes any segmental or severely comminuted closed or open fractures, regardless of the size of the wound

Type III B

Soft tissue coverage of the bone is adequate.

Extensive injury to or loss of soft tissue, with periosteal stripping and exposure of bone.

Massive contamination

Severe comminution of fracture

Type III C

After debridement a segment of bone is exposed and a local or free flap is required to cover it.

Any fracture with an arterial injury which requires repair, regardless of the degree of soft tissue injury

 

Tscherne Classification ( see it here ) 


Treatment

  • Non Operative

     

    • Emergency Department : 

       

      • ATLS
      • Control bleeding by direct pressure ( Not tornique ,  Not Blind clamping )
      • Clinical and radiographic examination
      • Antibiotic and tetanus prophylaxis

         

        • Gustilo I , II : 1st generation cephalosporin for 72 hours after each debridment.
        • Gustilo III : 1st generation cephalosporin + Aminoglycosides
        • Farm injuries : 1st generation cephalosporin + Aminoglycosides + Penicillin
        • Tetanus prophylaxis should be started in the emergency room. Toxoid and Immunoglobulin are taken intramuscular with 2 different syringes in 2 different sites.

           

          • Toxoid dose is 0.5 ml ( for all ages )
          • Immunoglobulin : 

             

            • 75 U for patients < 5 years
            • 125 U for patients from 5 – 10 years.
            • 250 U for patients older than 10 years old.
      • Place saline soaked dressing over the wound.
      • Reduction and splinting of all fractures
      • Patient prepararation to emergent surgical debridment and fixation of the fractures.

         

        • preferred within 8 hours of injury to reduce the incidence of infection
        • Avoid midnight operations. Delay it to the morning if possible.

Operative treatment

  • Irrigation and debridment:

     

    • It's the most important surgical step in open fractures management.
    • The wound should be explored by proximal and distal extension
    • Debridment should be  meticulous and begins with skin and subcutaneous fat down to bone.
    • Tendons are preserved unless severly contaminated or damaged.
    • Fracture surface should be exposed and bone fragments are debrided if not attached to soft tissue
    • Exploration , irrigation and debridment to adjacent joint should be done if there's extension into it.
    • Pulsatile lavage irrigation with or without antibibiotics.
    • Fasciotomy may be needed.
    • Serial debridment maybe performed every 24-48 hours until there's no necrotic tissues
  • Wound Closure:

     

    • The standard is to leave the wound open and just cover it  with:

       

      • saline soaked gauze dressing
      • synthetic dressing
      • VAC Sponge
      • Antibiotic bead pouch
    • It could be closed but with close opservation of signs and symptoms of infection and compartment syndrome.
  • Fracture Stabilization:

     

    • ​Either External or Internal fixation depending on the type and location of the fracture.
    • It provides protection  of soft tissue from further injury , facilitates patient mobilization and wound care is easier.
  • ​Soft tissue coverage:

     

    • Wound coverage is indicated once there's no evidence of soft tissue necrosis :

       

      • Primary closure
      • Split thickness skin graft
      • rotational muscle flap
      • free muscle flap
  • Bone grafting : Can be done when the wound is clean , dry and closed
  • Limb Salvage vs amputation

     

    • ​​Indications for amputation

       

      • Non viable limb
      • Irreparable vascular injury
      • ​​​Sever crush injury with minimal viable tissue
      • warm ischaemia more than 8 hours

Complications : 

  • Infection
  • Compartment syndrome

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