4. 4
Open Fracture
Definition: as one in which a break in the skin and
underlying soft tissues leads directly into or
communicates with the fracture and the hematoma
Surgery Block - 6th MBBS
October 19, 2013
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Open Fracture
Mechanism:
Occurs most commonly after high-energy limb
injuries.
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Open Fracture
General Considerations:
one of the true orthopedic emergencies.
Such a fracture is suspect to contamination by the
environment at the time of injury.
Can present as isolated injuries or in the context of a
multiply injured patient.
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Open Fracture
Diagnosis:
Soft tissue injuries may be threatening to life or limb.
Clinical examination is required BEFORE obtaining
the X-ray.
it is essential to check for neurological and vascular
compromise.
Diagnosed clinically and often difficult to appreciate
on X-rays.
Soft tissue should be assessed on x-rays.
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Open Fracture
Classification:
The classification of open fractures as described by
Gustilo and Anderson.
Type I:
Skin wound less than 1 cm.
Clean.
Simple fracture pattern.
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October 19, 2013
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Open Fracture
Classification:
Type II:
Skin wound more than 1 cm.
Soft-tissue damage not extensive.
No avulsions.
Simple fracture pattern.
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Open Fracture
Classification:
Type III:
High-energy injury involving extensive soft-tissue damage
Or multifragmentary fracture, segmental fractures, or
bone loss irrespective of the size of skin wound
Or severe crush injuries
Or vascular injury requiring repair
Or severe contamination including farmyard injuries
Surgery Block - 6th MBBS
October 19, 2013
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Open Fracture
Classification:
Type III:
More than 10 cm.
Is subdivided based on the degree of contamination, the
extent of periosteal stripping, and the presence of
vascular injury.
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Open Fracture
Classification:
Type IIIA: Adequate soft-tissue cover of bone despite
extensive soft-tissue damage
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Open Fracture
Classification:
Type IIIB:
Extensive soft-tissue injury with periosteal stripping and
bone exposure.
Major wound contamination.
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Open Fracture
Classification:
Type IIIC:
High-energy injury involving extensive soft-tissue damage.
Major arterial injury.
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Open Fracture
Management:
The treatment aims of open fracture is to:
1. Prevention of infection.
2. Soft-tissue coverage.
3. Fracture stabilization.
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Open Fracture
Management:
1. Prevention of infection:
In all open fracture injuries, the patient must receive anti-tetanus
prophylaxis and appropriate antibiotic coverage.
Antibiotics should be given intravenously as soon as possible.
Classification
I
0–2%
II
2 – 10 %
III
Surgery Block - 6th MBBS
Infection Risks
10 – 50 %
October 19, 2013
19. 19
Open Fracture
Management:
1. Prevention of infection:
Classification
I
Likely
organisms
Coverage Antibiotics (I.V)
II
Gram + Cocci
1st Generation
Cephalosporin
III
Gram + Cocci
and Gram Rod
1st Generation
Cephalosporin +
Gentamicin
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October 19, 2013
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Open Fracture
Management:
2. Soft tissue coverage:
Debridement of open fractures is one of
the single most important principles in
management of open fractures.
The recommended time for
debridement within 6 hours has for long
been considered critical in prevention
of infection.
Irrigation is very important principle in
open fracture management with
amount around 6 liters.
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October 19, 2013
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Open Fracture
Management:
2. Soft tissue coverage:
Surgical incisions performed
during initial debridement can
be closed primarily and original
open fracture wound left open.
Assisted wound closure using
antibiotic bead pouch or
vacuum assisted dressings are
useful methods.
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October 19, 2013
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Open Fracture
Management:
3. Fracture stabilization:
External fixation is the mainstay of treatment in severe
open fracture. Allowing easy access to management of
soft tissues injuries.
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October 19, 2013
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Open Fracture
Management:
3. Fracture stabilization:
Definitive fixation is considered, when:
1. The patients clinical status is optimized
2. The wounds are healthy and the soft-tissue envelope will
allow for chosen surgical approach
3. A good preoperative plan has been created.
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Acute Compartment
Syndrome
Definition:
Is a true surgical emergency with increasing in tissue
pressure prevents capillary blood flow and produces
ischemia in muscle and nerve tissue.
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Acute Compartment
Syndrome
Types:
Compartment of the leg:
Anterior compartment.
Posterior superficial compartment.
Posterior deep compartment.
Lateral compartment.
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October 19, 2013
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Acute Compartment
Syndrome
Types:
Compartment of the forearm:
Anterior (Flexor).
Posterior (Extensor).
Mobile wad of henry (Medially).
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October 19, 2013
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Acute Compartment
Syndrome
Diagnosis:
The key to successful treatment of
compartment syndrome is early diagnosis
and decompression.
The hypoxic muscle will become necrotic
within hours.
Any peripheral nerve passing through the
compartment is likely to suffer permanent
functional impairment.
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October 19, 2013
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Acute Compartment
Syndrome
Diagnosis:
Muscle, once infarcted, can
never recover and replaced by
inelastic fibrous tissue (Volkmann’s
ischemic contracture).
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Acute Compartment
Syndrome
Diagnosis:
Clinical:
The classical signs (5P)
Pain. (out of proportion on passive stretch of the muscles
compartment).
pallor.
Parasthesia.
Paralysis.
Pulselessness.
These signs and symptoms are subjective.
Surgery Block - 6th MBBS
October 19, 2013
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Acute Compartment
Syndrome
Diagnosis:
Intercompartmental pressure monitoring.
Incase of disturbance of level of conscious,
impose the use of objective methods
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October 19, 2013
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Acute Compartment
Syndrome
Management:
Remove cast or dressing
Place at level of heart
decompress the affected compartment (
Fasciotomy )
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References
Textbook of Orthopedics (John Ebnezar).
Aply’s System of Orthopedics and Fractures.
Essential of Orthopedics (RM Shenoy).
Essential Orthopedics (J.Maheshwari).
Field Guide to Fracture Management (Richard
B. Birrer).
Current Diagnosis and Treatment of Orthopedic
(Harry B. Skinner).
Essential Orthopedic and Trauma (David J.
Dandy)
Pocket of Orthopedics and Fractures. (Ronald
McRae).
Surgery Block - 6th MBBS
October 19, 2013
