1. COMPOUND FRACTURES OF
LOWER LIMB- PRINCIPLES
OF MANAGEMENT

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DefinitionDefinition
A FRACTURE IN WHICH FRACTURE HAEMATOMAA FRACTURE IN WHICH FRACTURE HAEMATOMA
COMMUNICATES WITH EXTERIORCOMMUNICATES WITH EXTERIOR

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Gustillo Classification
• Grade I:
- wound less than 1 cm
w/ minimal soft tissue injury;
- wound bed is clean

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Gustillo Classification
• Grade I:
- wound less than 1 cm w/
minimal soft tissue injury; wound
bed is clean

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Type IIType II ::
 greater than 1cm in lengthgreater than 1cm in length
 moderate amount of soft tissue damagemoderate amount of soft tissue damage
 higher energy trauma.higher energy trauma.
(Usually confined to one compartment(Usually confined to one compartment
and amount of debridement required is minimal)and amount of debridement required is minimal)
ClassificationClassification
[Gustillo & Anderson][Gustillo & Anderson]

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¤ Type III¤ Type III ::
Wound longer than 10cmWound longer than 10cm
with extensive muscle devitalisationwith extensive muscle devitalisation

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Type IIIaType IIIa ::
Limited stripping of periosteum and softLimited stripping of periosteum and soft
tissues from bone.tissues from bone.
adequate soft tissue coverage for bone,adequate soft tissue coverage for bone,
tendons and neurovascular bundle.tendons and neurovascular bundle.

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¤¤ Type IIIbType IIIb : Extensive stripping of soft: Extensive stripping of soft
tissue and periosteum from bone.tissue and periosteum from bone.
Requires a local flap or free tissue transferRequires a local flap or free tissue transfer

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¤¤ Type IIIcType IIIc : A major vascular: A major vascular
injury requiring repairinjury requiring repair
((AA tibia # with disruption of ant. tibialtibia # with disruption of ant. tibial
arteryartery
but preservation of post. tibial artey isbut preservation of post. tibial artey is
not Type IIIc)not Type IIIc)
ClassificationClassification
[Gustillo & Anderson[Gustillo & Anderson

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Depending on mechanism
a. Compounding from with in
b. Compounding from with out

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MANAGEMENT
EMERGENCY
GOLDEN HOUR CONCEPT
AIM:-
To convert contaminated wound into clean woundTo convert contaminated wound into clean wound
To convert the open # into a closed one.To convert the open # into a closed one.
To establish a union in a good positionTo establish a union in a good position
To prevent pyogenic and clostridial infection.To prevent pyogenic and clostridial infection.

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MANAGEMENT
ORDER OF PRIORITY
1. PATIENT
2. LIMB
3. WOUND
4. FRACTURE

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PATIENT
POLYTRAUMA
RESUSCITATION
LIMB
VASCULAR STATUS
NEUROLOGICAL STATUS
COMPARTMENT SYNDROME

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WOUND
CLEAN
STERILE DRESSING
CULTURE SWAB?
FRACTURE
DONOT REDUCE
POSITION AND SPLINT
ANTIBIOTICS
BROAD SPECTURM

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PRINCIPLES OF MANAGEMENT
SURGICAL TECHNIQUE
TOURNIQUET
UsesUses
DisadvantagesDisadvantages
Never use as a routineNever use as a routine

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SKIN AND S/C TISSUESKIN AND S/C TISSUE
Expose entire zone of injuryExpose entire zone of injury
Meticulous hemostasisMeticulous hemostasis
Elliptical wound preferredElliptical wound preferred
Wound extensionsWound extensions
Be conservativeBe conservative

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FASCIAFASCIA
Excise contaminated fasciaExcise contaminated fascia
Enlarge small rents in fasciaEnlarge small rents in fascia
Prophylactic fasciotomyProphylactic fasciotomy

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MUSCLEMUSCLE
Mechanism of injuryMechanism of injury
Necrotic muscle : pabulum of infectionNecrotic muscle : pabulum of infection
““When in doubt,take it out” is approachWhen in doubt,take it out” is approach
10 % muscle belly is enough10 % muscle belly is enough

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Vascular anatomyVascular anatomy
Viability of muscle :4 C’sViability of muscle :4 C’s
Look beyond superficial layerLook beyond superficial layer

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FACTORS OF VIABILITY
1. COLOUR
2. CONSISTENCY
3. CONTACTILITY
4. CAPACITY TO BLEED

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TENDONSTENDONS
Not a pabulum of infectionNot a pabulum of infection
Adequate coverageAdequate coverage
RepairRepair
Usually preservedUsually preserved

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BONEBONE
Retain bones with soft tissueRetain bones with soft tissue
attachmentattachment
DebridementDebridement
ViabilityViability
Adequate coverageAdequate coverage

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JOINTSJOINTS
ArthrotomyArthrotomy
Irrigation and debridementIrrigation and debridement
Loose fragmentsLoose fragments
Tight closure of capsuleTight closure of capsule

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NERVES AND VESSELSNERVES AND VESSELS
Layer by layer hemostasisLayer by layer hemostasis
Delayed repair if contaminatedDelayed repair if contaminated
Total loss of blood supply-moreTotal loss of blood supply-more
than 8 hrs:AMPUTATIONthan 8 hrs:AMPUTATION
Emergency repairEmergency repair

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Wound coverWound cover
TypesTypes
1)Split thickness free skin graft1)Split thickness free skin graft
2)full thickness free skin graft2)full thickness free skin graft
3)Local flap graft3)Local flap graft
4)fasciocutaneous flaps4)fasciocutaneous flaps

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5)Myo-cutaneous flaps5)Myo-cutaneous flaps
6)Pedicle flaps6)Pedicle flaps
7)Free micro vascularised muscle flap7)Free micro vascularised muscle flap
Biological dressingsBiological dressings

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STABILIATION OF OPEN FRACTURESTABILIATION OF OPEN FRACTURE
METHODSMETHODS
1.1. PLASTER IMMOBILISATIONPLASTER IMMOBILISATION
2.2. PINS &PLASTERPINS &PLASTER
3.3. SKELETAL TRACTIONSKELETAL TRACTION
4.4. EXTERNAL FIXATIONEXTERNAL FIXATION
5.5. INTERNAL FIXATIONINTERNAL FIXATION
6.6. HYBRID FIXATIONHYBRID FIXATION
trade-off between bony stability
and foreign body response

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External fixatorsExternal fixators
Method of choice in most open fracturesMethod of choice in most open fractures
ADVATAGESADVATAGES
•Easily appliedEasily applied
•Good skeletal & soft tissue stabilityGood skeletal & soft tissue stability
• Anatomical reduction.Anatomical reduction.
• No additional traumaNo additional trauma

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ADVATAGES of EX.FIXADVATAGES of EX.FIX
•Risk of infection is comparatively less.Risk of infection is comparatively less.
•Allows wound inspection & wound dressing.Allows wound inspection & wound dressing.
•Temporarizing frame ,restoring the limb to lengthTemporarizing frame ,restoring the limb to length
until definitive fixation.until definitive fixation.
•Allows transportationAllows transportation
•Better nursing careBetter nursing care

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INTERNAL FIXATIONINTERNAL FIXATION
CONTROVERSIALCONTROVERSIAL
IndicationIndication
1.1. Type- I #Type- I #
2.2. Type-II # - 5-8% infectionType-II # - 5-8% infection
3.3. Type III # - 26-43 % infectionType III # - 26-43 % infection
4.4. Intra articular #Intra articular #
5.5. Reimplantation surgeryReimplantation surgery
6.6. Vascular repairsVascular repairs
7.7. Old patientsOld patients
8.8. Polytrauma patientsPolytrauma patients

47. BONE GRAFTINGBONE GRAFTING
INDICATIONSINDICATIONS
1.1. Bone lossBone loss
2.2. High velocity traumaHigh velocity trauma
3.3. Severe comminutionSevere comminution
TimingTiming
type-I immediatetype-I immediate
type II &III 6-12 weekstype II &III 6-12 weeks

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AMPUTATIONAMPUTATION
IndicationsIndications
1.1.vascular injury – norepair possiblevascular injury – norepair possible
2.functional outcome better with prosthesis2.functional outcome better with prosthesis
3. Life saving to arrest bleeding3. Life saving to arrest bleeding
4. Associated diseases OVD- DM etc.4. Associated diseases OVD- DM etc.

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COMPLICATIONSCOMPLICATIONS
EARLYEARLY
1. Gas gangrene1. Gas gangrene
2. Tetanus 2. Tetanus
3. Crush syndrome 3. Crush syndrome
1.1.Chronic osteomyelitisChronic osteomyelitis
2.Delayed union & Non union2.Delayed union & Non union
3.Joint stiffness3.Joint stiffness
LATELATE

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OPEN FRACTURES IN CHILDRENOPEN FRACTURES IN CHILDREN
differ from those in adultsdiffer from those in adults
1.1. healing capacity of the soft tissues & bonehealing capacity of the soft tissues & bone
excellentexcellent
2.2. No bone grafting neededNo bone grafting needed
3.3. Infection rareInfection rare
4.4. External fixation left in place until unionExternal fixation left in place until union
5.5. social and psychological impactsocial and psychological impact

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