1. Open
Fractures

2. Definition
• Break in the skin and underlying soft
tissue leading directly into or
communicating with the fracture and
its hematoma.

3. open fracture
classification
• Provides guidelines on prognosis and
treatment
– Fracture healing, infection and amputation rate
correlate with the degree of soft tissue injury
• Gustilo upgraded to Gustilo anD
anDerson
• ao open fracture classification
• Host classification of open fractures

4. type 1 open fractures
• Small less than 1cm
• Clean puncture through
which a bone spike protrudes
out.
• Minimal soft tissue damage
• No crushing
• Not comminuted(low-energy
fracture)

5. low enerGy fracture

6. type 2 open fractures
• More than 1cm
• No skin flap
• Minimal soft tissue
damage
• Moderate crushing or
comminution(low-
energy fracture)

7. type 3a open fractures
• Large wound more than
10cm
• Extensive muscle
devitalization
• High energy
• Comminuted
• bone coverage with
existing soft tissue
•

8. HiGH enerGy fracture

9. type 3b open fractures
• Large wound
• Cannot be covered by
soft tissue
• Severly comminuted
• Extensive muscle
devitalization
• High energy
• Requires a flap for
bone coverage and
soft tissue closure
• Periosteal stripping

10. type 3c open fractures
• High energy
• Increased risk of
amputation and
infection
• Any grade 3 with
major vascular injury
requiring repair
regardless the wound.

11. Why use
classification?
????

12. • Grades of soft tissue injury correlates with infection
and fracture healing
Grade 1 2 3A 3B 3C
Infection
Rates
0-2% 2-7% 10-25% 10-50% 25-50%
Fracture
Healing
(weeks)
21-28 28-30 30-35 30-35
Amputation
Rate
50%

13. common bacteria
encountereD witH open
fractures
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

14. Goals of treatment
1. Preserve life
2. Preserve limb
3. Preserve function
• Also….
– Prevent infection
– Fracture stabilization
– Soft tissue coverage

15. InItIal assessment &
manaGement
• ABC’s
• Assess entire patient
• Careful Physical examn
• Antibiotics and tetanus prophylaxis
• Local irrigation 1-2 liters
• Sterile compressive dressings
• Realign fracture and splint
• Do not culture wound in the ED*
– 8% of bugs grown caused deep
infection
– cultures were of no value and not to
be done
• Recheck pulse, motor and sensation
.

16. the 4 essentIals are :
• Wound debridement
• Antibiotic cover
• Stabilization of the fracture
• Early wound cover

17. Eckman JB Jr, Henry SL, Mangino PD, Seligson D. Wound and serum levels of tobramycin with the prophylactic use of tobramycin-
impregnated polymethylmethacrylate beads in compound fractures. Clin Orthop Relat Res. 1988; 237:213-5.

20. systemIc debrIdement
• Muscle viability determined by 4 C’s:
• COLOR
• CONSISTENCY
• CONTRACTILITY
• CAPACITY TO BLEED WHEN CUT

21. `

22. soaps In the
IrrIGatIon ?
• Surfactants (i.e. Soaps)
– Less bacteria adhesion
– Emulsify and remove
debris
– No significant difference
in infection or bone
healing compared to
bacitracin solution, but
more wound healing
problems in bacitracin
group

23. how to delIver the
IrrIGatIon?
• Bulb Syringe vs Pulsatile Lavage
– Pulsatile lavage
• Detrimental for early bone healing
– this is no longer present at 2 wks*
• More soft tissue destruction**
• More effective in removing
particulate matter and bacteria***
• High or low pressure?
– Higher pressure
• Better bone cleaning
• Worse soft tissue cleaning
• Slows bone healing

24. antIbIotIcs In the
IrrIGatIon?
No proven
benefit!
*Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS 2001. 9: 219-226.

26. sterIlIty and
antIbIotIc cover
• Wound should be covered until reaching
the OT
• Type 1 & 2 - Cefazolin 1gm IV 6 hours
• Type 3 - Aminoglycosides(gentamicin
IV)
• Farm or soil injury - + Metronidazole

27. Wound closure
• Type 1 – sutured without tension
• All others should be left open.Lightly packed
with sterile gauze and inspected after 2 days.
If clean – sutured or skin graft(delayed
primary closure)
• Type 3 – debridement more than once.

28. When to cover the
Wound?
• ASAP after wound adequately debrided.
• “Fix and Flap”
– For Type IIIB & IIIC open tibia fractures
Timing of flap placement Infection rate
< 72 hours 6%
> 72 hours 30%

29. Flap coverage for type 3b

30. contraindications to
primary closure
• Inadequate debridement
• Gross contamination
• Farm related or freshwater immersion injuries
• Delay in treatment >12 hours
• Delay in giving antibiotics
• Compromised host or tissue viability

31. VAC
• Vacuum assisted wound closure
– Recommended for temporary management
– Mechanically induced negative pressure in a closed
system
– Removes fluid from extravascular space
– Reduces oedema
– Improves microcirculation
– Enhances proliferation of reparative granulation
tissue
• Open cell polyurethane foam dressing ensures an
even distribution of negative pressure
-

33. types of fracture
stabilization
• splint
– Good option if operative
fixation not required
• internal fixation
– Wound is clean and soft
tissue coverage available
• external fixation
– Dirty wounds or extensive
soft tissue injury

35. aftercare
• Elevation of limb
• Continuation of antibiotic cover
• If open wound –inspected every 2 – 3 days.
-cultures are obtained

36. We can do both, salvage & amputate.
• Vascular surgery can revascularize
with bypass graft
– Generally before fracture stabilization
• Plastics can provide soft tissue
coverage
• However, in the tibia, the severity
to soft tissue envelope and bone
may result in infected nonunion
• If salvage…. long course of
repeated surgical procedures
– Painful and psychologically distressing
– Functional outcome may be poor and
no better than amputation

37. How to decide, salvage or amputate?
• Important factors in decision making:*
– General condition of the patient (shock)
– Warm ischemia time (>6hours)
– Age (>30 years)
– Cut to crush ratio (blunt injuries has a large zone
of crush)
Howe HR Jr, Poole GV Jr, Hansen KJ, Clark T, Plonk GW, Koman LA, Pennell TC: Salvage of lower extremities following combined
orthopedic and vascular trauma. A predictive salvage index. Am Surg. 1987 Apr;53(4):205-8.

38. Advances…
• BMPs
– 40% decreased infection rate with BMP in type 3
open tibia fractures*
• Antibiotic Laden Bone Graft**
– Tobramycin-impregnated calcium sulfate pellets
with demineralized bone matrix
– Animal study: successful in preventing infection

39. Thank you

40. Closed fraCtures
It’s broken bone that does not penetrate the
skin.
Treatment requires manipulation to improve
position of fragments , splintage ,
preservation of joint movement and
function.

41. Closed fraCture
ClassIfICatIoN
tsCHerNe(1984) :
• Grade 0 – simple fracture with little or no soft
tissue injury
• Grade 1- fracture with superficial bruising or
abrasion of skin and subcutaneous tissue
• Grade 2 – severe fracture with deep soft –
tissue contusion and swelling
• Grade 3 – marked soft tissue damage and
threatened compartment syndrome

42. reduCe
• Adequate apposition and normal alignment of
bone fragments
• 2 types :
open and closed
• Closed usually for minimally displaced
fractures.

43. Hold reduCtIoN
Continuous traction
Cast splintage
Functional bracing
Internal fixation
External fixation

44. traCtIoNs
• Reduction of fractures and dislocation
• Immobilising a painful inflamed joint
• Prevention of deformity by counteracting
muscle spasms
• Correction of soft tissue contractures
• Types : traction by gravity
• skeletal traction
• skin traction

45. ComplICatIoNs of
traCtIoN
• Circulatory embarassement
• Nerve injury
• Pin site infection

46. Cast splINtage
• Pop
• Stiffness can be minimised by :
• delayed splintage ie.by using traction until
movement is regained and then only applying
a plaster
• Starting with a conventional cast and later a
functional brace – permits joint movement

47. ComplICatIoNs
• Tight cast – diffuse pain
• Pressure sores –localised pain
• Skin abrasion or laceration
• Loose cast

48. INterNal fIxatIoN
• Indications
• Types : 1. interfragmentory screws
2.wires(transfixing , cerclage,tension –
band)
3.plates and screws(metaphyseal
fractures of long bones and diaphyseal
fractures of radius and ulna)
4.intramedullary nails

49. When to use IM nails?
• Treatment of choice for most
diaphyseal fractures of the
lower extremity
• Inserted without disrupting
the already injured soft tissue
envelope
• Preserves the remaining extra
osseous blood supply to
cortical bone
• Malunion is uncommon

50. When to use external fixation?
 Severe soft tissue
damage
 Assoc nerve or
vessel damage
 Severly
comminuted and
unstable
 Fractures of
pelvis not
controllable by
other methods

51. • Infected fractures for which internal fixation
might not be suitable
• Sever multiple injuries where early
stabilization reduces the risk of serious
complications.

52. Ex-fix: Weigh the pros and cons!
• Historically was definitive treatment
• Now, more commonly as temporary fixation
• Can be applied almost always and everywhere
• Severe soft tissue damage and contamination
• Advantages:
– Easy and quick
– Relatively stable fixation
– No further damage done
– Avoids hardware in the
open wound
• Disadvantages:
– Pin track infections
– Malalignment
– Delayed union
– Poor patient
compliance