1. Management ofManagement of
Open FracturesOpen Fractures

2. IntroductionIntroduction
 An open fracture is one in which a break inAn open fracture is one in which a break in
the skin and underlying soft tissue leadsthe skin and underlying soft tissue leads
directly into or communicates with thedirectly into or communicates with the
fracture and its hematoma.fracture and its hematoma.
 When wound occurs in the same limbWhen wound occurs in the same limb
segment as a fracture, the fracture mustsegment as a fracture, the fracture must
be considered open until provenbe considered open until proven
otherwise.otherwise.

4. Methods of ClassificationMethods of Classification
 Grading System- Focus on severity of limbGrading System- Focus on severity of limb
injury only. Ex: Gustilo Anderson,injury only. Ex: Gustilo Anderson,
Tscherne and Gotzen, Bryd and Spicer etc.Tscherne and Gotzen, Bryd and Spicer etc.
 Scoring System-Focus on limb injury andScoring System-Focus on limb injury and
general health; also gives Amputationgeneral health; also gives Amputation
Score. Ex: MESS, NISSA, LSI, PSI etc.Score. Ex: MESS, NISSA, LSI, PSI etc.
 Comprehensive System- Combines theComprehensive System- Combines the
above two systems. Ex: AO System,above two systems. Ex: AO System,
Ganga hospital score.Ganga hospital score.

5. GradeGrade WoundWound Level ofLevel of
ContaminationContamination
Soft TissueSoft Tissue
InjuryInjury
Bone InjuryBone Injury
11 < 1 cm long< 1 cm long CleanClean MinimalMinimal Simple #Simple #
MinimalMinimal
comminutioncomminution
22 > 1 cm long> 1 cm long ModerateModerate No extensiveNo extensive
soft tissuesoft tissue
damage.damage.
ModerateModerate
crushing injurycrushing injury
ModerateModerate
comminutioncomminution
3 A3 A Severe withSevere with
crushingcrushing
Segmental orSegmental or
severelyseverely
comminuted.comminuted.
Soft tissueSoft tissue
coverage ofcoverage of
bone possiblebone possible
BB Usually > 10Usually > 10
cmscms
HighHigh Very severe lossVery severe loss
of coverage.of coverage.
Usually requiresUsually requires
soft tissuesoft tissue
reconstructivereconstructive
surgery.surgery.
PeriostealPeriosteal
stripping. Maystripping. May
be moderate tobe moderate to
severesevere
comminution.comminution.
CC Very severe lossVery severe loss
of coverage +of coverage +
vascular injuryvascular injury
requiring repairrequiring repair
Bone coverageBone coverage
poor. May bepoor. May be
moderate tomoderate to
severesevere
comminution.comminution.

6.  Tscherne system- this systemTscherne system- this system
includes compartment syndromeincludes compartment syndrome
which is not included in the otherwhich is not included in the other
grading systems.grading systems.
 Byrd and Spicer- lacks sophisticationByrd and Spicer- lacks sophistication
and hence not widely used.and hence not widely used.

7. Scoring systemScoring system
 MESS( Mangled Extremity SeverityMESS( Mangled Extremity Severity
Score) for prediction of amputationScore) for prediction of amputation
 Developed to identify patients whoDeveloped to identify patients who
will be benefited by primarywill be benefited by primary
amputation in retrospective analysis.amputation in retrospective analysis.
 The outcome of injured limb is eitherThe outcome of injured limb is either
salvage or amputation.salvage or amputation.
 A score of > or equal to 7 isA score of > or equal to 7 is
predicative of amputation.predicative of amputation.

8.  NISSA-Nerve injury, ischemia, soft tissue injury, skeletalNISSA-Nerve injury, ischemia, soft tissue injury, skeletal
injury, shock, age; more sensitive and specific than MESS.injury, shock, age; more sensitive and specific than MESS.
 LSI- limb salvage indexLSI- limb salvage index
Applied to limbs with arterial injury.Applied to limbs with arterial injury.
Warm ischemia time together with scores for injuredWarm ischemia time together with scores for injured
skin, muscle, bone, NV are added to give a total score.skin, muscle, bone, NV are added to give a total score.
LSI>6 AND Grade IIIC Gustillo with major nerve injuryLSI>6 AND Grade IIIC Gustillo with major nerve injury
are amputated.are amputated.

9. Comprehensive systemsComprehensive systems
AO SystemAO System
 Skin lesions, muscle tendons, NV, bone injuries areSkin lesions, muscle tendons, NV, bone injuries are
graded separately. AO system allows better prediction ofgraded separately. AO system allows better prediction of
outcome when compared to Gustilo. Due to its complexity,outcome when compared to Gustilo. Due to its complexity,
not widely accepted.not widely accepted.
Ganga hospital scoreGanga hospital score
 Includes additional criteria like age>65, DM,Includes additional criteria like age>65, DM,
cardiorespiratory disease, trauma chest/abdomen,cardiorespiratory disease, trauma chest/abdomen,
farmyard/sewage contaminations, delay in debridementfarmyard/sewage contaminations, delay in debridement
>12h.>12h.

10. Initial managementInitial management
 Patient assessment: ABCPatient assessment: ABC
 Address life threatening injuries.Address life threatening injuries.
 Rule out cervical injuries, chest, abdominal injuries, head injuries inRule out cervical injuries, chest, abdominal injuries, head injuries in
polytrauma patients.polytrauma patients.
 Identify all injuries to extremities and assess neurovascular status ofIdentify all injuries to extremities and assess neurovascular status of
injured limb.injured limb.
 Assess skin and soft tissue damage.Assess skin and soft tissue damage.
 Obvious foreign bodies that are easily accessible may be removed- don’tObvious foreign bodies that are easily accessible may be removed- don’t
do digital exploration.do digital exploration.
 The open wound should be covered with a sterile saline soaked gauze pad.The open wound should be covered with a sterile saline soaked gauze pad.
 Identify skeletal injuries and obtain necessary radiographs.Identify skeletal injuries and obtain necessary radiographs.
 IV TetanusIV Tetanus
 IV AntibioticsIV Antibiotics

11. Principles of TreatmentPrinciples of Treatment
 Antibiotic prophylaxisAntibiotic prophylaxis
 Wound debridementWound debridement
 Fracture stabilizationFracture stabilization

12. DebridementDebridement
 Most important step.Most important step.
 Aim-Removal of dead tissue andAim-Removal of dead tissue and
foreign material to ensure goodforeign material to ensure good
blood supply.blood supply.
 Debridement done as soon asDebridement done as soon as
possible.possible.

13. Superficial DebridementSuperficial Debridement
 Wound margins are excised to identify and explore the entire zoneWound margins are excised to identify and explore the entire zone
of injury and to access ends of bone fragments. Extensileof injury and to access ends of bone fragments. Extensile
longitudinal incision to visualize deep tissue and can be extendedlongitudinal incision to visualize deep tissue and can be extended
till normal tissue encountered clearly.till normal tissue encountered clearly.
 Nonviable skin and subcutaneous tissue excised but of marginalNonviable skin and subcutaneous tissue excised but of marginal
viability may be left for later debridement.viability may be left for later debridement.
 Do not detach skin and subcutaneous tissue from the fascia. AnyDo not detach skin and subcutaneous tissue from the fascia. Any
nonviable shredded fascia and even the marginally viable onesnonviable shredded fascia and even the marginally viable ones
excised.excised.

14. Deep DebridementDeep Debridement
 Muscle because of water content are subject to hydraulic damageMuscle because of water content are subject to hydraulic damage
by fluid waves during injury. In muscle debridement, the conceptby fluid waves during injury. In muscle debridement, the concept
is when in doubt take it out.is when in doubt take it out.
 In type I, II, and IIIa open # all non-vital and in doubt muscleIn type I, II, and IIIa open # all non-vital and in doubt muscle
can be debrided.can be debrided.
 IIIb and IIIc fractures- removal of entire muscle compartmentIIIb and IIIc fractures- removal of entire muscle compartment
may be needed.may be needed.
 Viability of muscle is checked by its color, capacity to bleed,Viability of muscle is checked by its color, capacity to bleed,
contractility, and consistency(4c’s-last 2 more reliable).contractility, and consistency(4c’s-last 2 more reliable).

15. IrrigationIrrigation
 Usual irrigation fluid used is NSUsual irrigation fluid used is NS
 High volume low pressure repeated lavage isHigh volume low pressure repeated lavage is
performed.performed.
 Volume of fluid used varies- usually about 3 L isVolume of fluid used varies- usually about 3 L is
used for grade 1 #; 6-10 L is used for grade 2 orused for grade 1 #; 6-10 L is used for grade 2 or
3 #.3 #.

16.  Tendons, unless injured beyond repair should beTendons, unless injured beyond repair should be
preserved.preserved.
 In open wounds tendons are subject toIn open wounds tendons are subject to
desiccation and hence it should be covered withdesiccation and hence it should be covered with
soft tissues if not with moist dressings.soft tissues if not with moist dressings.
 In general bone devoid of soft tissue attachmentIn general bone devoid of soft tissue attachment
are removed and large fragments with soft tissueare removed and large fragments with soft tissue
attachments are preserved.attachments are preserved.
 One exception to strict removal of bone withoutOne exception to strict removal of bone without
soft tissue attachment, is significant portion ofsoft tissue attachment, is significant portion of
articular surface attached to bone fragment.articular surface attached to bone fragment.

17. Limb Salvage vs. AmputationLimb Salvage vs. Amputation
 Limb is nonviable as evidenced by irreparableLimb is nonviable as evidenced by irreparable
vascular injury, warm ischemia time >8 hrs,vascular injury, warm ischemia time >8 hrs,
severe crush injury with minimal remaining viablesevere crush injury with minimal remaining viable
tissue.tissue.
 Severely damaged limb may constitute a threatSeverely damaged limb may constitute a threat
to patients life especially in patients with severeto patients life especially in patients with severe
debilitating c/c illness. The severity of injurydebilitating c/c illness. The severity of injury
would demand multiple operative procedures andwould demand multiple operative procedures and
prolonged reconstruction time.prolonged reconstruction time.
 Mangled extremity severity score of >7Mangled extremity severity score of >7
accurately predicts amputation.accurately predicts amputation.
 Score doubles for ischemia>6 hrs.Score doubles for ischemia>6 hrs.

18. Skeletal StabilizationSkeletal Stabilization
 Done once vascular repair is completed and limbDone once vascular repair is completed and limb
salvaged or once irrigation and debridement issalvaged or once irrigation and debridement is
done.done.
 Restoring the length, rotational, and angularRestoring the length, rotational, and angular
alignment has many benefits for healing of softalignment has many benefits for healing of soft
tissues.tissues.
 Fracture reduction unkinks NV conduits and helpsFracture reduction unkinks NV conduits and helps
in soft tissue healing.in soft tissue healing.
 Minimizing motion of fragments also decreasesMinimizing motion of fragments also decreases
further damage, pain and permits mobilization offurther damage, pain and permits mobilization of
joints.joints.

19. Skeletal Stabilization-TypesSkeletal Stabilization-Types
 Extra osseous- In low grade open fracturesExtra osseous- In low grade open fractures
splints, plasters, wt bearing casts, etc.splints, plasters, wt bearing casts, etc.
 Internal fixation- usually appropriate if wound clean, andInternal fixation- usually appropriate if wound clean, and
soft tissue coverage available.soft tissue coverage available.
 External fixation- in high grade open fracturesExternal fixation- in high grade open fractures
in dirty wounds, or extensive soft tissuein dirty wounds, or extensive soft tissue
injuries.injuries.

20. External fixationExternal fixation
 Excellent stability obtained.Excellent stability obtained.
 Reasonable anatomic reductionReasonable anatomic reduction
possible.possible.
 Minimal additional soft tissue traumaMinimal additional soft tissue trauma
 Risk of infection-minimized.Risk of infection-minimized.
 Ability to convert to internal fixation.Ability to convert to internal fixation.

21. Internal fixationInternal fixation
 Plates and screws- to minimize complications IVPlates and screws- to minimize complications IV
anti staph antibiotics should be started as soon asanti staph antibiotics should be started as soon as
possible, sterile dressing, meticulouspossible, sterile dressing, meticulous
debridement, copious irrigation and minimaldebridement, copious irrigation and minimal
stripping and accurate anatomical reduction is tostripping and accurate anatomical reduction is to
be done.be done.
 IM nail- currently the treatment of choice forIM nail- currently the treatment of choice for
grade I,II,IIIa, and IIIb fractures as ex-fixgrade I,II,IIIa, and IIIb fractures as ex-fix
devices leads to more malalignment, nonunion,devices leads to more malalignment, nonunion,
and delayed return to function.and delayed return to function.

22. Wound closure and coverageWound closure and coverage
 Wounds without skin loss: tension free primary closureWounds without skin loss: tension free primary closure
after thorough debridement.after thorough debridement.
 Contraindications for primary closureContraindications for primary closure
Delayed presentation >12 hrs.Delayed presentation >12 hrs.
Delayed administration of antibiotics>12 hrs.Delayed administration of antibiotics>12 hrs.
Deep seated contaminationDeep seated contamination
ImmunocompromisedImmunocompromised
NV injuryNV injury
Inability to achieve tension free sutureInability to achieve tension free suture
High risk of anaerobic contamination like farm yardHigh risk of anaerobic contamination like farm yard
injuries.injuries.
 Wounds with skin loss: healing by secondary intention.Wounds with skin loss: healing by secondary intention.
Delayed primary closure, SSG, free flaps.Delayed primary closure, SSG, free flaps.

23. ComplicationsComplications
 EARLY-ShockEARLY-Shock
Compartment syndromeCompartment syndrome
Crush syndromeCrush syndrome
Infection and sepsisInfection and sepsis
DVT and embolismDVT and embolism
ARFARF
 Late- OsteomyelitisLate- Osteomyelitis
Non unionNon union

24. THANK YOUTHANK YOU