Open Fractures - Ortho - 015358

OPEN FRACTURES SHINES MARIYA
 Fracture with a break in the overlying skin

INTRODUCTION
and soft tissues, leading to
communication of the fracture with the
external environment.
 Also described as compound fracture.
 2 Types: Internal and External

 Open fractures occur as a result of direct
high energy trauma either from road
traffic collisions , falls from height, gun
shot injuries, blast injuries, industrial and
sports injuries….
 Consequences:
* Infection of bone
* Inability to use traditional
methods
*Problems related to union-
Non union, malunion.
GUSTILLO AND
ANDERSON
CLASSIFICATION
(based on :
A) Size
B) Level of
contamination
C) Involvement of soft
tissue and blood vessels)
 General physical examination –since the patient
usually in shock. level of consciousness, pulse, bp,
breathing should be recorded
 Examination of other system- for head injury, neck

APPROACH and face injury, chest injury, blunt injury abdomen,
IN OPEN
FRACTURES pelvic &spine fractures
 Examination of compound injury-look for soft tissue

injury and wound, bone loss, absence of bone pieces,
distal neurovascular status of limb
 Laboratory tests: Hb%, blood group, BT,
CT, HIV, HBS Ag, routine urine
examination etc.
INVESTIGATIONS
 Special investigations: Plain radiographs
are usually adequate to assess the extent
of the fracture
Radiological examination
 Radiograph should be taken after the
initial primary dressing and radiolucent
splinting.
 Air present on plain radiographs in the
muscle, subcutaneous tissue or joint and
visualized foreign bodies indicate an
open injury.
 AP and lateral views of the injured bone
should be obtained.
 Fracture site radiographs should include
the joint above and below, as the fracture
could extend into the adjacent joints or
involve articular surfaces.
 It is important to rule out injuries to the
cervical spine, chest and pelvis by taking
radiographs.
 A CT of the ankle or knee joint may be
helpful to characterize the orientation of
the fracture and aid in reduction
and plans for fixation.
 To convert a contaminated wound into a clean
wound and thus make an open fracture into a
MANAGEMENT closed fracture.
PRINCIPLES
 To establish union in a good position.
 To prevent any infections.

 Phase 1 – Emergency Care
 Phase 2 – Definitive Care Open fracture

MANAGEMENT  Phase 3 – Rehabilitation
Closed fracture
 Tight circular bandaging in order to stop
bleeding.
 Wound washed with clean tap water or saline
 Splinting of fracture
 Look for neurovascular injuries
 Wound care
EMERGENCY -washing wound under aseptic
CARE precautions
-sterile dressing is done
 Prophylactic antibiotics
 Tetanus prophylaxis
 Analgesics
 X rays
Includes:
DEFINITIVE  Wound Debridement
CARE  Definitive Wound Management
Wound Debridement
 Exploration of wound – Extend
Criteria to evaluate tissue status the wound
Features Viable Nonviable
 Excision of all devitalized
Color Pink Pale tissues
Consistency Firm Flabby  Skin, subcutaneous tissue
Capacity to Preserved Lost  Muscle, fascia
bleed
 Bones
Circulation Present Absent
 Nerves and Vessels repaired
Contractility Present Absent
 Evacuation of all foreign bodies
 Irrigation of the wound
Definitive Wound Management
 Primary closure
-suturing the skin or raising
a flap
 Delayed primary closure
-wound debrided after 6-8
hours, closure not done
immediately
-covered with sterile dressing
-closure done later
Secondary Closure
 The wound must be closed as early as
possible, preferably within a week.
Methods used for secondary closure:
 Full thickness graft
 Rotational flaps
 Free flaps
 Secondary healing
 Grade III open fractures may need bone
grafting.
 Wait for the wound to heal before intervening
 If possible non operative methods give good result
FRACTURE
 In extensive damage to soft tissue –external fixation of
MANAGEMENT fracture
 External fixators provide excellent access
to wound care and stability, so they are
used in Type II and III open fractures.
 External fixation provides excellent
stability, wound access, minimal
additional tissue or bone devitalization.
 Involves insertion of metal screws or pins
into the bone above and below the
fracture site. The pins and screws project
out of the skin where they are attached to
metal or carbon fiber bars.
Advantages of stabilization of bone are as
follows:
 Re-establishes alignment of soft tissue and bone
 Provides optimal circulation
STABILIZATION
 Prevents further damage of soft tissue by the
OF BONE
bone ends
 Plaster immobilization is used in Type 1 open
fractures
 Indicated when arterial repair is done or if there
FASCIOTOMY are signs of compartment syndrome.
Timely amputation saves unnecessary suffering of the
patient.
Indications:
 8 hours after arterial injury most of the limbs need
amputation.
 If the limb is severely damaged, that is if it is functionally
far less satisfactory
AMPUTATION Considered in:
 Grade III open fractures with neurovascular injury
 Associated with crush injury
Decision to amputate:
 Mangled Extremity Severity Score
 Score >7 amputate
Mangled Extremity Severity Score (MESS)
CATEGORY CHARACTERISTICS SCORE
Skeletal and soft tissue injury Low energy injury 1
Medium energy injury 2
High energy injury 3
Very high energy injury 4
Limb ischaemia Pulse reduced or absent, perfusion 1

(double the score for ischaemia > 6 normal
hours) Pulseless, paraesthetic with 2
diminished capillary refill
Cool, paralysed, insensate or numb 3
Presence of shock Systolic BP always >90mmHg 0

Transient hypotension 1
Persistent hypotension 2
Age of the patient < 30 0
30 – 50 1
> 50 2
 Consist of joint mobilisation
 Muscle exercise during and after removal of
immobilisation
REHABILITATION
 Advice regarding mobilisation of the injured
limb
 Wound infection
 Osteomyelitis
 Non union
 Tetanus infection
COMPLICATIONS
 Neurovascular injury
 Compartment syndrome
 Debridement is the main stay of treatment
 The procedure is 4E’s
 Explore the wound
 Excision of devitalized tissue
 Evacuation of foreign bodies
 External fixators
 Devitalized tissues recognized by 5C’s
 Wound irrigation most important step
 Antibiotics cannot replace wound debridement
 Primary aim is to convert open fracture into
closed fracture
 Wound closure to be decided with caution
 Restore patients limb and function as early as
possible
Thank You!

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OPEN FRACTURES SHINES MARIYA

 Fracture with a break in the overlying skin

 Also described as compound fracture.

 2 Types: Internal and External

 Examination of other system- for head injury, neck

 Examination of compound injury-look for soft tissue

 To prevent any infections.

 Phase 2 – Definitive Care Open fracture

Limb ischaemia Pulse reduced or absent, perfusion 1

Presence of shock Systolic BP always >90mmHg 0

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