Beruflich Dokumente
Kultur Dokumente
INTRODUCTION
INJURY ASSESSMENT
87
88
Current Orthopaedics
Table2 Open fracture classificationafter Gustilo and Anderson
Grade I
Grade II
Grade IIIA
Grade IIIB
Grade IIIC
SURGICAL CLASSIFICATION
Formal classification of the open fracture occurs after
surgical debridement. The most widely used system is
that attributed to Gustilo and Anderson. 7,8 This classifies the injury into three types, with the high-energy
injuries subdivided into three further groups (Table 2).
This system has stood the test of time and is widely
understood. The essential elements being the differentiation between high- and low-energy injuries and the
concept of adequacy of soft-tissue cover in the highenergy injuries.
The site of the fracture has an important effect on
the injury grade, particularly with regard to quantity
of local muscle cover and the vulnerability of the local
soft tissue to injury. A fracture in the normal femur
has to be high-energy because of the intrinsic strength
of the bone; accordingly all open femur fractures
must be grade III, although the thick muscle cover of
the thigh usually provides adequate soft-tissue cover.
In comparison, the tibia is unique with regard to its
poor soft-tissue cover and particular vulnerability to
injury. Accordingly, it is difficult to have a grade IIIa
injury to the tibial diaphysis where most high-energy
diaphyseal and distal tibial fractures are grade IIIb
and require complex reconstructive surgery. The most
severe injury (IIIc) is the open fracture associated with
a vascular injury that requires repair. These can occur
with either a severe or very a relatively 'minor' would.
The high grading is because of the primary risk to the
limb associated with the arterial disruption and the
susceptibility of ischaemic muscle to infection.
A similar classification system for closed fractures
has been proposed by Tscherne. 4 This also describes
the range of soft-tissue injuries from essentially no
significant injury to major vascular disruption, severe
muscle revitalization or compartment syndrome, all
within a closed skin envelope, a fuller classification
system considering both injury types is provided by
the comprehensive classification from the AO. 9 This
individually classifies the integument, nerve and vascular tissues producing a more comprehensive and
detailed system that has much to recommend it.
SURGICAL M A N A G E M E N T
History
Much open-fracture surgery has developed in response
to the stimulus of war. Historically, an open fracture
was a mortal injury and rapid amputation the surgeon's primary mode of treatment. 15'~6Eventually, the
practice of d6bridement and antisepsis developed I7
and, together with delayed wound closure, entered
normal practice during World War I. At the same time,
the application on skeletal stability by the introduction
of the Thomas splint reduced the wartime mortality of
open femur fractures from 80% to 15%. ~5 Trueta
soundly established these principles during the
Spanish Civil War, TM while World War saw the introduction of antibiotics. More recently, military surgery
in Korea and Vietnam saw the development of rapid
89
In lower-grade injuries (1,2, or IIIa) there is an adequate soft-tissue envelope after d6bridement. These
wounds should not be closed primarily so as to allow
for swelling and reassessment but can be closed at a
second look at 48-72 hours. 19,27
More severe injuries (IIIB) have deficient soft tissues associated with significant areas of degloving,
periosteal stripping and contamination (Fig. 1).
Modern plastic surgery has progressed from the difficulties of the tube pedicle to the scope provided by fasciocutaneous flaps and finally modern microvascular
techniques for free tissue transfer (as initially championed by Marco Godina] 8 see the next article by Simon
Knight). The use of these techniques has revolutionized our reconstructive potential, rapidly converting
the open to a closed injury and facilitating the use of
any appropriate implant. Our experience and that of
others suggests that, in very experienced units, a protocol of repeated d6bridements and delayed closure for
90
Current Orthopaedics
Fig. 1 A: Severe III-c open fracture of the tibia; B: immediate flap coverage; C: final soft-tissue result; D: final bony consolidation after
plate removal.
Grade 1
OVERVIEW
A logical approach to the management of open fractures is focused on the prevention of infection, with a
clear route of referral of the more serious injuries.
The treatment of the open wound is essential.
Obtaining early skeletal stability is critical and can be
achieved with both internal and external fixation
devices. The aims in management of these injuries
should be considered in a logical sequence. The first is
limb salvage by obtaining soft-tissue healing without
REFERENCES
12. Fairhurst MJ. The function of below knee amputees versus the
patient with salvaged grade-III tibial fracture. Clin Orthop
1994; 301: 227-232.
13. Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr.
Objective criteria accurately predict amputation following
lower limb extremity trauma. J Trauma 1990; 30:568 573.
14. Robertson PA. Prediction of amputation after severe lower
limb trauma. J Bone Joint Surg 1991; 73-A: 816-818.
15. Russell TA. General principles of fracture treatment. In:
Campbell's Operative Orthopaedics, 8th edn. Grenshaw AH:
Mosby Year Book 1992: 768, vol. 2.
16. Kocher MS. Early limb salvage: open tibial fractures of
Ambroise Par6 (1510-1590) and Percival Pott (171 4-1789).
World J Surg 1997; 21: 116-122.
17. Wangesteen OH, Wangensteen SD. Carl Reyher - his
demonstration of the role of debridement in gunshot wounds
and fractures. Surgery 1973; 74: 641-649.
18. Trueta J. War surgery of the extremities; treatment of war
wounds and fractures. Br Med J 1942; 1: 616.
19. Hansen ST. In Hansen ST, Swinotowski MF, eds.
Traumatology at Harbour View Medical Center 3-8.
Orthopaedic Trauma protocols. New York: Raven Press, 1993.
20. Worlock P, Slack R, Harvey L, Mawhiney R. The prevention
of infection in open fractures: an experimental study of the
effect of fracture stability. Injury 1994; 25(1): 31 38.
21. Court-Brown CM, McQueen MM, Quaba AA, Christie J.
Locked intramedullary nailing of open tibial fractures. J Bone
Joint Surg 1991; 73-A: 959 964.
22. Tornetta PIII, Bergman M, Watnik N, Berkowitz G, Steuer J.
Treatment of grade-IIIB open tibial fractures. J Bone Joint
Surg 1994; 76-B: 13 19.
23. Hertel R, Lambert SM, Muller S, Ganz R. Rebuilding severe
open fractures of the leg: immediate is better than early soft
24.
25.
26.
27.
28.
29.
30.
31.
91