Fractures with Soft Tissue

Injuries
Gary E. Benedetti, MD
Created March 2004: Revised February 2006

Introduction
All fractures have some degree of soft tissue
injury
Prognosis determined by:
Amount of energy
transferred to the soft tissue
and bone
Degree of contamination
and type of bacteria
Patient factors

Introduction
Energy Transfer
Fall from curb
100 ft-lbs

Skiing
300-500 ft-lbs

High-Velocity GSW
2000 ft-lbs

Automobile Bumper @
20 MPH
100,000 ft-lbs

Classification of Soft Tissue

Injuries-Closed Fractures
Tscherne Type 0:
Minimal soft tissue injury
Indirect injury mechanisms
Simple fracture patterns.

Classification of Soft Tissue

Injuries-Closed Fractures
Tscherne Type I:
Superficial abrasion
or contusion
(pressure from
within)
Mild to moderate
severe bony injury

Classification of Soft Tissue

Injuries-Closed Fractures
Tscherne Type II:
Deep,
contaminated
abrasions or
muscle contusion
Impending
compartment
syndrome
Severe fracture
pattern

Classification of Soft Tissue

Injuries-Closed Fractures
Tscherne Type III:
Extensive skin contusion or
crush
Severe underlying muscle
damage
Subcutaneous avulsion
(degloving)
Associated major vascular injury
Severe, comminuted fracture
pattern

Skin Lesions
Blisters
Clear
Sanguineous

Abrasions
Degloving
Morel-Lavalle

Treatment of Closed Fractures

with Soft Tissue Injury
Control swelling

Provisional reduction
Stabilize: splint/traction/brace
Elevate
Consider foot pump in lower extremity

Serial evaluation for compartment

syndrome

Treatment of Closed Fractures

with Soft Tissue Injury
Treat fracture operatively or non operatively as
appropriate
Timing of definitive internal fixation
In tenuous areas (such as the ankle) await for skin lines
to reappear prior to surgical intervention-- wrinkle
sign
With skin lesions await for adequate resolution
Healing of abrasions, blisters or use alternate approach

Open Fracture
Definition
A break in the skin and
soft tissues
communicating with a
fracture or its
hematoma.

Classification of Open Fractures

Gustilo & Anderson

Gustilo-Anderson
Grade I

Gustilo-Anderson
Grade II

Gustilo-Anderson
Grade IIIA

Gustilo-Anderson
Grade IIIA
IIIA Includes severe
comminution despite
size of skin wound.

Gustilo-Anderson
Grade IIIB

Gustilo-Anderson
Grade IIIC

Limitations of Gustilo-Anderson
Classification
Tibia model
Emphasis on size of
skin lesion
Reproducibility
Does not differentiate
degree of vascular
insult

Prognosis & Gustilo-Anderson

Classification
INFECTION & AMPUTATION: Correlates with
degree of soft tissue injury
GRADE
INFECTION
AMPUTATION
*Tibia Fractures

II

0-2%

2-7%

IIIA

IIIB

IIIC

10-25% 10-50% 25-50%

50%

Prognosis & Gustilo-Anderson

Classification
FRACTURE HEALING: Correlates with degree of
soft tissue injury
IM NAIL TIBIA

GRADE I

GRADE II

GRADE
IIIA

GRADE
IIIB

HEALING

21-28
WKS

26-28 WKS

30-35 WKS

30-35
WKS

Assessment
History
Mechanism
High or low
energy?
Time since injury
Pre-morbid
conditions
Other injuries

Assessment
Physical Exam
One look soft tissue
exam
Neurological status
Vascular status
Compartments

Assessment
X-rays
Standard two 90
views
Joint above and
below fracture

Emergent Treatment
Stabilize the Patient
ATLS
SPLEEN

Emergent Treatment
One Look Exam
Sterile Dressing
No ER Cultures
Poor indicator of
probability of infection
and organism
expensive

Realign and Splint

Tetanus Toxoid
Tetanus Toxoid 2.5 cc to all poly-trauma patients, otherwise:
IMMUNIZATION HISTORY NON-TETANUS
PRONE

TETANUS
PRONE*

UNKNOWN

YES

YES

>3 IMMUNIZATIONS
(<5 YEARS)

NO

NO

*Tetanus Prone: >6 hours old, complex soft tissue injury, wound >1 cm
deep, missile, crush, burn, frostbite, devitalized tissues, soil contaminants,
denervated, ischemic, early infection.

Tetanus Immune Globulin

250-500 units IM:
IMMUNIZATION HISTORY NON-TETANUS
PRONE

TETANUS
PRONE*

UNKNOWN

NO

YES

>3 IMMUNIZATIONS
(<5 YEARS)

NO

NO

Bacteriology of 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

Recommended Antibiotic Treatment

1 Gen Ceph
Grade I
Grade II
Grade III
Farm/War
Wounds

Gent

PCN

+/-

+/-

(Gustilo, et al; JBJS 72A 1990)

Duration of Antibiotic Treatment

Initial 72 hours
48 hours after each subsequent
procedure

Treatment
Principles
Decrease
contamination and
remove devitalized
tissues

Timing of Initial I&D?

Traditional <6 hour
rule.

May not be a factor

with modern wound
care techniques.
Most authors still
recommend I&D
ASAP.

Treatment
Principles
Limb Salvage?
Vascular Injury?

Mangled Extremity
Can limb be save?
Should it be saved?

Lessons Learned from LEAP Study

No one does really
well
Scoring systems do
not predict outcome
Psycho-social issues
play important role in
long term outcomes

Absent plantar
sensation not an
indication for
amputation
Avoid complications
regardless of treatment
path

Principles of I&D
Longitudinal incisionsextensile exposures
Excise non viable
tissue
Systematic and detailed
approach

Irrigation
Stabilize fracture

I&D
Systematic
Skin
Fascia and fat
Muscle: 4 Cs of

muscle viability
Contractility
Capacity to bleed
Consistency
Color

I&D
Bone
Deliver, inspect
and cleanse bone
ends
Remove fragments
without soft tissue
attachment
Cleanse and retain
all major articular
fragments

I&D
Pulsatile Irrigation
Copious volume
Pulsatile action reduces
bacteria counts in tissue
Consider brush cleaning
bone
Antibiotics in solution
controversial
May impair bone healing

Stable Fixation
Reduces infection
Options:
External fixation
+/- delayed
internal
fixation
IM Nail
ORIF

IM Nailing of Open Fractures

Immediate IM Nail
After External Fixation
Generally safe if < 2-3 wks of placement
Avoid if evidence of pin tract infection

Reamed vs. Unreamed?

No difference in infection rate

Treatment
No routine
intraoperative
cultures
Unless clinically
suspect infection

Consider Antibiotic beads

Antibiotic Beads
Pros
Very high levels of
antibiotics locally
Dead space
management

Cons
Requires removal
Limited to heat
stable antibiotics
Increased drainage
from wound

Wound Closure
Primary Closure?
Delayed
closure/coverage
DPC
STSG
Flaps
VAC

Temporary vessel loops,

awaiting DPC

Timing of Delayed Closure?

When the wound is clean!
Aggressive initial
debridement
No devitalized tissue

Early Soft Tissue Coverage

Early <7 days
decrease secondary
infection rate.
Requires Clean
Defect
Gastrocnemius Flap

Delayed Primary Closure

No tension
Trauma Stitch

Pie-Crusting
Multiple Relaxing Incisions
Useful if closure under excess
tension
Alternative to STSG

Multiple Relaxing Incisions

Multiple Relaxing Incisions

Multiple Relaxing Incisions

STSG
Best with clean,
vascular bed

Negative Pressure Wound Therapy

VAC Devise (KCI
Inc)
After I&D
Infected wound after
I&D
Dead Space
Over STSG
Exposed tendon, bone,
joint
Webb, JAAOS 2002

Negative Pressure Wound Therapy

Negative Pressure Wound Therapy

Negative Pressure Wound Therapy

Soft Tissue Transfer

Questions?

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about
Questions/Comments

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