[Open] Fractures

Potchefstroom Hopital
Orthopedics
Outline
Epidemiology
General Principles (Pathological Anatomy)
Classification systems
Management
Complications
 Epidemiology of Open Fractures1
Majority associated with low
energy injuries.
Only 22.3% caused by RTA or
falls from a height.
Incidence:
More common in younger males
(sports, falls, MVA's & PVA's)
75% are fingers, tibia's, fibular
diaphyses, distal radius, toes &
ankles.
Lower limb # > Upper limb #
Higher energy & more severe
 General
Principles
Name of bone
2

Open vs Closed
Location/Mller's (epiphyseal,
metaphyseal, diaphyseal or
physis)
Fracture patterns (transverse,
oblique, spiral, comminuted,
compression, buckle, greenstick,
intra-articular, pathological)
Alignment (nondisplaced,
displaced, distracted, impacted,
angulated, rotated)
 ORTHOPEDIC TRAUMA ASSOCIATION (OTA)3:

Classification
Skin injury
1. Laceration but edges approximate.
2. No approximation.
GUSTILO-ANDERSON2: 3. Extensive degloving.
1 = <1cm, minimal Muscle injury
contamination & soft tissue 1. No necrosis, some muslce injury but intact functioning.
damage. 2. Functional muscle, some necrosis requiring excision.
3. Dead muscle, loss of function, muscle-tendon unit
2 = 1-10cm, moderate disrupted.
contamination & soft tissue Arterial injury
damage. 1. No major disruption
3 = >10cm; 2. Injury without distal ischaemia
A: Adequate soft tissue coverage. 3. Injury with distal ischaemia

B: Periosteal bone stripping & Contamination

exposed bone. 1. None or minimal
2. Surface contamination
C: Arterial injury.
3. Embedded in bone or soft tissue
Bone loss
1. None
Management2&4
Orthopedic emergency
Stabilise patient (ABC's) according to ATLS
Quick history (AMPLE) & analgesia
Irrigate wound with normal saline. (3L upper limbs, 6L lower
limbs)
IV antibiotics STAT (Kefzol) & tetanus IMI
Reduce & splint fracture
Cover with a sterile dressing
Imaging (2, 2, 2, 2)
NPO & pre-med for surgery (ORIF - Screws, plates, nails, wires VS
external fixation) depends on degree of contamination, soft
tissue damage & length of time from injury to operation.
Prophylactic Antibiotics 2&4

1 & 2 = 1st Gen ceph (Kefzol) x 3/7, if allergy use fluoroquinolone, if MRSA+ use vancomycin.
3 = Kefzol x 3/7, add gentamicin for Gram (-), add a penicillin if soil contaminated for clostridial cover.
Complications 2&4

EARLY
Local
Compartment syndrome LATE

(closed #'s) Malunion, Non-union, delayed union

AVN
Neurological injury Osteomyelitis

Vascular injury OA
Joint stiffness
Infections Joint instability

Systemic Muscle contractures

Sepsis
DVT
PE
ARDS (esp with fat embolism)
References
1. Court-Brown, C. M., Bugler, K. E., Clement, N. D.,
Duckworth, A. D., & McQueen, M. M. (2011). The
epidemiology of open fractures in adults. A 15 year
review. Injury, Int. J. Care. Injured. 43; 891-897.
2. Apley's System of Orthopaedics and Fractures. 9th Ed.
(2010). Solomon, Warwick, Nayagam.
3. Calhou, J. (2016). Open Fractures. Medscape
4. Orthopaedic Toronto notes 2016.