Open Fracture

An Orthopaedic Emergency
Dr.Chowdhury Iqbal Mahmud MBBS,FRCS(UK),MCh(MS, Ortho, UK) Fellow in Orthopaedics (Singapore) Registrar, Dept.Of Orthopaedics BIRDEM & IMC.

Introduction


An open fracture refers to osseous disruption in which a break in the skin and underlying soft tissue or body cavity communicates directly with the fracture and its haematoma. haematoma. Open fractures often result from highhigh-energy trauma and are characterized by
 

variable degrees of soft tissue and skeletal injury, both of which impair local tissue vascularity.

In addition, bone, tendons, nerves, and articular cartilage may be exposed and subject to damage.

Introduction


The annual incidence of open fractures of long bones has been estimated to be 11.5 per 100 000 persons 1 with 40% 11. 40% occurring in the lower limb, commonly at the tibial diaphysis. diaphysis. OneOne-third of patients with open fractures are multiply injured. injured.

Incidence

Significance of Open fracture (Why it is an emergency)

   

Significant increase in risk of infection (up to 25-50%). 25Risk of eventual amputation. Degloving injuries and ischaemic necrosis of skin Muscles  Crush and compartment syndromes Blood vessels  Vasospasm and arterial laceration Nerves  Neurapraxias, axonotmesis, neurotmesis Ligaments  Joint instability and dislocation

Significance of Open fracture



Soft tissue injuries in an open fracture may have three important consequences
Contamination of the wound and fracture

INFECTION
Crushing, stripping & devascularization

Destruction or loss of the soft tissue envelope

Affect method of immobilization Fracture Healing

Results in loss of function from Muscle Tendon Nerve Vascular Ligament or Skin damage

Significance of Open fracture

IN SHORT

Open fractures communicate with the outside environment, and the resulting contamination of the wound with microorganisms, coupled with the compromised vascular supply to the region, leads to an increased risk of infection as well as to complications in healing.

Mechanism of Injury


Usually high energy trauma. Open fracture results from the application of a violent force. The amount of osseous displacement and comminution is suggestive of the degree of soft tissue injury and is proportional to the applied force.

Management


The initial evaluation of a patient with an open fracture of a limb should always follow the principles and guidelines of the Advanced Trauma Life Support System. System.

     

Primary Survey (ABCDE) & Resuscitation Adjuncts to Primary Survey & Resuscitation Consider need for Patient Transfer Secondary Survey (with AMPLE History) Continued Post-Resuscitation Monitoring & Re-evaluation PostReTransfer to Definitive Care

Management
PRIMARY SURVEY A - Airway & Cervical Spine Control B - Breathing & Oxygenation C - Circulation & Haemorrhage Control D - Dysfunction & Disability of the CNS E - Exposure & Environmental Control

Management
PRIMARY SURVEY

Management
Immediately Life Threatening Injuries or Conditions which should be picked up in ABCDE and treated immediately :
1. 2. 3. 4. 5. 6. 7. 8. 9.

Inadequate Airway Protection Airway Obstruction Tension Pneumothorax Open Pneumothorax Flail Chest with Hypoxia Massive Haemothorax Cardiac Tamponade Severe Hypothermia Severe Shock from Haemorrhage Unresponsive to Fluid Resuscitation.

Management
PRIMARY SURVEY


The 4 most common causes of shock in trauma patients:  Haemorrhage  Bleeding  Exsanguination  Hypovolaemia Hypovolaemia is the most common cause of shock in trauma. trauma. Therefore, in the presence of hypotension, it is reasonably safe to assume haemorrhage and direct team efforts toward stopping the bleeding. bleeding.

Management

All obvious external haemorrhage should be identified by adequate patient exposure and managed by applied pressure. Appropriate pressure. splinting of long bone fractures through alignment and immobilisation is also important. important.

Management
PRIMARY SURVEY
DISABILITY


Disability, in terms of the primary survey, is assessed by the AVPU scale: scale:
A - alert, that is responds to voice appropriately, i.e. obeys commands V - vocalises, may be inappropriate or incomprehensible sounds P - responds to pain only (should be assessed in all 4 limbs if initial limb fails to respond) U - unresponsive to pain.

   

Management
PRIMARY SURVEY
EXPOSURE
  

Expose the patient. Log roll and examine the back. Attend to PR examination. This must be done prior to male catheterisation.
Expose the patient only for the duration of the external examination. Once this has been completed, cover the patient with warm blankets and keep him / her covered unless re-examination is necessary. re-

Management


LIMBS IN PRIMARY SURVEY Quickly move onto the limbs, cutting off clothes as necessary, and examining for the presence of obvious deformity or soft tissue haematoma. haematoma. Any sources of external haemorrhage should immediately be stemmed by applying direct pressure and wrapping in a bandage. bandage. If there are Open (Compound) Fractures, Fractures,

The surgeon send a swab for bacteriological analysis. analysis. The wound should be immediately covered with a Betadine swab or cling film, preferably after taking a polaroid photograph. The wound should not be photograph. uncovered again until the patient is in theatre. theatre. The patient should be given intravenous morphine, a tetanus injection and intravenous antibiotics (usually cefuroxime & metronidazole). metronidazole). The orthopaedic team should be informed and asked to attend the A&E department. department.

Management
ADJUNCTS TO THE PRIMARY SURVEY


Adjuncts to the primary survey include: Radiology: CXR first PXR second C-spine third C-

Management
SECONDARY SURVEY


The secondary survey covers (in this order):

1. Head and scalp / maxillofacial. 2. Cervical spine and neck. 3. Chest. 4. Abdomen and pelvis. 5. Back and perineum. 6. Extremities. 7. Neurological.

AMPLE History A - Allergies M - Medicines P - Past Medical History / Pregnancy L - Last Meal E - Events / Environment leading to the current trauma

Management
The principles that govern open fracture management include
   

Assessment of the patient and classification of the injury, prevention of infection, wound management, and fracture stabilization.

Management of open fractures can be challenging, and multiple surgical procedures frequently are needed to achieve soft-tissue softcoverage and fracture union. union.

Management
A complete history and physical examination is essential, which include complete assessment of open fracture Complete assessment of the open fracture includes  reviewing the mechanism of injury,  condition of the soft tissues,  degree of bacterial contamination, and characteristics of the fracture. The evaluation of these factors will help to  classify the fracture,  determine the treatment regimen, and  establish the prognosis and potential clinical outcome. In particular, the degree of bacterial contamination and soft-tissue damage is softimportant in classifying an open fracture.

Management
ASSESSMENT OF OPEN FRACTURE

Management
ASSESSMENT OF OPEN FRACTURE
HISTORY Knowledge of the mechanism of injury is essential. It will often give the only indication of the level of energy transfer to the tissues. The features that should alert the admitting doctors to the possibility of a high energy injury include:
      

Any road traffic accident. Drivers, passengers or pedestrian. Falls from a significant height. Any injury mechanism involving extensive or localised crushing. Missile wounds. Contamination from the scene of the accident. A history of entrapment or lying immobile on the injured limb for a prolonged period. Any suggestion of possible limb ischaemia.

Management
ASSESSMENT OF OPEN FRACTURE
EXAMINATION OF WOUND Assess skin and soft tissue damage: Exploration of the wound in the emergency setting is not indicated because it risks further contamination.  Location and extent of the wound A small wound doesnt always necessarily carries  Length of the wound a good prognosis because  Number of skin wound there may be significant  Degree of wound and skin contamination associated contamination and tissue damage.  Apparently intact tissues of the limb should also be examined.  Palpate the wound for foreign bodies.

Management
Systematic examination of the affected limb will reveal the following features of high energy injury: SKIN
   

Large or multiple wounds. Imprints or tattooing from dirt or tyres. Crush or burst wounds. Closed degloving. Skin is intact but with no blood supply due degloving. to shearing between the deep fascia and subcutaneous tissues. tissues. It can be difficult to diagnose but may be suspected from the boggy feel of the skin or the abnormal looseness of the skin when it is pinched. pinched.

Management
Signs of Nerve Injury


Signs of Vascular Injury



Abnormal sensation is more important than loss of motor power as it occurs earlier. Never merely ask Can you feel this?. Compare the two sides. Check all peripheral nerve territories, particularly that of the posterior tibial nerve, the plantar surface of the foot. Always examine several zones of each nerve territory in case of a partial nerve lesion.

Absence of peripheral pulses or reduced capillary return after correction of hypovolaemia and reduction of limb deformity.

Classification


Although there are other classifications of open fractures, the Gustilo classification has now been adopted worldwide. It is based on the
  

size of the wound, the amount of soft tissue damage or contamination, and the type of fracture.

There are three fracture types, with the Gustilo type III fractures divided into three subtypes based on
  

the extent of the periosteal damage, the presence of contamination, and the extent of arterial injury.

Classification

Classification


Gustilo classification used for prognosis Fracture healing, infection and amputation rate correlate with the degree of soft tissue injury by Gustilo Fractures should be classified in the operating room at the time of initial debridement
 

Evaluate periosteal stripping Consider soft tissue injury

Type I Open Fractures

   

InsideInside-out injury Clean wound,<1cm wound,<1cm Simple Fracture Minimal soft tissue damage No significant periosteal stripping

Type II Open Fractures



Moderate soft tissue damage Clean, >1cm Usually Simple Fracture OutsideOutside-in mechanism Higher energy injury Some necrotic muscle, some periosteal stripping

 

Type IIIA Open Fractures



High energy OutsideOutside-in injury Extensive muscle devitalization Bone coverage with existing soft tissue not problematic

Type IIIB Open Fractures

  

High energy Outside in injury Extensive muscle devitalization Requires a local flap or free flap for bone coverage and soft tissue closure Periosteal stripping

Type IIIC Open Fractures

High energy Increased risk of amputation and infection Major vascular injury requiring repair

Type III Open Fractures

Beware


High velocity gunshot injuries Farm injuries Severe contamination more than 8 hours Traumatic amputation

Management
ASSESSMENT OF OPEN FRACTURE Signs of Compartment Syndrome


  

More pain than expected, even when the fractured leg is immobilised. immobilised. Never assume that severe pain is from the bone. bone. Relentless pain unrelieved by opiates is more likely to be produced by ischaemic muscle. muscle. Pain on passive stretching of the muscles in the affected compartment. A tense, swollen limb. Sensory disturbance of the foot. Tender or indurated muscle compartment (Late sign).

Management
ASSESSMENT OF OPEN FRACTURE Radiological Examination Usually, only anteroposterior and lateral radiographs are required They should include adjacent joints and any associated injuries.

 

Management
The fracture pattern can often give clues to the degree of energy transfer through the bone. Important features include:
Multiple bone fragments. Wide displacement of fracture fragments. Any segmental injury. Air in the tissues. More than one fracture in the same limb.

MRI and CT scans are rarely required in the acute situation but may be helpful in open pelvic, intra-articular, carpal, and tarsal fractures. Angiography may be required in Gustilo IIIb or IIIc fractures. In the polytraumatized patient, the surgeon must decide if a delay for further imaging is appropriate.

Management


The goals in the treatment of open fractures are to

   

prevent infection, achieve bone union, avoid malunion, and restore the limb and patient to full function as early as possible.

Of these, it is most important to avoid infection, as infection is the most common complication leading to nonunion and loss of function.

Management
TREATMENT OF OPEN FRACTURE Treatment in the ER
        

Haemorrhage should be addressed and managed. Antibiotics (IV). Tetanus prophylaxis. Analgesics. Irrigation of wound and removal of foreign bodies. Coverage of wound with sterile dressing. Temporary splinting of Fracture. Consideration of early amputation in severe cases. Decompression of compartment Wound exploration and debridement, and definitive fracture and soft tissue management should not be done in the ER . Increases the chance of contamination!

Management
TREATMENT OF OPEN FRACTURE Prevention of Infection  IV Antibiotics


Wound Lavage (Irrigation) Secondary Debridement Wound Closure:  Delayed primary or secondary Closure Fracture Stabilization  External Fixation Internal Fixation Soft tissue cover or reconstruction


Local Antibiotics

Treatment of Wound  Wound extension



Wound Debridement

Skin Fat and Fascia Muscle, Nerve and Tendon Bone Joint

Management
TREATMENT OF OPEN FRACTURE

Prevention of Infection
The first orthopaedic procedure has as one of its objectives the removal of microorganisms contaminating the fracture from the scene of the injury. injury. However by far the greatest micro-biological threat comes from microorganisms in the hospital environment many of which will have developed antibiotic resistance. Contamination can occur very resistance. quickly and must be prevented. prevented.

Management
TREATMENT OF OPEN FRACTURE Prevention of Infection IV Antibiotics: Some 60% to 70% of open wounds are associated with positive cultures in the emergency department. Gustilo type I and II open fractures


 

Cephalosporin Cephalsporin +Aminogycosides

Gustilo type III open fractures



If the patient is allergic to penicillin, clindamycin or metronidazole should be used.

Management

Management


IV Antibiotics: Duration Antibiotics should be started as soon as possible after the injury occurs because a delay >3 hours increases the risk of infection. The duration of antibiotic administration is controversial.
Dellinger et al16 demonstrated that a prolonged course of 5-day 5antibiotic administration was not superior to a 1-day course for 1prevention of fracture site infections.

The duration of therapy should be limited to 3 days, with repeated 3-day administration of antibiotics at wound 3closure, bone grafting, or any major surgical procedure.

Management


Local Antibiotics: AntibioticAntibiotic-impregnated polymethylmethacrylate (PMMA) beads can be placed into the wound after debridement has been undertaken. These beads usually contain gentamycin or tobramycin. The advantages of the bead pouch technique include


a high local concentration of antibiotics, often 10 to 20 times higher than that with systemic administration; a low systemic concentration, which protects from the adverse effects of aminoglycosides

Management
TREATMENT OF OPEN FRACTURE Treatment of Wound

 

Wound extension and Debridement:

The size of the traumatic skin wound does not always reflect the degree of damage to the soft tissues of the leg. Therefore the skin wounds in all open fractures, including Gustilo type I fractures, must be extended to allow adequate inspection of both the soft tissues and bone ends. Wound extensions should be longitudinal and transverse incisions should be avoided. The exact direction and length of the wound extension will depend on the extent and location of the subcutaneous damage. be aware of the position of the medial and lateral perforators so that these are not damaged during the procedure. The surgeon should also avoid cutting undamaged skin overlying the subcutaneous border of the tibia.

   

Management
Treatment of Wound


Debridement really means exposure and that is the key to these procedures.

Management
Treatment of Wound
Wound Debridement: The objective of wound excision is to remove all devitalised or contaminated tissue so that at the end of the procedure the remaining tissue looks clean and healthy and has an adequate blood supply.

Management
Treatment of Wound
Wound Debridement

Skin and Subcutaneous Tissues:

The wound edges must be excised until good dermal bleeding is encountered however large a skin defect this creates. Shearing forces may produce extensive degloving injuries, which particularly affect the lower limb and may be circumferential. Elderly patients are particularly at risk of degloving and circumferential degloving in an elderly multiply injured patient may require amputation. amputation.

Management
Wound Debridement Skin and Subcutaneous Tissues: Tissues:


All degloved skin should be resected until dermal bleeding is encountered. encountered. If a large area of degloved skin is excised, split skin graft can be harvested from the excised skin for later use. use. If there are several wounds in close proximity, they should be excised en bloc, as there will be extensive associated soft tissue damage. All devitalized fat must be removed.

Management
Wound Debridement

Management
Wound Debridement Muscle:  Dead and devitalized muscles should be removed. removed.  Muscle may appear to be quite healthy in the initial debridement and be completely necrotic 48 hours later. The basic rule of muscle later. is when in doubt take it out because that can be a significant problem if necrotic muscle is left in situ. situ.  The key to determining if muscle is viable are the four C's Dead muscle is purplish Mushy consistency Fail to contract and bleed Dead muscle is heaven for bacteria

Management
Wound Debridement Bone:  All devitalized separate bone fragments should be removed regardless of their size.

Management
Wound Debridement Nerve and Tendon:

Management
Wound Debridement Joint: For open joint injuries you want to perform an arthrotomy. Irrigate the joint and debride it.

Management
Treatment of Wound Wound Lavage (Irrigation) Lavage with fluids such as normal isotonic saline or antibiotic solutions is an essential part of the debridement procedure. Ten to 15 liters of lavage fluid should be used to remove bone clots and other devitalized debris and ideally reduce the level of bacterial contamination.

Management
Treatment of Wound Secondary Debridement


It is suggested that all open long-bone and pelvic fractures be relongreexplored 36 to 48 hours after the initial debridement. debridement. The wound should not be closed until all devitalized or contaminated tissue has been removed. removed. If the wound does require further debridement, this should be undertaken, and the patient returned to the operating room 36 to 48 hours later for a further debridement. debridement.

Management
Treatment of Wound Wound Closure: Primary Closure:  Open wounds should not be closed primarily.


If wound closure is possible, it should be undertaken at the re-look reprocedure 36 to 48 hours after the initial surgery. Even closure of the wound extensions may cause tissue tension. It is impossible to close an excised wound in an oedematous area without tension.

Management
Wound Closure: Soft tissue cover or Reconstruction:  The most frequently used plastic procedures involve  split skin grafting,  local muscle flaps such as the gastrocnemius flap,  local flaps such as the proximal or distal fasciocutaneous flap ,  or free flaps.

Management
Fracture Stabilization


Fracture stability is essential for initial wound care and for fracture union . Restoring normal length and alignment of the extremity minimizes dead space and restores muscle planes to their normal position. This reduces the space available for serum and hematoma, which are pabulum for bacterial growth. Bone fixation often eliminates the need for casts, splints, and skeletal traction, thereby allowing optimal access to the limb for wound care. Early stability provides an opportunity for early muscle and joint rehabilitation, which, in turn, reduces edema, facilitates lymphatic and venous return, lowers the incidence of deep vein thrombosis, and improves the overall physiology of the limb.

Management
1. 2.  

 

Fracture Stabilization External Fixation Internal Fixation Open fractures should be treated by surgical stabilization. stabilization. Cast management is associated with poorer results than operative management in open long-bone fractures and longusually used for type I and low-grade type II fractures with lowstable configurations when external or internal fixation is unnecessary. unnecessary. This usually applies to fractures distal to the elbow and knee. knee. Surgical stabilization minimizes later soft tissue injury and promotes capillary ingrowths. ingrowths. There is also good evidence it is associated with a decreased infection rate. rate.

Management
Fracture Stabilization External Fixation: 1. Severe comminution, any site 2. Periarticular Fracture Definitive

Distal Radius Elbow Dislocation

Temporary

Knee Ankle Elbow Wrist Pelvis

Management
Fracture Stabilization Internal Fixation:
1. 2.

Periarticular Fracture Diaphyseal Fracture

Implants  Screws and Plate  IM Nail

Management
Fracture Stabilization


If plating is employed care must be taken not to strip soft tissues from the bone unnecessarily and thereby reduce its vascularity. The plate must be covered with soft tissues at the end of treatment and this may necessitate the use of local or free flaps. Intramedullary nailing of open diaphyseal fractures has become an accepted technique. If external skeletal fixation is used care must be taken to place the pins so as not to compromise either the potential skin flaps or access to the vessels for microvascular anastomoses.

If plastic surgery is required, fracture stabilization is mandatory. Traction should not be employed for open fractures.

Management
Fracture Stabilization Timing

Management
Fracture Stabilization

Management
The Decision to Amputate


Some limbs, particularly those subjected to prolonged ischaemia, crushing or nerve damage, although theoretically salvageable may function very poorly. The patient may well have multiple operations poorly. carried out over a prolonged period of time and end up with a leg which is painful and functions poorly Circumferential degloving of skin. skin. MESS Score more than 7 ISS Score more than 20

Management



At the end of the first orthopaedic procedure the following goals should have been met: met:
All devitalised tissues should have been excised with the wound being extended as far as is required to achieve this. this. The fracture should have been stabilised to permit subsequent plastic surgery preferably using a method which is definitive and does not require to be changed at a later date. date.

Complication


Infection  Cellulitis  Osteomyelitis Defects in Union  Malunion  Delayed union  Nonunion Compartment Syndrome

Reason Gross contamination Retained foreign body Soft tissue compromise Multisystem injury

The most important prognostic factor that determines the longlongterm result in open fractures is the amount of energy absorbed by the limb at the time of initial injury. This determines the amount of injury. devitalized soft tissue and the level of contamination, which are more important than the configuration of the fracture

Management
SUMMARY


Open fractures are complex injuries that involve both the bone and surrounding soft tissues. tissues. Management goals are prevention of infection, union of the fracture, and restoration of function. function. Achievement of these goals requires a careful approach based on detailed assessment of the patient and injury. injury. The classification of open fractures is based on type of fracture, associated soft-tissue softinjury, and bacterial contamination present. present. Tetanus prophylaxis and intravenous antibiotics should be administered immediately. immediately. Local antibiotic administration is a useful adjunct. adjunct. The open fracture wound should be thoroughly irrigated and debrided, debrided, Extensive soft-tissue damage may necessitate the use of local or free muscle flaps. softflaps. Techniques of fracture stabilization depend on the anatomic location of the fracture and characteristics of the injury. injury.

END

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