42. Open fractures

Question 1

open fracture classification (Gustilo Anderson)

Answer 1

I. < 1 cm wound created from inside, mild bruising, cleanII. > 1 cm wound created from outside, without extensive ST injuryIIIa. extensive ST damage with ST flaps but can still cover woundIIIb. extensive ST damage and loss with bone exposure and periosteal strippingIIIc. extensive ST damage, bone exposure and injury to vascular supply

Question 2

T/Fearly administration of broad spectrum Ab is described by many to be the single most important factor for reducing infection in open fracture cases

Answer 2

Truesystemic Ab most often (other treatment option is implantation of Ab beads)

Question 3

initial surgical debridement of open fractures

Answer 3

clip, clean, lavage, culture, cut, initial Ab, stabilizationprompt but 6 hours is a “golden rule” that is not necessarily demonstrated to have a significant difference in infection rates

Question 4

goals of definitive surgical treatment of open fractures

Answer 4

1. prevent infection2. promote bone union3. repair ST injury4. restore function

Question 5

benefits to vacuum assisted wound healing for management of ST injuries in open fractures

Answer 5

-125 mm Hg (continuous or intermittent)decreases edemapromotes vascularization/incr tissue blood flowaccelerates GT formationpromotes wound contraction+/- increases bacterial clearance

Question 6

Options for surgical repair of extensive ST injury over a fracture

Answer 6

1. primary closure2. second intention3. pedicle muscle transfers4. microvascular free muscle transfers5. axial pattern skin flap6. microvascular free skin grafts7. mesh skin or punch skin grafts8. local skin/transposition flaps

Question 7

internal fixation with bone plates can be used for most open fractures but is ideally best for what types of open fractures

Answer 7

I-III that do not involve extensive ST injury with the need for flaps, grafts

Question 8

advantages of ESF for tx of open fractures

Answer 8

1. decreased application time2. location of implants away from wound3. easy access for open wound management4. minimal disruption to tissues5. expect implant removal

Question 9

complications of ESF for tx of open fractures

Answer 9

1. pin loosening2. pin track drainage3. infection4. delayed union/malunion5. fixation failure

Question 10

what is the theoretical risk for ILN system in management of open fractures

Answer 10

spread of bacteria to the entire medullary cavity

Question 11

methods to improve fracture healing in open fractures

Answer 11

1. bone grafts (autogenous cancellous or corticocancellous, allogenic materials, demineralized bone matrix)2. bone graft substitutes3. recombinant mitogenic/stimulatory factors

Question 12

T/Fa cortical bone graft is at risk for infection and subsequently becoming a sequestrum

Answer 12

TRUEa cortical bone graft is at risk for infection and subsequently becoming a sequestrumcancellous bone grafts can be used safely in a contaminated wound.

Question 13

potential complications with open fracture

Answer 13

1. superficial infection2. deep infection3. delayed or malunion4. fixation failure5. necrosis of ST or damage to ST repair techniques6. temporary or permanent neurologic dysfunction