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A - MSRA MSK [11] > [5] Open Fractures > Flashcards

[5] Open Fractures Flashcards

1
Q

Why are open fractures important?

A

They are a common presentation to A&E, and require rapid assessment and management by the orthopeadic team

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2
Q

How quickly do open fractures need to be managed?

A

Most of these injuries can be safely managed on next day emergency lists, but there are some instances where emergency out-of-hours treatment is required

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3
Q

What are open fractures associated with?

A

High rates of morbidity and mortality

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4
Q

When is a fracture considered to be ‘open’?

A

When there is direct communication between the fracture site and the external environment

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5
Q

How can fracture sites communicate with the external environment?

A

Most often through the skin, however pelvic fractures may be internally open having penetrated into the vagina or rectum

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6
Q

What are the ways that a fracture may become open?

A
  • ‘In-to-out’ injury
  • ‘Out-to-in’ injury
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7
Q

What happens in an ‘in-to-out’ injury?

A

Sharp bone ends penetrate the skin from beneath

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8
Q

What happens in an ‘out-to-in’ injury?

A

A high energy injury, e.g. ballistic injury or direct blow’ penetrates the skin, traumatising the subtending soft tissues and bone

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9
Q

What fractures most commonly become open?

A
  • Tibial
  • Phalangeal
  • Forearm
  • Ankle
  • Metacarpal
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10
Q

What injury to the skin can occur in open fractures?

A

Can range from a very small wound to significant tissue loss, whereby coverage will not be achieved without the aid of plastic surgery

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11
Q

What plastic surgery may be used to cover skin damage in an open fracture?

A

Skin grafting or flap

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12
Q

What soft tissue can occur in open fracture?

A

Can range from very little tissue divitalisation to significant muscle/tendon/ligament loss requiring reconstructive surgery

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13
Q

What neurovascular injury can occur in an open fracture?

A

Nerves and vessels may be compressed due to limb deformity or transected altogether

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14
Q

Why is the rate of infection very high following an open fracture?

A
  • Direct contamination
  • Reduced vacularity
  • Systemic compromise, such as following major trauma
  • Need for insertion of metalwork for fracture stabilisation
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15
Q

What is essential in the immediate management of open fractures?

A

Initial resuscitation and suitable management, especially in cases of major trauma

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16
Q

How do patients with open fractures present?

A

Pain, swelling, and deformity with an overlying wound or punctum. In severe cases, the bone end may be visible protruding through the wound

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17
Q

What should be checked on examination in open fractures?

A
  • Neurovascular status
  • Skin or tissue loss
  • Evidence of contamination
18
Q

What kind of contamination is of the highest importance in open fractures?

A
  • Marine
  • Agricultural
  • Sewage
19
Q

Why should the need for plastic surgery input be identified early in open fractures?

A

To allow both specialities to be present at the first operation, and therefore avoid multiple procedures

20
Q

What system can be used to classify open fractures?

A

The Gustilo-Anderson classification

21
Q

What is a type 1 open fracture according to the Gustilo-Anderson classification?

A

<1cm wound and clean

22
Q

What is a type 2 open fracture according to the Gustilo-Anderson classification?

A

1-10cm wound and clean

23
Q

What is a type 3A open fracture according to the Gustilo-Anderson classification?

A

>10cm wound and high energy, but with adequate soft tissue coverage

24
Q

What is a type 3B open fracture according to the Gustilo-Anderson classification?

A

>10cm wound and high-energy, but with inadequate soft tissue coverage

25
Q

What is a type 3C open fracture according to the Gustilo-Anderson classification?

A

All injuries with vascular injury

26
Q

Who is involved in the management of 3A Gustilo-Anderson open fracture?

A

Orthopaedics alone

27
Q

Who is involved in the management of 3A Gustilo-Anderson open fracture?

A

Orthopaedics and plastics

28
Q

Who is involved in the management of 3C Gustilo-Anderson open fracture?

A

Orthopaedics, vascular, and potentially plastics

29
Q

What investigations are required in open fractures?

A
  • Basic blood tests, including clotting screen and group & save
  • Plain film radiograph of affected area(s)
30
Q

When might CT scans be required in open fractures?

A

To aid management for very communited or complex fracture patterns

31
Q

How should open fractures be managed following suitable resuscitation and stabilisation?

A

Urgent realignment and splinting of the limb

32
Q

What should be done following any realignment or reduction of an open fracture?

A

Re-assessment and documentation of neurovascular status

33
Q

What infection control measures should be involved in open fracture management?

A
  • Broad-spectrum antibiotic cover should be administered
  • Tetanus vaccination is require if patient is not fully up to date with vaccination
34
Q

Why should the wound be photographed in open fractures?

A

To avoid repeated uncovering of dressings for inspection

35
Q

How should the wound be cleaned and dressed in the immediate management of an open fracture?

A

Any gross debris should be removed, and then dressed with a saline-soaked gauze

An out of theatre washout is not indicated

36
Q

What does definitive surgical management of open fractures require?

A

Debridement of the wound and fracture site, and removing all devitalised tissue present

37
Q

How quickly should surgical debridement be performed in open fractures?

A

Immediate if contaminated with marine, agricultural, or sewage material, or <12-24 hours in all other cases

38
Q

What should happen in the surgical management of open fractures?

A
  • Ensure the wound is washed out with copious volumes of saline
  • Ensuring definitive skeletal stabilisation
39
Q

How quickly should surgery be performed if soft tissue coverage is required in an open fracture?

A

Within 72 hours, or as guided by a plastic surgeon

40
Q

What is required if there is vascular compromise in an open fracture?

A

Immediate surgical exploration by vascular surgery

A - MSRA MSK [11] (38 decks)

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