[5] Open Fractures Flashcards
Why are open fractures important?
They are a common presentation to A&E, and require rapid assessment and management by the orthopeadic team
How quickly do open fractures need to be managed?
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
What are open fractures associated with?
High rates of morbidity and mortality
When is a fracture considered to be ‘open’?
When there is direct communication between the fracture site and the external environment
How can fracture sites communicate with the external environment?
Most often through the skin, however pelvic fractures may be internally open having penetrated into the vagina or rectum
What are the ways that a fracture may become open?
- ‘In-to-out’ injury
- ‘Out-to-in’ injury
What happens in an ‘in-to-out’ injury?
Sharp bone ends penetrate the skin from beneath
What happens in an ‘out-to-in’ injury?
A high energy injury, e.g. ballistic injury or direct blow’ penetrates the skin, traumatising the subtending soft tissues and bone
What fractures most commonly become open?
- Tibial
- Phalangeal
- Forearm
- Ankle
- Metacarpal
What injury to the skin can occur in open fractures?
Can range from a very small wound to significant tissue loss, whereby coverage will not be achieved without the aid of plastic surgery
What plastic surgery may be used to cover skin damage in an open fracture?
Skin grafting or flap
What soft tissue can occur in open fracture?
Can range from very little tissue divitalisation to significant muscle/tendon/ligament loss requiring reconstructive surgery
What neurovascular injury can occur in an open fracture?
Nerves and vessels may be compressed due to limb deformity or transected altogether
Why is the rate of infection very high following an open fracture?
- Direct contamination
- Reduced vacularity
- Systemic compromise, such as following major trauma
- Need for insertion of metalwork for fracture stabilisation
What is essential in the immediate management of open fractures?
Initial resuscitation and suitable management, especially in cases of major trauma
How do patients with open fractures present?
Pain, swelling, and deformity with an overlying wound or punctum. In severe cases, the bone end may be visible protruding through the wound
What should be checked on examination in open fractures?
- Neurovascular status
- Skin or tissue loss
- Evidence of contamination
What kind of contamination is of the highest importance in open fractures?
- Marine
- Agricultural
- Sewage
Why should the need for plastic surgery input be identified early in open fractures?
To allow both specialities to be present at the first operation, and therefore avoid multiple procedures
What system can be used to classify open fractures?
The Gustilo-Anderson classification
What is a type 1 open fracture according to the Gustilo-Anderson classification?
<1cm wound and clean
What is a type 2 open fracture according to the Gustilo-Anderson classification?
1-10cm wound and clean
What is a type 3A open fracture according to the Gustilo-Anderson classification?
>10cm wound and high energy, but with adequate soft tissue coverage
What is a type 3B open fracture according to the Gustilo-Anderson classification?
>10cm wound and high-energy, but with inadequate soft tissue coverage
What is a type 3C open fracture according to the Gustilo-Anderson classification?
All injuries with vascular injury
Who is involved in the management of 3A Gustilo-Anderson open fracture?
Orthopaedics alone
Who is involved in the management of 3A Gustilo-Anderson open fracture?
Orthopaedics and plastics
Who is involved in the management of 3C Gustilo-Anderson open fracture?
Orthopaedics, vascular, and potentially plastics
What investigations are required in open fractures?
- Basic blood tests, including clotting screen and group & save
- Plain film radiograph of affected area(s)
When might CT scans be required in open fractures?
To aid management for very communited or complex fracture patterns
How should open fractures be managed following suitable resuscitation and stabilisation?
Urgent realignment and splinting of the limb
What should be done following any realignment or reduction of an open fracture?
Re-assessment and documentation of neurovascular status
What infection control measures should be involved in open fracture management?
- Broad-spectrum antibiotic cover should be administered
- Tetanus vaccination is require if patient is not fully up to date with vaccination
Why should the wound be photographed in open fractures?
To avoid repeated uncovering of dressings for inspection
How should the wound be cleaned and dressed in the immediate management of an open fracture?
Any gross debris should be removed, and then dressed with a saline-soaked gauze
An out of theatre washout is not indicated
What does definitive surgical management of open fractures require?
Debridement of the wound and fracture site, and removing all devitalised tissue present
How quickly should surgical debridement be performed in open fractures?
Immediate if contaminated with marine, agricultural, or sewage material, or <12-24 hours in all other cases
What should happen in the surgical management of open fractures?
- Ensure the wound is washed out with copious volumes of saline
- Ensuring definitive skeletal stabilisation
How quickly should surgery be performed if soft tissue coverage is required in an open fracture?
Within 72 hours, or as guided by a plastic surgeon
What is required if there is vascular compromise in an open fracture?
Immediate surgical exploration by vascular surgery
