Fractures

Question 1

What is an open fracture

Answer 1

Direct communication between external environment and fracture - usually through break in skin (can be through orifice however)

Question 2

Most common open fractures

Answer 2

fingers and tibial shaft

Question 3

What classification is used for open fractures

Answer 3

Gustilo Classification

Question 4

Grading of gustilo classification

Answer 4

Type 1 - low energy wound <1cm, clean, often bone piercing skin from inside

Type 2 - moderate soft tissue damage, wound <10cm, no soft tissue flap or avulsion

Type 3 - high energy injuries (>10cm, any gunshot, farm, segmental #, bone loss, crush, marine)

• A: soft tissue damage but not grossly contaminated
• B: periosteal stripping, extensive damage, heavy contamination
• C: neuromuscular complication

Question 5

Indications for open reduction internal fixation (ORIF)

Answer 5

Failed conserved Rx
2 #s in 1 limb 
Bilateral identical #s
Intra-articular #s
Open #s

Question 6

Types of fracture patterns

Answer 6

Transverse or short oblique # of tibia with fibula #s at a similar level (significant energy)
Tibial #s with comminution / butterfly fragments with fibular fractures at a similar level
Segmental tibial #s (2 breaks)
#s with bone loss

Question 7

Types of soft tissue injury patterns

Answer 7

Skin loss
Degloving
Injury to muscles
Injury to 1 or more major arteries of the leg

Question 8

Management of open fracture

Answer 8

1. Correct shock, give blood if >1.5L lost or continued bleeding. Monitor BP/15min, UO, Stop bleeding - may mean open surgery
2. Relieve pain - morphine IV and restore alignment
3. Sterile cover over protruding bones and torn skin
4. Prevent infection - Cefuroxime / Clindamycin and gentamicin at time of fixation - tetanus toxoid
5. Radiographs - orthogonal views including joint above and below

Question 9

Indications for emergency urgent surgery (<6 hours)

Answer 9

Polytrauma
Marine or Farmyard environment (bacteria, nec fas)
Gross contamination 
Neurovascular compromise 
Compartment syndrome

Question 10

6 A’s of emergency management of open fractures

Answer 10

1. Assessment - neurovascular status, soft tissues, photograph wound (reduce inspection)
2. Antisepsis - take swab from wound and cover
3. Alignment - and splint
4. Anti-tetanus - check status
5. Antibiotics - 3rd gen cephalosporin (cefuroxime, clindamycin, Gentamicin)
6. Analgesia - IV opiate

Question 11

4 C’s to examine for before surgical debridement and fixation

Answer 11

Colour of muscle
Contraction
Consistency - what it feels like
Capacity to bleed - make little cut does it bleed?

Question 12

what score is used for indications for amputation

Answer 12

Mangled Extremity severity score
Assesses 
- limb ischaemia
- patient age range
- shock
- injury mechanism

A score >7 likely to need amputation