Fractures Flashcards
What is an open fracture?
• Direct communication between the outside world and the fracture
• Usually through a break in the skin (not always)
○ e.g. fragments of bone from a fractured pelvis penetrating the rectum
• Can be big or small
• Gustilo classification of open fractures (1 is less bad 3)
What is the epidemiolgy of open fractures?
○ 23 per 100,000 population per year
○ fingers + tibial shaft account for >50%
○ Probably about 3,500 open tibial shaft fractures in UK per year
○ 1/3 of polytraumatised patients have open fractures- distracting injuries
Why are open fractures important?
○ Higher energy injury
○ Increased infection rate
○ Soft tissue Complications
○ Long term morbidity….
What is a type 1 fracture acording to gustilo classification of open fractures?
- Low energy
- Wound <1cm
- Clean
- Simple fracture pattern
What is a type 2 fracture acording to gustilo classification of open fractures?
- Wound >1cm, <10cm
- Moderate soft tissue dmage
- Adequate skin coverage
- Simple fracture pattern
What is a type 3A fracture acording to gustilo classification of open fractures?
- High energy
- Extensive soft tissue damage
- Complex fracture pattern
- Wound >10cm
- Any gunshot, farm accident, segmental fracture, bone loss, severe crush, marine
- Adequate periostal coverage
- Soft tissue damage +++ but not grossly contaminated
What is a type 3B fracture acording to gustilo classification of open fractures?
- High energy
- Extensive soft tissue damage
- Complex fracture pattern
- Wound >10cm
- Any gunshot, farm accident, segmental fracture, bone loss, severe crush, marine
- Tissue loss requiing soft tissue coverage procedure (such as a flap or graft)
- Periostal stripping
- Extensive muscle damage
- Heavy contamination
What is a type 3C fracture acording to gustilo classification of open fractures?
- High energy
- Extensive soft tissue damage
- Complex fracture pattern
- Wound >10cm
- Any gunshot, farm accident, segmental fracture, bone loss, severe crush, marine
- Vascular injury requiring repair
- Associated with neurovascular complicatiuons
What guidlines are used for the treatment of open fractures?
BOAST guidlines
Explain multi-disiplinary team that manages open fractures
- Needs orthopaedic and plastic surgeons with appropriate experience
- Hospitals lacking this should immediately refer to the closest specialist centre
- The primary surgery treatment (wound debridement/ excision and skeletal stabilisation) of these complex injuries takes place at the specialist centres whenever possible
- Specialist centres for the management of severe open fractures are organized on a regional basis as part of a regional trauma system. Usually these centres also provide regional service for major trauma
How are open fractures managed?
- Full ATLS assessment and treatment
- tetanus and antibiotic prophylaxis
- Cefuroxime / Augmentin / Clindamycin- Gent at time of fixation
- Repeated examination neurological/ vascular status
- Wounds only handled to remove gross contamination,
- photograph, cover (saline swabs) and stabilise limb
- No provisional irrigation / exploration
- Radiographs- orthogonal views including joint above and below
When should surgery for open fractures be preformed?
- Perform surgery within 24 hours of the sustained injury
- Cases where you need to perform surgery within 6 hours
□ Polytraumatised patient
□ Marine or Farmyard environment
□ Gross contamination
□ Neurovascular compromise
□ Compartment syndrome
What do surgeons look for when debriding and fixing open fractures?
- Colour
- Contraction
- Constancy
- Capacity to bleed
- Second looks may be necessary but multiple debridement can be associated with poorer outcomes
What happens in definitive skin coverage?
- Plastic surgeons
- Split Skin Graft (SSG)/ Myofasciocutaneous/ fasciocutaneous/ rotation/ free flaps
- Rob Peter to pay Paul
What are the different fracture pattens of tibial fractures?
○ Transverse or short oblique tibial fractures at a similar level
○ Tibial fractures with comminution/ butterfly fragments with fibular fractures at a similar level
○ Segmental tibial fractures
○ Fractures with bone loss, either from extrusion at the time of injury or after debridement
What are the different soft tissue injury patterns in open fractures?
○ Skin loss such that direct tension-free closure is not possible following wound excision
○ Degloving
○ Injury to the muscles which requires excision of devitalised muscle via wound extensions
○ Injury to one or more of the major arteries in the leg
What is the scoring system for amputation in open fractures?
□ Limb ischaemia
□ Patient age range
□ Shock
□ Injury mechanism
Explain amputation in open fractures
- Dual consultant decision
- Insensate limb / foot
- Irretrievable soft tissue or bony damage
- Other life threatening injuries
- “Guillotine” type and refashion at a later stage
Why are some rib fractures fixated?
- Less time in ITU
- Decrease instances of tracheostomy
- Makes people feel better
- Makes a massive difference to poly traumatised patients
How are patients selected for rib fracture fixation?
○ Large flail section ○ Paradoxical breathing ○ Multiple rib fractures ○ Significant displacement ○ Intrathoracic pathology e.g. herniation ○ Chest wall deformity ○ Inability to control pain
What is a dislocation?
Complete joint disruption
What is a subluxation?
Partial disruption- not fully out of the joint
How are dislocations diagnosed?
○ Clinical and Radiological diagnosis
○ Associated injuries, soft tissue, musculoskeletal, multi-system
- Make sure you assess them
○ Associated injuries - #’s, neurovascular damage- assessment pre post
○ Emergency treatment
○ Surgery
○ Sequelae
○ Recurrent instability (e.g. shoulder) or stiffness
What are the top 2 most common shoulder dislocations and what would they look like on examination?
- Anterior (90%): squared off
- Posterior (9%): locked in internal rotation (lightbulb appearance)
What is the most common elbow dislocation and what would it look like on examination?
Posterior: olecranon prominant posterior
What is the most common hip dislocation and what would it look like on examination?
Posterior: leg short, flexed, internal rotation, adducted
What is the most common knee dislocation and what would it look like on examination?
Anteroposterior: loss of normal contour, extended
What is the most common ankle dislocation and what would it look like on examination?
Lateral: Externally rotated, prominant medial malleolus
What is the most common subtalar joint dislocation and what would it look like on examination?
Lateral: lateraly displaced os calcis
