Mini Symposium: Fractures 1 (Basics, healing and complications) - Open fractures

Question 1

what is an open fracture?

Answer 1

There is a direct communication between the external environment and the fracture.

usually through a break in the skin,

not always, e.g. fragments of bone from a fractured pelvis penetrating the rectum

Question 2

why are open fractures important?

Answer 2

• Higher energy injury
• Increased infection rate
• Soft tissue Complications
• Long term morbidity….

Question 3

what are the 2 different kinds of open fractures?

Answer 3

Can be outside in or inside out

Inside out fracture - bone poking out the skin

you can also get soft tissue damage as shown in bottom right photo

Question 4

what is the epidemiology of open fractures?

Answer 4

• 23 per 100,000 popu. per year
• fingers + tibial shaft account for >50% (Normally ends of extremities)
• Probably about 3,500 open tibial shaft fractures in UK per year (gives us the most problems)
• 1/3 of polytraumatised (multiple injures) patients have open fractures- distracting injuries (can lose track of other important injuries like circulation or breathing)

Question 5

how are open fractures classified?

Answer 5

Gustilo classificaiton

Escalating severity form 1-3

3 are bad news open fractures with soft tissue damage

Treatment gets harder with severity

Question 6

what is gustilo type 1 open fracture?

Answer 6

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

Question 7

what is gustilo type 2 open fracture?

Answer 7

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

Question 8

what is a gustilo type 3 open fracture?

Answer 8

• high energy, extensive soft tissuedamage,
• severe fracture (comminution,displacement),
• wound >10cm;
• any gunshot, farm accident, segmental fracture (bone broken in 2 places), bone loss, severe crush injury, marine
• IIIA - soft tissue damage +++ but not grossly contaminated
• IIIB - periosteal stripping, extensive muscle damage, heavy contamination
• IIIC - assoc. neurovascular complication

Question 9

Epidemiology of open tibial shaft fractures - how common is each different type?

Answer 9

• Type I 24%
• Type II 22%
• Type IIIA 22%
• Type III B 30%
• Type IIIC 4%

About 70% of type IIIB tibial shaft fractures require flap cover

Question 10

what is the historical treatment of a open fracture?

Answer 10

• Preservation of life
• Preservation of limb
• Avoidance of infection
• Rehabilitation of function

Question 11

what treatment do doctors use now a days in the UK?

Answer 11

Contemporary Treatment

Multi-disciplinary standardised approach

Improved outcomes for patients

This treatment should be done by everyone in the UK

Tells you what you should do with a patient admitted with an open fracture

Question 12

what are the principal recommendations of what should be done?

Answer 12

Primary treatment should be done at the same place as the definitive treatment

Question 13

what ar ethe different fracture patterns seen?

Answer 13

Question 14

what are the different soft tissue injury patterns seen?

Answer 14

Degloving – skin stripped off

Question 15

what is the management of an open fracture?

Answer 15

• Full ATLS assessment and treatment
• tetanus and antibiotic prophylaxis
• Cefuroxime / Augmentin / Clindamycin- Gent at time of fixation
• Repeated examination n/v 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

Question 16

Timing - Indications for emergency urgent surgery? 6 hour rule?

Answer 16

• Right people at the right time
• Polytraumatised patient
• Marine or Farmyard environment (because of the organisms present)
• Gross contamination
• Neurovascular compromise
• Compartment syndrome (swelling within compartment of leg or arm, muscle swells in fascia compartment and blood supply is reduced and the muscle will die)

Question 17

How is Surgical Debridement and Fixation carried out and what is it based on?

Answer 17

Taking away any dead tissue

Take out as much dead tissue that is required

Experienced surgeons- Consultants

4 c’s

Colour

Contraction – contract if stimulate and if it doesn’t its dead

Consitency

Capacity to bleed – if no bleed then its dead and will get taken out

Second looks may be neccessary but mulptiple debridements can be asociated with poorer outcomes

Question 18

Fixation can be temporary or ________

Answer 18

definitive

(Treating distal tibial fracture in picture)

Question 19

How is Derfinitive skin coverage done?

rewatch

Answer 19

• Plastic surgeons
• SSG (Split skin graft) / Myofasciocutaneous / fasciocutaneous / rotation / Free flaps
• Principles- “Rob Peter to pay Paul”

Question 20

how is it decided whether or not amputation is needed?

Answer 20

Cant save everything

Scoring system

• Dual consultant decision
• Insensate limb / foot (severe damage to nerve)
• Irretrievable soft tissue or bony damage
• Other life threatening injuries
• “Guillotine” type and refashion at a later stage (take limb off at lowest level that is alive and dead tissue below)

Question 21

Conclusion:

Answer 21

• Important
• Emergency - recognise other injuries
• National guidelines exist
• Multidisciplinary combined senior approach improves outcomes - Senior experienced clinicians make the final decisions