Mini Symposium - Fractures Flashcards
Define an open fracture?
One with direct communication from the fracture to the outside, usually via skin but sometimes elsewhere e.g. pelvic fragments pierce rectum
Where do most open fractures occur?
> 50% are in the fingers or shaft of tibia
How do we classify open fractures?
Using the Gustilo Classification Types 1-3 based on: - Wound size - Soft tissue damage - Periosteal of neurovascular damage - Complexity of fracture
,What guidelines do we follow for management of open fractures?
The national guidelines for orthopaedic & Plastic teams.
Made by BAPRAS which is the British Association of Plastic, reconstructive & Aesthestic surgeons
How do we initially manage a open fracture?
ATLS assessment
Remove gross contaminents, photograph, cover with saline swabs and stabilize the limb
Also tetanus and Abx prophylaxis
What drugs do we give for tetanus and Abx prophylaxis of an open fracture?
E.g. Cefuroxime/ augmentin/ clindamycin/ Gentamicin
For Tetanus:
- Booster Vaccine
- Tetanus Immunoglobulin
What investigation is standard for any open fracture?
A bare-bones, basic-bitch, X-ray
What would indicate you should do emergency (<6hrs) surgery for an open fracture?
If:
- Patient is polytraumatised
- Occurred in a marine or farmyard environment (infection risk)
- Gross contamination
- Neurovascular compromsie
- Compartment syndrome
How do we surgically manage an open fracture?
Either Debridement and fixation if viable or an amputation
+ Plasic surgery for skin coverage
How do we determine if muscle is viable for debridement and fixation?
Check the 4 Cs:
- Colour
- Contraction
- Consistency
- Capacity to Bleed
Need for an amputation is scored by what factors?
- Limb ISchaemia
- Age
- Shock
- Injury mechanism (contamination/energy/complexity)
It’s a dual consultant decision
Define Type I
low energy wounds
<1cm long
caused by bone piercing skin
Define type II
- Low energy wound
- <10cm long
- Cause moderate, soft-tissue damage
- No skin flap or avulsion
Define type III- OVERALL
High energy
>10cm
gunshot, farm accident , segmental fracture, bone loss, severe crush injury, marine.
IIIA
Fractures have adequate local soft tissue coverage. Extensive damage to soft tissue but not high risk of contamination.
IIIB
Fractures have inadequate local soft tissue coverage. Periosteal stripping, muscle damage and heavy contamination
IIIC
CArterial injury and need repair
Which is the most common type of fracture
IIIB
What are some of the complications of open fractures
- Infection
- soft tissue complication
- Long term morbidity.
Management of an open fracture
- Give IV antibiotics e.g. cefuroxime/ augmentine/ clindamycin
- Continuosly assess the neurovascular supply of the limb
- Immediate surgery in vascular impairment of compartment syndrome
- Urgent surgery if multiply injured patient or the wound is covered in marine/ sewage/ agricultural waste.
- Debridement carried out by orthopedic/ plastic surgeons together within 24hrs of the injury
- Cover wound in saline soaked gauze
- Splint the limb
- If single soft tissue cover is not achieved in one instance then: vacuum foam dressing/ antibiotic bead pouch
- Definitive skeletal stabilization and wound cover within 72 hrs and should not exceed 7 days
Types of soft tissue cover
- Myofaciocutaneos
- fasciocutaneos
- rotation
- free flaps
when would you amputate?
- Dual consultant decision
- Insensate limb/foot
- Irretrievable soft tissue/ bony damage
- Other life-threatening injuries
which are the most difficult fractures to heal?
- Open
- Adult
- Lower limb
- Diaphyseal
what are some common risk factors for poor healing
- Older age
- Co-morbidities
- Recent trauma
- Smoker
- Osteoporosis
- Corticosteroids
- NSAIDs
- Local complications to fractures
