Mini Symposium - Fractures

Question 1

Define an open fracture?

Answer 1

One with direct communication from the fracture to the outside, usually via skin but sometimes elsewhere e.g. pelvic fragments pierce rectum

Question 2

Where do most open fractures occur?

Answer 2

> 50% are in the fingers or shaft of tibia

Question 3

How do we classify open fractures?

Answer 3

Using the Gustilo Classification
Types 1-3 based on:
- Wound size
- Soft tissue damage
- Periosteal of neurovascular damage
- Complexity of fracture

Question 4

,What guidelines do we follow for management of open fractures?

Answer 4

The national guidelines for orthopaedic & Plastic teams.

Made by BAPRAS which is the British Association of Plastic, reconstructive & Aesthestic surgeons

Question 5

How do we initially manage a open fracture?

Answer 5

ATLS assessment
Remove gross contaminents, photograph, cover with saline swabs and stabilize the limb

Also tetanus and Abx prophylaxis

Question 6

What drugs do we give for tetanus and Abx prophylaxis of an open fracture?

Answer 6

E.g. Cefuroxime/ augmentin/ clindamycin/ Gentamicin

For Tetanus:

• Booster Vaccine
• Tetanus Immunoglobulin

Question 7

What investigation is standard for any open fracture?

Answer 7

A bare-bones, basic-bitch, X-ray

Question 8

What would indicate you should do emergency (<6hrs) surgery for an open fracture?

Answer 8

If:

• Patient is polytraumatised
• Occurred in a marine or farmyard environment (infection risk)
• Gross contamination
• Neurovascular compromsie
• Compartment syndrome

Question 9

How do we surgically manage an open fracture?

Answer 9

Either Debridement and fixation if viable or an amputation

+ Plasic surgery for skin coverage

Question 10

How do we determine if muscle is viable for debridement and fixation?

Answer 10

Check the 4 Cs:

• Colour
• Contraction
• Consistency
• Capacity to Bleed

Question 11

Need for an amputation is scored by what factors?

Answer 11

• Limb ISchaemia
• Age
• Shock
• Injury mechanism (contamination/energy/complexity)

It’s a dual consultant decision

Question 12

Define Type I

Answer 12

low energy wounds
<1cm long
caused by bone piercing skin

Question 13

Define type II

Answer 13

• Low energy wound
• <10cm long
• Cause moderate, soft-tissue damage
• No skin flap or avulsion

Question 14

Define type III- OVERALL

Answer 14

High energy
>10cm
gunshot, farm accident , segmental fracture, bone loss, severe crush injury, marine.

Question 15

IIIA

Answer 15

Fractures have adequate local soft tissue coverage. Extensive damage to soft tissue but not high risk of contamination.

Question 16

IIIB

Answer 16

Fractures have inadequate local soft tissue coverage. Periosteal stripping, muscle damage and heavy contamination

Question 17

IIIC

Answer 17

CArterial injury and need repair

Question 18

Which is the most common type of fracture

Answer 18

IIIB

Question 19

What are some of the complications of open fractures

Answer 19

• Infection
• soft tissue complication
• Long term morbidity.

Question 20

Management of an open fracture

Answer 20

• 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

Question 21

Types of soft tissue cover

Answer 21

• Myofaciocutaneos
• fasciocutaneos
• rotation
• free flaps

Question 22

when would you amputate?

Answer 22

• Dual consultant decision
• Insensate limb/foot
• Irretrievable soft tissue/ bony damage
• Other life-threatening injuries

Question 23

which are the most difficult fractures to heal?

Answer 23

• Open
• Adult
• Lower limb
• Diaphyseal

Question 24

what are some common risk factors for poor healing

Answer 24

• Older age
• Co-morbidities
• Recent trauma
• Smoker
• Osteoporosis
• Corticosteroids
• NSAIDs
• Local complications to fractures