Open fractures Flashcards
In open fractures, why is there an increased infection potential?
- contamination
- reduction in local host defenses due to presence of foreign material and debris
- necrotic tissue
- dead space
Grading of open wounds?
Grade 1 - 3
1 is mild, 3 is severe
Grade 1 open fracture?
Grade 1
- small puncture wound caused by bone puncturing skin (<1cm)
- clean
- no fracture contamination
NB! Severe bruising equates to a grade 1
Can be treated as a similar manner as a closed fracture
Grade 2 open fracture?
Grade 2
- larger skin wound (>1cm) caused by external trauma with loss of skin
- contamination and soft tissue injury greater than grade 1
- foreign material might be carried into the wound
- no flaps, avulsions or fracture comminution
Grade 3 open fracture?
Grade 3
- exensive loss of skin and bone - often severe fractures, high energy
- crushing injuries
- vascular injury requiring repair
- severe comminution
What are the phases of normal wound healing?
1) Inflammatory phase (immediate)
2) Proliferative phase (day 3-7 post injury)
3) Remodelling phase (day 5-7 post injury)
4) Maturation phase
Phases overlapping
Classification of wounds according to time passed?
Traumatic wounds - classification
Class 1
- 0-6h old (“golden period”)
- clean laceration
- minimal contamination
Class 2
- 6-12h old
- significant contamination
Class 3
- >12h duration
- gross contamination
Classification of wounds based on level of contamination?
Clean:
- created under sterile conditions
Clean contaminated
- minimal contamination, easily removed
- surgical - tract penetrated, minimal spillage
- can close after appropriate treatment
Contaminated
- gross contamination with foreign bodies
- e.g. dog fight, RTA, gunshot
- can be closed after appropriate treatment
Dirty/infected
- infection already exists (>10^5 organisms per gram)
- never close primarily
Why is primary closure rarely a good idea in the early stages of the majority of wounds?
Bacteria may be trapped under the wound - if primary closure is chosen, must place drain!)
What are the aims of wound management?
1) prevent further wound contamination
2) remove foreign debris and contamination
3) debride dead and dying tissue
4) promote viable vascular bed
5) provide drainage
6) select appropriate method of closure
Principles of wound lavage?
Aims: remove gross debris, dilute bacteria, treat in sterile manner
Method: Giving set, 18G needle with 20-50ml syringe (8psi)
Cannot overflush!
Choice of solution
- Hartmanns/RAC/Saline
What is the most common cause for wound infection?
Failure to debride!
Aims of debridement?
- remove devitalised tissue
- convert wound to a clean status
- single or staged
- surgical: layered (spfc to deep) or en bloc
- mechanical: wet to dry bandages
- hydrodynamic (lavage)
Debridement of different tissues?
1) Skin - immediate assessment of viability may be misleading -> staged debridement
2) Fat - debride all exposed fatty tissues to a clean plane
3) Muscles - debride muscle that is dark or friable
4) Nerves - conserve and protect from damaged tissues
5) Joints - lavage thoroughly
6) Tendons - preserve as much as possibe. Anastomosis will fail if infection
Layers of a dressing?
1) Primary (contact) layer
- most important layer in terms of wound healing
- choose according to condition of wound
2) Secondary (intermediate) layer
- secures contact layer to wound
- Absorbs wound fluid/exudate (wick effect)
- provides immobilisation (protect, support, compress, analgesia)
3) Tertiary (outer) layer
- holds bandage in place and protects underlying bandage
Type of closure related to description and type of wound?
