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MBBS 3: Surgery > Open Fractures > Flashcards

Open Fractures Flashcards

1
Q

What is an open fracture?

A

an injury where the fracture and the fracture hematoma communicate with the external environment through a traumatic defect in the surrounding soft tissues and overlying skin
Note: The skin defect may not lie directly above the fracture site

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2
Q

Epidemiology of open fractures?

A
  1. Incidence
    - 30.7 per 100,000 persons per year
  2. Demographics
    - Average age is 45 years old
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3
Q

Common open fractures?

A

Tibia and finger phalanx

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4
Q

What is the pathophysiology of open fractutres?

A

MOI = high-energy trauma
- “inside-out” open fractures

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5
Q

Associated conditions for open fractures?

A
  1. Additional injuries :30 %
  2. Compartment syndrome
    Note: Presence of an open wound does not preclude the presence of compartment syndrome in the injured limb.
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6
Q

How do you classify open fractures?

A
  1. Gustilo-Anderson Classification
  2. Oestern and Tscherne
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7
Q

GAS Type I?

A

Energy - low
Wound size - <1 cm
Soft tissue damage - minimal
Contamination - clean
Fracture comminution - minimal
Periosteal stripping - no
Skin coverage - local coverage
Neurovascular injury - normal

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8
Q

GAS Type II?

A

Energy - moderate
Wound size - 1-10 cm
Soft tissue damage - moderate
Contamination - moderate
Fracture contamination - moderate
Periosteal stripping - no
Skin coverage - local coverage
Neurovascular injury - normal

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9
Q

GAS Type IIIA?

A

Energy - high
Wound size - usually > 10 cm
Soft tissue damage - extensive
Contamination - extensive
Fracture comminition - severe
Periosteal stripping - yes
Skin coverage - local coverage
Neurovascular injury - normal

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10
Q

GAS Type IIIB?

A

Energy - high
Wound size - usually > 10 cm
Soft tissue damage - extensive
Contamination - extensive
Fracture comminution - severe
Periosteal stripping - yes
Skin coverage - free tissue flap or rotational flap coverage
Neurovascular injury - normal

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11
Q

GAS Type IIIC?

A

Energy - high
Wound size - usually >10cm
Soft tissue damage - extensive
Contamination - extensive
Fracture comminution - severe
Periosteal stripping - yes
Skin coverage - typically requires flap coverage
Neurovascular injury - exposed fracture with arterial damage that requires repair

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12
Q

How do you classify closed fractures?

A

Oestern and Tscherne classification

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13
Q

Things to note in History of open fractures?

A
  1. MOI
  2. location
  3. timing.
  4. Co morbidities
  5. Other injuries
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14
Q

Things to note in Physical examination of open fractures?

A
  1. Stabilize the patient: life before limb
  2. Inspection: assess soft tissue damage
  3. Neurovascular: ABI if concern for vascular insult
    - Normal ratio is >0.9
    - Vascular surgery consult and angiogram warranted if <0.9
  4. Provocative tests: saline load test if concern for traumatic arthrotomy.
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15
Q

Indications for Imaging of open fractures?

A
  1. Radiographs
    - obtain radiographs including joint above and below fracture
    - Rule of 2s
  2. CT
    - Peri-articular injuries
    - Evaluation for traumatic arthrotomy of the knee
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16
Q

Principles of treatment?

A
  1. Initiate prophylaxis
    - Antibiotics
    - Tetanus
  2. Plan surgical intervention
    - Debridement
    - Irrigation
    - Stabilization of fractures
  3. Early soft tissue coverage of bones
17
Q

Goals of treatment?

A
  1. Prevent infection
  2. Restore soft tissue and cover bones
  3. Stabilize fractures
    - Achieve bone union
    - Avoid malunion
  4. Restore function
18
Q

Antibiotics for GAS Grade I and II?

A

1st gen cephalosporin
- Clindamycin or vancomycin if allergies exist

19
Q

Antibiotics for GAS Grade IIIA, IIIB and IIIC?
- For gram positive and gram negative

A
  1. gram positive - 1st gen cephalosporin
  2. gram negative - aminoglycoside (gentamicin)
20
Q

Antibiotics when its an OF farm injury?

A

high dose penicillin for clostridium (anaerobic organism)

21
Q

Antibiotics when its a OF saltwater injury?

A

Doxycycline + ceftazidime or fluoroquinolone

22
Q

Timing of antibiotics?

A

ASAP
- continued for over 24 hours in primary wound closure.
Note: Increased rates of infection if delayed >3hours
- Continue for 24 hours after final wound closure if wound not closed during first debridement.

23
Q

Tetanus prophylaxis?

A
  1. Timing
    - Initiate in casualty
  2. Forms
    i. Toxoid: 0.5 mL regardless of age
    ii. Immunoglobulin
    <5 years: 75U
    5-10 years: 125 U
    >10 years: 250U
    Note: Given IM in 2 separate syringes in 2 different location
24
Q

Describe stabilization and its function?

A

splint, brace, or traction for temporary stabilization
1. decreases pain
2. minimizes soft tissue trauma
3. prevents disruption of clot

25
Describe dressing?
1. Remove debris but not bones from the wound 2. Sterile soaked gauze on wound 3. Avoid aggressive irrigation
26
When to do irrigation and debridement ?
within 24 hours for type III, 12 for III B - Staged: every 24-48 as needed
27
How do you do perform irrigation and debridement?
1. Incision - extend wound proximally and distally in line with extremity to adequate expose open fracture 2. Irrigation - low pressure bulb recommended. - saline with soap-better wound healing than antibiotic solutions - On avg, 3L on each successive Gustilo type. 3. Debridement - Devitalized tissue to prevent infection - Remove bony tissue without soft tissue attachment.
28
What is temporary fracture stabilization?
Performed at the time of initial debridement 1. External fixation for majority of lower extremity #s 2. Local wound antibiotics in significantly contaminated wounds
29
When to do soft tissue coverage?
Early soft tissue coverage or wound is ideal - Flap coverage< 7 days desired. - Increased risk of infection beyond 7 days - No statistical difference between rate of infection when ORIF is performed before fasciotomy closure, at fasciotomy closure, or after fasciotomy closure
30
Whats the technique to perform soft tissue coverage?
1. Proceed with bone grafting after wound is clean and closed. 2. Negative pressure crucial before definitive wound coverage. - VAC: reduces infection
31
Surgical treatment when there is no critical bone defect?
ORIF or IMN depending on fracture location and morphology
32
Surgical treatment when there is critical bone defect?
Masquelet technique ("induced-membrane" technique) 1. distraction osteogenesis 2. vascularized bone flap/transfer
33
Complications of open fracture surgery?
1. Surgical site infection 2. Osteomyelitis - 1.8-27 % - Tibia is most common post-surgical OM 3. Neurovascular injury 4. Compartment syndrome 5. Non union 6. Malunion 7. Chronic pain 8. Physical dysfunction
34
Risk factors for osteomyelitis?
1. Blast MOI 2. Acute surgical amputation 3. Delay in soft tissue coverage>7 days 4. Higher Gustilo class
35
When to have surgery of open fractures to increase the prognosis?
Surgery within 24 hrs for all types and 12 hrs for Gustilo type IIIB recommended. - Contamination with dirty and debris and devitalization of soft tissue. Note: Higher infection rates in blunt compared with penetrating trauma

MBBS 3: Surgery (42 decks)

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