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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
Q

Describe dressing?

A
  1. Remove debris but not bones from the wound
  2. Sterile soaked gauze on wound
  3. Avoid aggressive irrigation
26
Q

When to do irrigation and debridement ?

A

within 24 hours for type III, 12 for III B
- Staged: every 24-48 as needed

27
Q

How do you do perform irrigation and debridement?

A
  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
Q

What is temporary fracture stabilization?

A

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
Q

When to do soft tissue coverage?

A

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
Q

Whats the technique to perform soft tissue coverage?

A
  1. Proceed with bone grafting after wound is clean and closed.
  2. Negative pressure crucial before definitive wound coverage.
    - VAC: reduces infection
31
Q

Surgical treatment when there is no critical bone defect?

A

ORIF or IMN depending on fracture location and morphology

32
Q

Surgical treatment when there is critical bone defect?

A

Masquelet technique (“induced-membrane” technique)
1. distraction osteogenesis
2. vascularized bone flap/transfer

33
Q

Complications of open fracture surgery?

A
  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
Q

Risk factors for osteomyelitis?

A
  1. Blast MOI
  2. Acute surgical amputation
  3. Delay in soft tissue coverage>7 days
  4. Higher Gustilo class
35
Q

When to have surgery of open fractures to increase the prognosis?

A

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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