Open Fractures

Question 1

What points do you need to know from history with open #?

Answer 1

• Nature of injury
• Protective equiptment worn?
• Need for plastic surgery?
• Stable - what are obs?
• Has there been contamination with marine, agriculture or sewage?
• How much tissue loss

Question 2

Assessment of someone with open #

Answer 2

• A-E
• Assess NV status of limbs
• Assess need for plastic surgery
• Gustilo Anderson classification of wound

Question 3

What are the MAIN steps of management of open #?

Answer 3

• Debridement - immediate if contaminated with marine, agriculture or sewage, within 12-24hrs for all others, washout with saline
• Splinting and realigment
• Assess NV compromise - need immediate vascular surgery exploration input if so, assess after realigment

Question 4

What are additional factors in managing open #?

Answer 4

• Photograph wound before and after, dress with saline soaked gauze (no need for washout out of theatre)
• Tetanus needed if not up to date with vaccines
• Broad spec abx needed as per local guidelines
• Splinting limb - needed to try and save NV status
• Adequate analgesia and antiemetics

Question 5

What is skeletal stabilisation?

Answer 5

• Stabilising the bone eg with internal or external fixation
• Need to ensure adequate soft tissue coverage
• If not this needs to be done within 72hrs with guidance from plastic surgeons

Question 6

Bloods for open #

Answer 6

• FBC, U&E, LFT, CRP
• Clotting screen
• Group and save

Question 7

Investigations for open #

Answer 7

• X-ray
• CT scan if complex

Question 8

How to classify open #

Answer 8

• Gustillo and Anderson Classification
• 1 - <1cm and wound clean
• 2 - 1-10cm and clean
• 3a - >10cm, high energy but adequate soft tissue coverage
• 3b - >10cm, high energy and inadequate soft tissue coverage
• 3c - all injuries with vascular compromise

Question 9

Guidance on management with Gustillo and Anderson

Answer 9

• 3a - ortho alone
• 3b - need plastics too
• 3c - need vascular too

Question 10

What to discuss during consenting patient for debridement, splinting and realignment?

Answer 10

• Process of procedure
• Risks - infection, delayed healing, worse case scario is amputation
• Benefits - promote healing, trying to minimise infection
• Post-op complications - VTE, loss skin graft, infection, pain, muscle wasting etc

Question 11

Post op complications to be aware of?

Answer 11

• Sepsis/infection - regular obs, check graft site/surgical site using clear dressing
• Compartment syndrome - when reperfuse ischaemic leg - pain, pallor, parasthesia, paralysis
• Pain - analgesia
• Urine output - may need catheter, may not
• Graft problem - monitor blood flow to graft with doppler
• VTE - check legs, ask about SOB etc

Question 12

Management of post op complications

Answer 12

• Infection - may need removal of fixation devices, blood culture, bone biopsy, US guided aspitation, x-rays if loosening etc and abx with low pressure saline lavage
• Flap loss - revision surgery, if delayed could be from venous congestion (assess tight dressings, haematoma etc) - medicinal leeches? or rheological agents?
• Wound leakage - soft tissue failure
• Loss alignment - revision surgery