open fractures

Question 1

What are your options for managing segmental bone defect?

Answer 1

1. shortening
2. bone graft
3. masquelet
4. bone transport

Question 2

BOAST open fractures

Answer 2

Initial management
- Antibiotics within 1hr
- assessment of NV status
- realign, splint fracture, remove gross contaminants only, photograph and saline soaked gauze
- Trauma CT - head to toe scanogram, include angiography for open fractures

Operative
- combined orthoplastic approach
- debridement - along fasciotomy lines
immediately - gross contamination
within 12hrs - high energy
within 24hrs - low energy
- procedures after debridement - clean drapes/ instruments

Further procedures
- definitive coverage/ closure within 72hrs
- definitive fixation once definitive coverage
- limb salvage vs amputation - MDT approach
- delayed amputation - within 72hrs of injury

Data submitted to TARN
All patients receive info on recovery

Question 3

classification of open fractures

Answer 3

Gustillo-anderson
grade I - open clean wound <1cm
grade 2 - open fracture >1cm - no extensive soft tissue or periosteal damage
grade 3
- a - extensive soft tissue damage - adequate skin coverage
- b - extensive soft tissue damage and periosteal stripping
- c - associated arterial damange

classification can only be determined at time of debridement

Question 4

Management of a mangled extremity

Answer 4

Initial management:
-ATLS principles - concurrent resuscitation, identify and treat life-threatening injuries
- address catastrophic bleeding:
1. compression, elevation and tourniquet
2. major haemorrhage protocol
- BOAST 4
- broad spectrum IV abx within 1hr
- Photograph before contaminants removed
- neurovascular status +/- doppler
- remove gross contaminants
- saline soaked gauze, bandage +/- plaster
- +/- CT angio - but shouldnt delay treatment

Operative management
- combined procedure - orthopaedics, plastics +/- vascular
- Decision - early amputation or revascularise/ debride and stabilise

Factors determining outcome for patient:
- absence of pain
- abscence of depression
- ability to work
- severe foot injuries do better with BKA

Question 5

what are the findings of the LEAP and METAL study?

Answer 5

LEAP study
- 8 trauma units
- outcome measure = sickness index profile
- amputation and limb salvage had a similar SIP and return to work at 2 yrs
- most important factor determining patients function - ability to return to work
- severe foot injuries do better with BKA

METAL study
- based on army personnel
- did slightly better with amputation - returned to vigorous activity
- less PTSD
- better access to rehabilitation/ prothesis

Question 6

Amputation for mangled limb - indications and principles

Answer 6

Amputation
Absolute indications for amputation:
- contaminated traumatic amputation
- mangled limb in a shocked and severely injured patient
- crushed extremity with arterial injury and warm ischaemia > 6hrs

Relative indications:
- severe bone or soft tissue loss
- anatomic transection of the tibial nerve
- open tibial fracture with severe ipsilateral foot trauma
- prolonged predicted course to obtain skin coverage

• limb salvage scores unhelpful for predicting outcome
• Plantar sensation no longer an idicator for amputation - 50% regain some sensation by 2 yrs

Principles of amputation surgery:
1. shared decision making - patient, plastics and ortho consultants
2. level of amputation based on soft tissue coverage available
2. preservation of length to improve energy expenditure during rehabilitation - not compromise debridement
3. clean wound - definitive procedure at first sitting
4. contaminated wound - staged procedure - flaps fashioned on second sitting