Open Fractures Flashcards
What is the definition of open fractures?
There is a direct communication between external environment and fracture
Usually through break in skin but not always
Why are open fractures important?
High energy injury
Increased infection rate
Soft tissue complications
Long term morbidity
What is the epidemiology of open fractures?
23 per 100000 population per year
Fingers and tibial shaft account for >50%
Probably about 3,500 open fractures in UK per year
What is used to classify open fractures?
Gustilo Classification
Describe Gustilo classification of open fractures
Type 1 - wound less than 1cm and clean simple fracture
Type 2 - wound more than 1cm, moderate soft tissue damage and adequate skin coverage
Type 3 - extensive soft tissue damage and complex fracture pattern
What is included in type 3A, B and C of Gustilo classification?
A - adequate periosteal coverage (not grossly contaminated)
B - tissue loss repairing soft tissue coverage procedure and heavy contamination
C - vascular injury requiring repair
Describe type 1 Gustilo grading
Low energy, wound <1cm and often bone piercing skin from inside
Describe type 2 Gustilo grading
Moderate soft tissue damage, wound more than 10cm and no soft tissue flap or avulsion
Describe type 3 Gustilo grading
High energy, extensive soft tissue damage, severe fracture and wound more than 10cm
Any gunshot, farm accident, segmental fracture, bone loss, severe crash and marine
What do majority of type 3B tibial shaft fractures require?
Flap cover
What is the epidemiology of open tibial shaft fractures?
Type 3B - 30%
Type 1 - 24%
Type 3A and 2 - 22%
What is the principal recommendations for open fractures?
MDT team
Immediate referral to specialist centre if hospital lack team
Primary surgical treatment - wound debridement/ excision and skeletal stabilisation
What are the different type of fracture patterns?
Transverse or short oblique tibial fracture
Comminution/ butterfly fragments
Segmental
Fractures with bone loss
What are types of soft tissue injury patterns?
Skin loss such that direct tension free closure is not possible following wound excision
Degloving
Injury to muscles which requires excision of devitalised muscle
Injury to one or more major arteries of leg
What is involved in management of open fractures?
ATLS assessment and treatment
Tetanus and antibiotic prophylaxis
Cefuroxime/ Augmentin/ Clindamycin - gent at time of fixation
Repeated examination of neurovascular status
Radiographs
When are wounds handled?
To remove gross contamination, photograph, cover (saline swabs) and stabilise limb
What are the indications for emergency urgent surgery (under 6hrs)?
Polytraumatised patients
Marine or farmyard environment
Gross contamination
Neurovascular compromise
Compartment syndrome
What is done in absence of emergency criteria for open fractures?
Performed by senior plastic and orthopaedic surgeons that can do the surgery within 24hrs as 6hr rule does not apply for solitary open fractures
Describe surgical debridement and fixation
Experienced surgeons
4C’s colour
Contraction
Consistency
Capacity to bleed
Fixation can be temporary or definitive
Describe definitive skin coverage
Plastic surgeons
SSG/ myofasciocutaneous/ fasciocutaneous/ rotation/ free flaps
What is assessed for amputation?
Limb ischaemia - reduced pulse, parasthesias, paralysis, cold…
Patient age range
Shock - SBP >90mmHg and hypotension
Injury Mechanism
Describe amputation decision
Dual consultant decision
Insensate limb/ foot
Irretrievable soft tissue or bony damage
Other life threatening injuries
Guillotine type and refashion at later stage
