Open Fractures

Question 1

What is the definition of open fractures?

Answer 1

There is a direct communication between external environment and fracture
Usually through break in skin but not always

Question 2

Why are open fractures important?

Answer 2

High energy injury
Increased infection rate
Soft tissue complications
Long term morbidity

Question 3

What is the epidemiology of open fractures?

Answer 3

23 per 100000 population per year
Fingers and tibial shaft account for >50%
Probably about 3,500 open fractures in UK per year

Question 4

What is used to classify open fractures?

Answer 4

Gustilo Classification

Question 5

Describe Gustilo classification of open fractures

Answer 5

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

Question 6

What is included in type 3A, B and C of Gustilo classification?

Answer 6

A - adequate periosteal coverage (not grossly contaminated)
B - tissue loss repairing soft tissue coverage procedure and heavy contamination
C - vascular injury requiring repair

Question 7

Describe type 1 Gustilo grading

Answer 7

Low energy, wound <1cm and often bone piercing skin from inside

Question 8

Describe type 2 Gustilo grading

Answer 8

Moderate soft tissue damage, wound more than 10cm and no soft tissue flap or avulsion

Question 9

Describe type 3 Gustilo grading

Answer 9

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

Question 10

What do majority of type 3B tibial shaft fractures require?

Answer 10

Flap cover

Question 11

What is the epidemiology of open tibial shaft fractures?

Answer 11

Type 3B - 30%
Type 1 - 24%
Type 3A and 2 - 22%

Question 12

What is the principal recommendations for open fractures?

Answer 12

MDT team
Immediate referral to specialist centre if hospital lack team
Primary surgical treatment - wound debridement/ excision and skeletal stabilisation

Question 13

What are the different type of fracture patterns?

Answer 13

Transverse or short oblique tibial fracture
Comminution/ butterfly fragments
Segmental
Fractures with bone loss

Question 14

What are types of soft tissue injury patterns?

Answer 14

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

Question 15

What is involved in management of open fractures?

Answer 15

ATLS assessment and treatment
Tetanus and antibiotic prophylaxis
Cefuroxime/ Augmentin/ Clindamycin - gent at time of fixation
Repeated examination of neurovascular status
Radiographs

Question 16

When are wounds handled?

Answer 16

To remove gross contamination, photograph, cover (saline swabs) and stabilise limb

Question 17

What are the indications for emergency urgent surgery (under 6hrs)?

Answer 17

Polytraumatised patients
Marine or farmyard environment
Gross contamination
Neurovascular compromise
Compartment syndrome

Question 18

What is done in absence of emergency criteria for open fractures?

Answer 18

Performed by senior plastic and orthopaedic surgeons that can do the surgery within 24hrs as 6hr rule does not apply for solitary open fractures

Question 19

Describe surgical debridement and fixation

Answer 19

Experienced surgeons
4C’s colour
Contraction
Consistency
Capacity to bleed
Fixation can be temporary or definitive

Question 20

Describe definitive skin coverage

Answer 20

Plastic surgeons
SSG/ myofasciocutaneous/ fasciocutaneous/ rotation/ free flaps

Question 21

What is assessed for amputation?

Answer 21

Limb ischaemia - reduced pulse, parasthesias, paralysis, cold…
Patient age range
Shock - SBP >90mmHg and hypotension
Injury Mechanism

Question 22

Describe amputation decision

Answer 22

Dual consultant decision
Insensate limb/ foot
Irretrievable soft tissue or bony damage
Other life threatening injuries
Guillotine type and refashion at later stage