Open Fractures Flashcards
What is an open fracture?
open fractures are defined as any kind of fracture in which there is communication through the skin with the environment.
What is another name for open fractures?
Compound fractures
What is a key fact to remember when deciding how to treat an open fracture?
Open fractures are often indicative of high energy trauma and thus other injuries may be present
What are three common injuries in high energu trauma?
C-spine injury
Pelvic fracture
Other injuries
What is the name of the classification system for open fractures
Gustilo & Anderson Classification System
How does Gustilo Classification system rate severity of open fracture injury
Type of fracture
Nature of soft tissue injury
Degree of contamination
Scale of 1-3
What is a type 1 open fracture?
Wound
- Small (
What is a type 2 open fracture?
Wound
- >1cm but
What is a type 3 open fracture?
- > 10 cm wound
- Extensive damage to skin (possible flap)
- Significant contamination
What are three special type sof open fracture which fall under type 3?
Arterial injury, Farming injuries, Fractures open 8hrs
What is 3A?
The fractured bone can be adequately covered by soft tissue despite the laceration
What is 3B?
There is extensive periosteal stripping and fracture cover requires flaps
What is 3C?
Arterial injury that needs to be repaired, regardless of soft tissue injury
What is the first step in treating an open fracture?
Initial assessment and ATLS principles (ABCDEFG)
DEGF - Don’t Ever Forget Glucose
What occurs after ATLS?
Stop haemorrhage
Give two methods of stopping haemorrhage
Direct pressure preferably
Application of a tourniquet if not
What are the dangers of inexpert tourniquet placement?
Limb ischaemia and unecessary amputation
What occurs after haemorrhage has stopped (NV assessment procedure, 4 steps)
Neurovascular assessment of limb
Analgesia
Straighten and realign limb
Repeat neurovascular assessment
What occurs in a neurovascular assessment?
Capillary refill, peripheral pulses
Wiggle toes, appreciate light touch
When does muscle death start in warm ischaemia?
3-4 hours
How does the incidence of wound infection correlate to soft tisue damage?
10% in type 3
How do you splint fracture?
Apply traction to help realign limb and close venous channels
Apply traction splint, box splint or vacuum splint
What are the four bonuses of splinting?
Reduces pain
Reduces blood loss
Reduces pressure on skin
Reduces chance of fat embolus
What antibiotics should be given in normal patient?
13) IV antibiotics: Co-amoxiclav (1.2g) or cefuroxime (1.5g) 8 hours
What antibiotics should be given in penicillin allergic patient?
clindamycin (600mg) 6 hourly if the patient is allergic to penicillin
What other anti-bacterial precautions should be taken?
Check tetanus status
What kind of x-rays should be taken?
15) X-ray: Two orthogonal views (views at right angles to each other) and two joints
What antibiotic should be given for open fracture operation?
Gentamicin (1.5mg/kg) OR Vancomycin (1g) OR Teicoplanin (800mg)
When should open fractures be operated on?
Within 24 hours, but on apporpiate scheduled day list with plastic and orthopaedic surgeon
What are the three instances in which open fractures should be operated on immediately?
Gross contamination of the wound
Compartment Syndrome
Devascularized limb
Multiply injured patient
What is the mangled extremity severity score
MESS is used to predict the necessity of amputation after lower extremity trauma. It has four variables and has a high specificity for predicting amputation, but low sensitivity.
What score is needed for MESS to point to amputation
> 7
What are the four criteria of MESS
Limb ischaemia
Patient age range (50)
Shock (Hypotension level)
Injury mechanism (low to very high energy)
Give four common post op complications of open fracture
- Pain
- Infection
- Malunion
- Compartment Syndrome
Give some distressing repercussions of open fractures
- Vascular injury
- Visceral injury
- Nerve injury
- Compartment syndrome
- Gas gangrene
Give two methods of post-operative thromboprophylaxis
LMWH
Pressure stockings
What is special about open fracture rehabillitation
Mobility is encouraged
Give three ways in which gun shot wounds cause damage
a) Direct impact of bullet
b) Contusion of the soft muscles around the missile track
c) Bruising and congestion of soft tissues at a greater distance from the primary track
Define a high velocity bullet wound
Bullet travelling >600m/s, usually from a rifle
Causes marked cavitation and tissue destruction
Bone splinters and forms secondary missles
How do you treat high velocity bullet wound?
Thorough cleansing of then wound and debridement is necessary, with excision of deep damaged tissues and, if necessary, splitting of fascial comparments to prevent ischaemia.
How do you treat high velocity bullet wounds?
Thorough cleansing of then wound and debridement is necessary, with excision of deep damaged tissues and, if necessary, splitting of fascial comparments to prevent ischaemia.
Define low velocity bullet wounds
Bullets travelling 300-600m/s cause less cavitation and often the injury will be confined to the bullet track.
Debris can be sucked into the wound and thus must be counted as contaminated.
How do you treat low velocity bullet wounds?
Can be treated as gustilo type I injuries by superficial debridement, splintage of the limb and antibiotic cover.
What is gas gangrene caused by?
Clostridium perfringens
How is gas gangrene treated?
Treatment is usually debridement and excision, with amputation necessary in many cases. Antibiotics alone are not effective because they do not penetrate ischaemic muscles sufficiently to be effective. However, penicillin is given as an adjuvant treatment to surgery. In addition to surgery and antibiotics, hyperbaric oxygen therapy is used and acts to inhibit the growth of and kill the anaerobic C. perfringens
What is a tetanus booster?
Tetanus Toxoid (tetanus (tetanus toxoid) toxoid) for intramuscular or subcutaneous use, is a sterile solution of toxoid in isotonic sodium chloride solution. The vaccine is clear or slightly turbid in appearance. 0.5ml/syringe booster given to avoid tetanus.
