Open Fractures

Question 1

Open fractures

Answer 1

There is a direct communication between the external environment and the fracture usually through a break in the skin (but not always)

Question 2

Why are open fractures important?

Answer 2

• Higher energy injury
• Increased infection rate
• Soft tissue -Complications
• Long term morbidity

Question 3

What is the epidemiology of open fractures?

Answer 3

• 23 per 100,000 popu. per year
• Fingers + tibial shaft account for >50%
• Probably about 3,500 open tibial shaft fractures in UK per year
• 1/3 of polytraumatised patients have open fractures- distracting injuries

Question 4

How are open fractures classified?

Answer 4

Gustilo classification of open fractures

• Type 1
• Type 2
• Type 3

Question 5

What is a type 1 open fracture?

Answer 5

Wound <1cm, clean, simple fracture pattern

Question 6

What is a type 2 open fracture?

Answer 6

Wound >1cm, moderate soft tissue damage, adequate skin coverage, simple fracture pattern

Question 7

What is a type 3 open fracture

Answer 7

Extensive soft-tissue damage, complex fracture pattern

• 3A: adequate periosteal coverage
• 3B: Tissue loss requiring soft-tissue coverage procedure (such as a flap or a graft)
• 3C: Vascular injury requiring repair

Question 8

What is the epidemiology of open tibial shaft fractures?

Answer 8

• Type I: 24%
• Type II: 22%
• Type IIIA: 22%
• Type III B: 30%
• Type IIIC: 4%

Question 9

What is the historical treatment principles of open fractures?

Answer 9

• Preservation of life
• Preservation of limb
• Avoidance of infection
• Rehabilitation of function

Question 10

What are the principles recommendations for modern open fracture treatment?

Answer 10

• MDT approach
• Hospitals lacking staff or equipment have a contingency plan
• Primary surgical treatment takes place at specialist centre
• Specialist centres organised on a regional basis

Question 11

Give examples of fracture patterns.

Answer 11

• Transverse or short oblique tibial fractures with fibular fractures at a similar level
• Tibial fractures with comminution/butterfly fragments with fibular fractures at a similar level
• Segmental tibial fractures
• Fractures with bone loss, either from extrusion at the time of injury or after debridement

Question 12

Give examples of soft tissue injury patterns.

Answer 12

• Skin loss such that direct tension-free closure is not possible following wound excision
• Degloving
• Injury to the muscles which requires excision of devitalised muscle via wound extensions
• Injury to one or more of the major arteries of the leg

Question 13

How are open fractures managed before treatment?

Answer 13

-Full ATLS assessment and treatment
-Tetanus and antibiotic prophylaxis
-Cefuroxime / Augmentin / Clindamycin- Gent at time of fixation
-Repeated examination neurovascular status
-Wounds only handled to remove gross contamination,
photograph, cover (saline swabs) and stabilise limb
-No provisional irrigation / exploration
-Radiographs- orthogonal views including joint above and below

Question 14

Who is the 6 hour surgical rule pertinent for?

Answer 14

• Polytraumatised patient
• Marine or Farmyard environment
• Gross contamination
• Neurovascular compromise
• Compartment syndrome

Question 15

Who does the 6 hour rule not apply to?

Answer 15

Solitary open fractures

Question 16

What are the 4Cs of surgical debridement?

Answer 16

• Colour
• Contraction
• Consistency
• Capacity t bleed

Question 17

What is multiple debridements associated with?

Answer 17

Poorer outcomes

Question 18

What techniques can be used for definitive skin coverage?

Answer 18

• SSG
• Myofasciocutanoeus
• Fasciocutaneous
• Rotational
• Free flaps

Question 19

The decision to amputate is based on…

Answer 19

• Limb ischaemia?
• Patient age
• Shock?
• Injury mechanism

Question 20

When is amputation considered?

Answer 20

• Insensate limb or foot
• Irretrievable soft tissue or bony damage
• Other life threatening injuries