T&O: Open Fracture Flashcards
Outline the pathophysiology of an Open Fracture
In-to-out = sharp bone ends penetrate the skin from beneath
Out-to-in = high energy injury (ballistic injury or a direct blow) penetrates the skin, traumatising the subtending soft tissues and bone
Infection risk is very high = direct contamination, reduced vascularity, systemic compromise (such as following major trauma), and need for insertion of metalwork for fracture stabilisation
Outline the aetiology of an Open Fracture
High energy injures = falls, car accident, sports injuries
Outline the classifications of Open Fractures
The Gustillo + Anderson classification
Type 1 = <1cm wound and clean
Type 2 = 1-10cm wound and clean
Type 3A = >10cm wound, adequate ST coverage
Type 3B = >10cm wound, inadequate ST coverage
Type 3C = all injuries with vascular injury
What are the symptoms of Open Fractures
Acute pain
Bleeding
Reduced ROM
How would you investigate further into an Open Fracture?
Bloods = FBC, clotting factors, group and save
X-ray = visualise fracture
Check neurovascular status
Hx = contamination with marine, agricultural or sewage material is important to identify
How would you manage an Open Fracture?
Urgent realignment and splinting
Broad spec Abx
Tetanus vaccine
Photograph the wound
Dress with saline soaked gauze
Surgical debridement and washout
Skeletal stabilisation
Soft tissue coverage
Involvement of Plastics/vascular teams were required
What are the complications of an Open Fracture?
Nerve injury
Vascular injury
Muscle injury
Infection risk = Gustilo-Anderson type I, 0-2%, type II, 2-10%, type III, 10-50%
Non/malunion
What is primary bone healing?
Compression across the fracture line - eliminating 1) interfragmentary gap, 2) motion
Direct regrowth of bone across the fracture line
** no fibrous callus phase
Achieved by screws, plates, wiring
What is secondary bone healing?
Motion is minimised by not eliminated
Healing must go through a fibrous callus phase which is then converted to bone
Achieved by K wires, external fixators = axial realignment but not compression
What factors contribute to non/mal-union?
Excessive load applied at or near the fracture site
Inadequate immobilisation
Factors that impair angiogenesis = NSAIDs, nicotine, DM, infection, surgical trauma, corticosteroids
Impaired ossification = osteopenia, malnutrition, instability
What are Bone Morphogenetic Proteins (BMPs)?
Growth factors
Involved in signalling pathway involved in the development of cartilage and post-natal bone development (heart, CNS, foregut, hindgut)
Recombinant human BMPs are used in spinal fusions, non-unions, oral surgery
BMP-2, BMP-7
What is Bone grafting?
replacing missing bone in order to repair bone fractures that are extremely complex
Osteoconduction = guiding the reparative growth of the natural bone
Osteoinduction = encouraging undifferentiated cells to become osteoblasts
Osteogensis = living bone cell in the graft contribute to remodelling
What are the effects of smoking on fracture healing?
Smoking inhibits the activity of stem cells required for bone healing
A study carried out by United Lincolnshire Hospitals NHS Trust (ULHT) and the University of Lincoln gathered 50 fracture patients, who volunteered to allow blood from the area of the fracture to be analysed. A smoking environment around the blood was set up that simulated smoking 20 cigarettes a day. Results showed that the healing cell in non-smokers were of superior quality (more active/quicker) than smokers
