T&O: Open fractures

Question 1

What is the classification system for open fractures and explain the types

Answer 1

Gustilo-Anderson classification

Type 1: <1cm wound and clean

Type 2: 1-10cm wound and clean

Type 3A: >10cm wound and high-energy, but with adequate soft tissue coverage

Type 3B: >10cm wound and high-energy, but with inadequate soft tissue coverage

Type 3C: All injuries with vascular injury

3A can be managed by orthopaedics alone, 3B requires plastics input, and 3C requires vascular input

Question 2

What are the common sites for open fracture?

Answer 2

Tibial

Phalangeal

Forearm

Ankle

Metacarpal

Question 3

Name the different classifications of fracture based on how they appear

Answer 3

Question 4

Open Fracture in A& E descibre immediate stesps

Answer 4

1) Look for polytrauma (often found with OF)
2) A- E assessment including Hx / contamination
3) Neurovascular exam

Treatment depends on location of fracture but generally requires immediate IV antibiotics (broad spec) and urgent irrigation and debridement followed by surgical fixation as needed.

Question 5

What complications are associated with open fractures? (Orthobullets)

Answer 5

Surgical site infection

Compartment syndrome

Osteomyelitis

Neurovascular injury

Question 6

What 4 ways can the outcome of an open fracture be thought of?

Answer 6

Skin - large wound will need plastics input for cover e.g. grafting

Soft Tissue - damage to ligaments /tendons may need reconstructive surgery

Neurovascular - nerves and blood vessesls may be compressed by deformity- arteriospasm, intimal transection or fully transected

Infection - High risk due to systemic compromise (trauma), contamination, reduced vasculaity and insertion of metal work when reducing.

Question 7

What initial (non surgical) and surgical management would you do for a pt with an open fracture?

Answer 7

Non surgical

IV broad spectrum AB (immeidate if contaminated e.g. farm)

Tetanus injection if out of date

Photograph (to avoid excessive undressings)

Remove large debris form wound

Resusitation and stablisation- realign and splint with saline covered gauze- assess neurovascular after re-aligning

Surgical

Surgical debridement and theatre saline wash

Definitive reconstruction and fracture fixation

Soft tissue cover (plastics) / neurovascular input (vascular)

Question 8

What investigations for an open fracture ?

Answer 8

Xray

Blood test - Group & Save (so transfusion blood is ready)

wound swab
FBC
U+E
ABG if systemically shocked
CRP
check tetanus status