T&O: Open Fractures

Question 1

What is the Classifcation for Open Fractures?

Answer 1

Gustilo-Anderson Classification

Question 2

Outline the Gustillo Anderson Classification

Answer 2

• Type 1: Wound ≤1 cm, minimal contamination or muscle damage
• Type 2: Wound 1-10 cm, moderate soft tissue injury
• Type 3a: Wound usually >10 cm, high energy, extensive soft-tissue damage, contaminated. Adequate tissue for flap coverage
  
  • farm injuries are automatically at least Gustillo IIIA
• Type 3b: Extensive periosteal stripping, wound requires soft tissue coverage (rotational or free flap)
• Type 3c: Vascular injury requiring vascular repair, regardless of degree of soft tissue injury

Question 3

What is the significance of the Gustillo Anderson Classification?

Answer 3

• Plastics involvement from Type 3b and above
• Vascular involvmeent from Type 3a

Question 4

When is emergency amputation indicated?

Answer 4

Perform emergency amputation when:

• Limb is the source of uncontrollable life-threatening bleeding, or
• Limb is salvageable but attempted preservation would pose an unacceptable risk to the person’s life, or
• Limb is deemed unsalvageable after orthoplastic assessment.

When indicated, perform the delayed primary amputation within 72 hours of injury.

Question 5

Who is involved in the decison on amputation?

Answer 5

Decision whether to perform limb salvage or delayed primary amputation on multidisciplinary assessment involving an

• Orthopaedic surgeon
• Plastic surgeon
• Rehabilitation specialist and the person
• Family members or carers (as appropriate).

Question 6

How is an open fracture managed?

Answer 6

• In ED
  
  • Prophylactic intravenous antibiotics
  • Consider a saline-soaked dressing covered with an occlusive layer (if not already applied)
  • Photograph open fractures at presentation before debridement and key stages of management.
  • Analgesia: IV morphine (1st line), IN diamorphine or ketamine if no IV access, IV ketamine (2nd line)
• Debridement, fixation and cover

Question 7

How is Debridement hospital approached?

Answer 7

Perform debridement:

• Immediately for highly contaminated open fractures
• Within 12 hours of injury: high-energy open fractures like type 3A or type 3B that are not highly contaminated
• Within 24 hours of injury for all other open fractures.

Consider negative pressure wound therapy after debridement if immediate definitive soft tissue cover has not been performed.

Question 8

How is Fixation and Cover approached in Hospital?

Answer 8

• Perform fixation and definitive soft tissue cover:
  
  • At the same time as debridement if the next orthoplastic list allows this within the time to debridement recommended above, or
  • Within 72 hours of injury if definitive soft tissue cover cannot be performed at the time of debridement.
• When internal fixation is used, perform definitive soft tissue cover at the same time.

Question 9

Who is involved in surgery performed in Open fracture?

Answer 9

Surgery to achieve debridement, fixation and cover of open fractures of the long bone, hindfoot or midfoot should be performed concurrently by consultants in orthopaedic and plastic surgery (a combined orthoplastic approach).

Question 10

What shouldnt be done to open fractures of long bone, hindfoot or midfoot?

Answer 10

Do not irrigate open fractures of the long bones, hindfoot or midfoot in the emergency department before debridement.