Trauma symposium - open fractures

Question 1

Define an open fracture

Answer 1

Any fracture where there is a direct communication between the external environment and the fracture

Pretty much always means when bone breaks thru skin - but not always (broken pelvis into rectum)

Question 2

What are the most common open fractures?

Answer 2

Tibial shaft

Fingers

^account for 50% of open fractures^

Question 3

How do we classify open fractures?

Answer 3

Gustilo classification system

Types 1, 2, 3a, 3b, 3c (worst)

Question 4

Give an overview of the Gustilo grades for fractures

Answer 4

Type I (simplest):

• wound <1cm, clean, simple fracture pattern

Type II:

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

Type III:

• Extensive soft tissue damage & complex fracture pattern
• Subdivided further into 3a, b & c

Question 5

What is described by Gustilo type 3A, 3B & 3C?

Answer 5

Type 3 - Extensive soft tissue damage & complex fracture pattern with:

3A - adequate periosteal coverage (enough viable bone)

3B - not enough skin to cover fracture - ie needing plastics or skin graft

3C - vascular injury requiring repair

Question 6

What sort of injuries cause type 3 fractures?

What features of fractures are often seen in type 3s?

Answer 6

gunshot, farm accident, segmental fracture, bone loss, severe crush injury, marine

Fractures with Comminution & displacement often fall under type 3

Question 7

Describe the initial management of someone with a severe open fracture…

(ie management in casualty)

Answer 7

Full ATLS assessment & treatment

Tetanus & antibiotic prophylaxis

Repeated examination of neurovascular status

Remove any gross contamination

Photograph wound then cover & splint

Radiography - joint below & above etc

Question 8

What antibiotics are given for prophylaxis in a severe open fracture?

Answer 8

Cefuroxime, augmentin & clindamycin (or gentamicin)

Question 9

When is the only time that open fracture wounds should be handled in casualty?

What other fairly invasive thing is not done in casualty?

Answer 9

Handled only to remove any gross contamination

There is also no irrigation or exploration of the wound done at this stage

Question 10

What are the indications for urgent/immediate surgery for an open fracture?

Answer 10

Polytraumatised patient

Marine or farmyard environment (infection risk i presume)

Gross contamination

Neurovascular compromise

Compartment syndrome

If above not present then <24 hours is grand

Question 11

What is debridement?

What are the 4 C’s of debridement?

Answer 11

Surgical removal of any dead tissue (skin, bone & muscle)

What is the dead tissue? - determined using the 4 C’s…

• Colour
• Contraction (for muscle tissue)
• Consistency
• Capacity to bleed

Question 12

What is fixation?

Answer 12

Using plates & screws to either temporarly or permanently fix bone fragments etc together

Can be external (usually temporary) or internal (more permanent)

Question 13

What are the different options for skin covering?

Answer 13

SSG - split skin graft

Myofasciocutaneous - skin, fascia & muscle

Fasciocutaneous - skin & fascia

Rotation - no clue

Free flaps

Question 14

The last management option for the most severe open fractures is amputation…

What are the indications for amputations?

Answer 14

Decision made based largely on dual consultant decision and using scoring systems…

However - in general - indications for amputation include:

• insensate limb/foot (irriversible neuro damage)
• irretrievable soft tissue/bony damage
• other life threatening injuries