OPEN FRACTURE

DR THIT LWIN
SCHOOL OF MEDICINE &
HEALTH SCIENCE
UMS
1

(1)General
considerations
(2)Assessment
(3)Emergency
management
(4)Dbridement and
irrigation
(5)Fracture stabilization
(6)Wound management
(7)Definitive treatment

 Open fractures of the tibia are the commonest of

open long-bone fractures, ( thin anteromedial softtissue coverage).
caused by low-energy twisting forces to highenergy motor vehicle crashes or penetrating
injuries (gun shots, blasts).
Although the principles of management for open
tibial fractures are constant, the path to the final
result may vary.
can present as isolated injuries or in the context of
a multiply injured patient.
Thorough evaluation of the entire patient is
essential before focusing on the injured leg.

 DEFINITION
CLASSIFICATION
MANAGEMENT

 DEFINITION
Fracture in which there is skin damage, so that
bacteria from without may contaminate the
fracture haematoma.
The skin may be cut or crushed (potential
skin loss) or there may be actual skin loss.
The highest incidence is in tibial diaphyseal
fracture 21%
5

 The severity of open fracture can varies

significantly
1. energy level (height of fall/speed of
car/caliber of bullet)
2. degree of contamination (soil/broken
glass/stagnant water)
3. degree of soft tissue injury
(crushed/avulse)
4. complexity of fracture pattern(number of
bone pieces)
5. vascular injury
6

 CLASSIFICATION (GUSTILO'S)
Type I:
Wound is small <1cm: clean
puncture through which a bone spike has
protruded.
- little soft tissue damage with no crushing
and the fracture is not comminuted.

 TYPE I OPEN FRACTURE

TYPE I OPEN FRACTURE

9

 Type II: Wound is more than 1cm long but

there is no skin flap. There is not much soft
tissue damage and no more than moderate
crushing (or) comminution of fracture.
Type III: There is extensive damage to skin,
soft tissue neurovascular structure with
considerable contamination of wound.

10

 TYPE II OPEN FRACTURE

11

TYPE II OPEN FRACTURE

12

 III.A
III.B

III.C

The fracture bone can be adequately

covered by soft tissue.
It can not and there is also periosteal
Stripping & severe comminution of
fracture.
There is an arterial injury which needs
to be repaired, regardless of amount
soft tissue damage.

13

 TYPE III A OPEN FRACTURE

14

 TYPE IIIB OPEN FRACTURE

15

 TYPE IIIC OPEN FRACTURE

16

 III.B & III.C are classified as high velocity

injury although the wound is small, internal
damage is severe.
Incidence of infection directly correlate with
extent of soft tissue damage, raising from less
than 2% in type I to over 10% in type III.

17

Gustilo and Anderson. (JBJS 1976)

Gustilo, Mendoza and Williams. (J.Trauma 1984).

AO classification (adapted from Tscherne)

 Challenging fact in open tibial fractures

1. Infection: The grade of open fracture, condition of the soft
tissues, degree of contamination and the thoroughness of surgical
debridement will have influence on the risk of infection. In the worst
injuries (type III b or c), open tibial fractures carry an infection risk
of up to 25-50 %.

2. Soft-tissue deficiency: Soft-tissue defects require early

closure with healthy tissue to reduce the risk of infection. Local or
free-tissue transfers may be required, if tension-free closure is not
possible.

3. Impaired bone healing: Failure to unite may require

additional surgery, such as bone grafting and/or revised fixation.
Stimulation of bone healing remains a developing field.

MANAGEMENT
3 Goals -prevent infection
-fracture union
-regain early good functional results
The order of priority in management of open
fracture include
1.patient 2.limb
3.wound 4.fracture

24

 Management

Many patients with open fractures have

multiple injuries and severe shock; for them,
appropriate treatment at the scene of the
accident is essential.
Treatment at the scene of accident
- immediate wound cover with sterile
dressing and left undisturbed until the patient
reaches the accident department.
- Treatment of shock
-Splint the limb

25

 2. Treatment at the hospital

- rapid general assessment (any life threatening
condition). GCS
- Wounds inspection
i. What is the nature of the wound?
ii. What is the state of the skin around the wound?
iii. is the circulation satisfactory?
iv. Are the nerve intact?
- Tetanus prophylaxis
- Antibiotic prophylaxis
- Early wound debridement
26

 Assessment

inspected the entire soft-tissue envelope -the posterior aspect of the leg.
Cover the open wound with a sterile dressing. It should not be again
inspected until the patient is in the OR for debridement.
Neurovascular assessment
The dorsalis pedis and posterior tibial pulses should be palpated in the foot.
Reduced pulses require urgent further assessment.
Motor function in each of the four leg compartments should be evaluated
(toe flexion, toe extension, ankle eversion and plantarflexion).
Sensory function : tibial (plantar surface of foot)
deep peroneal (dorsal webspace between 1st and 2nd toe)
superficial peroneal (dorsal lateral foot)
saphenous (medial foot)

This may not be possible in all patients (ie intubated, multiple

injured, comatose), but should be always be attempted and
documented.

 Emergency management

must receive anti-tetanus prophylaxis and appropriate antibiotic coverage.

Antibiotics should be given intravenously as soon as possible.
A temporary splint may be applied to protect the soft tissues while awaiting
the availability of an operating room.
Definitive classification of the open fracture is best done in the OR.

 Definition:
exploration of wounds, removal of foreign body,
excision of devitalized tissue.
The wound is irrigated thoroughly with copious
amounts of physiological saline.

SKIN : Only the merest sliver of skin is excised

from the wound edges; as much skin as possible is
spared .Planned the incisions to obtain adequate
exposure.
29

SUBCUTANEOUS TISSUE: can excise

liberally.

FASCIA:
is divided extensively so that
the circulation is not impeded.

MUSCLE : Dead muscle is dangerous. It

provides food for bacteria. Dead muscle can
be recognized by its purplish discoloration;
mushy consistency; failure to contract when
stimulated and failure to bleed when cut. All
dead and doubtfully viable muscle is excised.
30

 General principles of debridement

It is important to perform a thorough surgical dbridement in an organized
manner. Starting with the skin, each layer is debrided systematically. One
can imagine a clock face; wound dbridement starts at the 12 oclock
position and continues in a clockwise manner around the circumference of
the wound. This is repeated for each layer down to the level of the bone.
Necrotic tissue is removed and only viable tissue is left behind. The
exception is skin, where none is removed unless obviously necrotic.
The quality of the muscle tissue is assessed using the classic 4 Cs:
Color (red or brown)
Consistency (how does the muscle feel)
Capillary Circulation (does it bleed?)
Contractility (responds to pinch or electro-cautery)

4 C
Dead muscle

Live muscle

Color

Purplish

Beefy red

Consistency

Mushy

Firm

Contractility

Capacity to
bleed

+
32

BLOOD VESSEL:
Blood vessel are tied ridiculously but, to
minimized amount of catgut left in the
wound, small vessels are clamped with artery
forceps.
NERVES:
It is usually best to leave a cut nerve
undisturbed. If, however, the wound is clean
and the nerve end present without dissection
the sheath is suture using non-absorbable
material for ease of later identification.
33

TENDON: Cut tendons are also left alone. Suture

is permissible only if the wound is clean and
dissection unnecessary.
BONE: The fracture surfaces are gently cleaned
and replaced in correct position. Bone fragments
were removed only if they are small and totally
detached.
JOINT: Open joint injury are best treated by wound
toilet, closure of synovium and capsule, and
systemic antibiotic. Drainage or suction irrigation is
used only if contamination is severe.
34

 Dbridement does not necessarily need to be through the open

fracture wound. In fact, in certain situations it may be
advisable to incorporate the dbridement through the planned
surgical approach for fracture fixation so as to avoid additional
trauma to the injured soft tissues.
The initial dbridement thus requires consideration of, and
planning for, the definitive surgery.

 After removing visible dirt and necrotic tissue, irrigation with

several liters of fluid is a key component of the
decontamination of the injury zone. If available, a balanced
salt solution is routinely used. In more austere environments,
any water that is clean enough to drink is acceptable.
Controversies exist regarding the optimal volume and
delivery methods. We recommend large volumes, with low
pressure to avoid additional tissue injury. Gravity flow, with
large-bore cystoscopy tubing, is a well accepted method.

 Fracture stabilization
Temporary stabilization of the tibia is chosen in situations
where future dbridements are felt to be necessary. This is
most common in the high-grade open fractures.
Temporary stabilization, usually achieved with an external
fixator, minimizes additional soft-tissue injury. This fixation
facilitates access to the wound for inspection between
dbridements.
It also allows simple, rapid disassembly for repeated wound
dbridements when necessary.

 External fixation
External fixation can be applied using either modular or
uniplanar techniques (see Modular external fixator
and Standard external fixator). The modular frames have the
advantage of being more versatile, avoiding the complex
wounds that are often seen.
The disadvantage of a modular frame is, that it is less rigid than
the uniplanar fixator because of its multiple connections.

Pin placement outside of the anticipated zone of the definitive

implant is a consideration, although not always possible.
Reduce the fracture as well as possible, to avoid soft-tissue
tension.

Wound management
Systemic antibiotics are a critical part of open fracture wound
management. Their choice and duration will depend upon several factors
including severity of the wound, patient comorbidities, contamination etc.
Antibiotics may also be applied locally to deliver high concentrations
directly to the wound site itself.
Methylmethacrylate impregnated with heat-stable antibiotics is shaped into
small beads to increase their surface area and to optimize antibiotic elution.
After placement onto a suture, the beads are placed within the wound to fill
the dead space. The wound is then closed primarily or covered with an
adhesive drape.
Generally, beads are left in for at least 2-5 days.

 Vacuum assisted closure (VAC)

Negative pressure wound dressings (VACs) can provide
helpful temporary coverage of an open wound.
They reduce external wound contamination, remove edema
fluid, help to shrink wounds, and promote growth of
granulation tissue, even over exposed bone.
Such dressings may allow definitive closure by the subsequent
use of split thickness skin grafts, instead of more complex
flaps. In this manner, a VAC can be used as a bridge to
definitive soft-tissue coverage for type IIIA and IIIB wounds.
They should be changed every 48-72 hours.

 Repeat dbridement
Repeated dbridement may be necessary in the higher grade
open fracture wounds when there is a concern for additional
necrotic tissue or when initial wounds were so badly
contaminated that a second look is necessary.
This procedure should be repeated, generally every 2-3 days,
until only healthy, viable tissue remains and no further
necrotic tissue is found on follow-up dbridements.

 WOUND CLOSURE
It is difficult to decide close or not to close.
A small uncontaminated type I, operated within few hours
injury may, after debridement, be sutured (provided it can be
done without tension).
All others wounds must be left open until the dangers of
tension and infections have passed.
The wound is lightly packed with sterile gauzed and is
inspected after 3-5 days; if it is clean, it is sutured or skin
grafted (delayed primary closure).
Grade III wound have to be debrided more than once and skin
closure may call for advanced plastic surgery and use of
vascularized muscle flaps.
42

 STABILIZATION OF THE FRACTURE

Plaster. For type I and type II wound with a stable
fracture
External fixation.
Intramedullary nailing.
Plates and screws.
AFTER CARE
The limb is elevated and its circulation carefully
watched.
Continued chemotherapy with antibiotics.
Delay primary suture.
43

8 Steps in summary
1. Treat all open fractures as an emergency
2. Perform a thorough initial evaluation to
diagnose other life threatening injuries.
3. Begin appropriate AB therapy in the
emergency room or operating room and
continue therapy for 2-3 days only.
4. Immediately debride the wound using
copious irrigation and for type II and III
fractures, repeat the debridement in 24-72
hours.

44

5. stabilize the fracture

6. Leave the wound open for 5-7 days.
7. Perform early autogenous cancellous bone
grafting.
8. Rehabilitate the involved extremities.

45

Table 46-4 Mangled Extremity Severity Score

Type
Characteristics Injuries
SKELETAL/SOFT TISSUE GROUP
1. Low energy : Stab wounds, simple closed factures,
small-caliber gunshot wounds

point
1

2 . Medium energy: Open or multiple-level fractures,

dislocations, moderate crush injuries

3 .High energy : Shotgun blast (close range), highvelocity gunshot wounds

4.Massive crush : Logging, railroad, oil rig accidents

46

SHOCK GROUP
1 Normotensive hemodynamics

Blood pressure stable in field and in operating room 0

2 Transiently hypotensive
BP unstable in field but responsive to intravenous
fluids
3 Prolonged hypotension
blood pressure less than 90 mm Hg in field and responsive
to intravenous fluid only in operating room

47

 ISCHEMIA GROUP

1 None pulsatile limb without signs of ischemia

2 Mild Diminished pulses without signs of

ischemia
1
3 Moderate No pulse by Doppler, sluggish capillary refill
paresthesia, diminished motor activity
2
4 Advanced Pulseless, cool, paralyzed and numb
without capillary refill

48

 AGE GROUP
1

<30 years

>30 <50 years

>50 years

49

Definitive treatment
Definitive fixation is considered, when:
the patients clinical status is optimized
the wounds are healthy and the soft-tissue envelope will allow
for chosen surgical approach
a good preoperative plan has been created.