OP E N

presented by :
Ayu Kusumawati
Fatma Maulida Abiya
Lusi Rahmani Putri

adviser :
dr Muhammad Pandu Nugraha, Sp OT

OPEN FRACTURES ARE ALSO KNOWN AS COMPOUND

FRACTURES

Open fractures introduction

Definition
O a fracture with direct communication

to the external environment

Components of open fracture

O Fracture
O Soft-tissue damage
O Neurovascular compromise
O Contamination

History
O A century ago, the high mortality of

patients with open fractures led to

early amputations to prevent death.
O Trueta recommended open wound
treatment and subsequent enclosure
of extremity in a cast
O In 1943, the use of Penicillin reduced
the rate of wound sepsis

Mechanism of injury
O Open fractures occur as a result of

direct high energy trauma either

from Road traffic collisions or falls
from height.

Epidemiology
O Diaphyseal

fractures
were more common
than
metaphyseal
fractures. Highest rate
of diaphyseal fractures
were
seen
in
tibia(21.6%) followed
by
femur(12.1%),
radius and ulna(9.3%),
and humerus(5.7%)

Microbiology
O Poor

tissue
oxygenation
and
devitalization of the surrounding
tissues including the bone provide a
perfect medium for infection and
bacterial multiplication.

Open fractures grading and

classification

Gustilo and Anderson

Gustilo and Anderson

O Grades of soft tissue injury correlates with infection

and fracture healing

Grade

3A

3B

3C

Infection
Rates

0-2%

2-7%

10-25%

1050%

25-50%

Fracture
Healing
(weeks)

21-28

28-30

30-35

30-35

Amputati
on Rate

50%

Hannover fracture scale

O Total score - This considers every detail of

the injury to the involved extremity and is

made up as a checklist. The fracture type
according to the AO classification, the skin
laceration, the underlying soft tissues, the
vascularity, the neurological status, the
level of contamination, a compartment
syndrome, the time interval between injury
and treatment, and the overall severity of
the injury to the patient are added up to
prove the total score.

Hannover fracture scale

Interpretation
O minimum score: 0
O maximum score: 22
O The higher the score the worse the
injury.
O A score 11 indicates significant
trauma, with amputation
recommended.

AO classification

AO classification

Io 1 skin breakage from

inside out

Io 2- skin breakage from outside

in <5cm, contused edges

Io3 skin breakage from

outside in >5cm, increased
contusion, devitaised edges

IO 4 Considerable, full
thickness contusion, abrasion,
extensive open degloving, skin
loss

IO5 extensive
degloving

Neurovascular injury AO

Muscle/tendon injury
AO

Ganga hospital score

O Interpretation:
O The total score was used to address

the question of salvage and the

outcome was measured by dividing
the injuries into four groups (Group I
- < 5; II - 6-10; III - 11-15 and IV - 16
and above of the total score)
O All limbs in Group IV and one in
Group III underwent amputation

Mangled extremity severity

score(MESS)

Mangled extremity severity index

LSI- limb salvage index

Interpretationminimum score: 0
maximum score: 14
The higher the score the more severe the injury.
Limb Salvage Index

Outcome

05

limb salvage successful (51 of 51)

614

amputation (19 of 19)

Predictive salvage
index

Interpretation
O minimum score: 3 (based on the
point assignments; if no vascular,
bone or muscle injury then the score
could reach 1, but then it would not
be a seriously injured limb)
O maximum score: 13
O The higher the score the worse the
chances for a successful limb
PSI
Outcome
salvage.
7

good (12 of
14 limbs
salvaged

poor (7 of 7
amputated)

NISSSA
Parameters
O N = nerve injury
O I = ischemia
O S = soft tissue contamination
O S = skeletal injury
O S = shock
O A = age of the patient

NISSSA

NISSSA

NISSSA
Interpretation
O minimum score: 0
O maximum score: 19
O The higher the score, the more severe
the injury.
O A score 7 was 100% sensitive for
amputation, but with specificity of 46%.
O A score 11 had a 100% specificity and
positive predictive value for amputation.

ETIOLOGY
Indirect
trauma
Direct
trauma
HIGH ENERGY
TRAUMA

FRACTU
RE

Patolog
is
conditi
on

Traffic accident

Traffic accident

Traffic accident

Bicycle

DIAGNOSIS
ANAMNESIS

PHYSICAL
EXAMINATI
ON
General
examination
Local
examination
Look
Feel
Move
Neurogical
examination

DIAGNOSTI
C IMAGING

Anamnesis
How it
happened?
When it
happened?
Historical
story?

General Examination
Early examination
1. Syok, anemia or bleeding
2. Damage of the other organs,
such as the brain , spinal cord ,
or organs in the thorax , pelvis
and abdomen
3. Fracture predisposition , for
example on a pathological
fracture .

Local Examination
-Look Swelling
Hematom
Deformity (angulation,
rotation dan shortening)
SKIN (intact or not? any
related with the
fracture?)
Facial expressions
because of pain
Compare with the
healthy part

Local Examination
-Feel

Warm
Tenderness
Crepitation
Vascular
examination (area
distal of injury)
Capillary Refill Time
Measure of the
shortening

Local Examination
-Move Active
movement
Passive
movement
Strengh of
muscle

Local Examination
-Neurological Examination Sensoric examination
Motoric examination

Diagnostic Imaging

The aim is to determine

the severity of bone and
soft tissue damage

Rule of 2 :
2 views (AP and
Lateral position)
2 joints (proximal and
distal joint of fracture)
2 limbs (left and right)
2 injuries
2 occasions (before
and after treatment)

Diagnostic Imaging
CT
SCAN

MRI

COMPLICATION
EARLY COMPLICATIONS

LATE COMPLICATIONS

Vascular injury

Delayed union

Compartement syndrome

Non-union

Gas gangrene

Malunion

Infection

Growth disturbance

Acute Osteomielitis

COMPLICATION
-early complication1. Vascular Injury

COMPLICATION
-early complication2. Nerve Injury

COMPLICATION
-early complication3. Gas Gangrene

COMPLICATION
-early complication4. Compartement
Syndrome

COMPLICATION
-late complication1. Delayed union

COMPLICATION
-late complication2. Non-union

COMPLICATION
-late complication3. Malunion

PRINCIPLES OF
OPEN FRACTURE MANAGEMENT
Fracture
initial

management
trauma

begins

after

survey

and

resuscitation is complete.
All open fracture, no matter how trivial
they may seem, must be assumed
be contaminated.

to

BASIC PRINCIPLES OF OPEN FRACTURE

MANAGEMENT IN THE EMERGENCY
ROOM
Trauma survey
Antibiotics
Irrigation
Debridement
Stabilization of fracture

TRAUMA SURVEY

ANTIBIOTICS
Gustilo Type I and II
1st generation cephalosporin
Gustilo Type III
1st generation cephalosporin andaminoglycoside
Special cases:
Addpenicillin for anaerobic coverage (clostridium)
Doxycicline for salt water wounds
Floroquinolone for fresh water wound, salt water wound or if

allergies exist for cephalosporin or clindamycin

Duration
Initiate as soon as possible

ANTITETANUS
Guidelines

for

tetanus

prophylaxis depend on 3
factors:
1. Complete or incomplete
vaccination history (3
doses)
2. Date

of

most

vaccination
3. Severity of wound

recent

 Two forms are :

1. Toxoid Tetanus vaccine dose 0.5 mL.
2. Immune globulin (human) dose, regardless of age:
<5 years old receives

75U

5-10 years old receives

125U

>10 years old receives

250U

Immune globulin (serum kuda) dose

Toxoid

and

immunoglobulin

should

1500U
be

given

intramuscularly with two different syringes in two

different locations.

IRRIGATION
Saline shown to be most
effective irrigating agent
On average, 3L of saline are
used for each successive
Gustilo type
Low pressure lavage more
effectivein
bacterial

counts

pressure lavage

reducing
than

high

DEBRIDEMENT

Thorough

debridement

is

critical to prevention of deep

infection.

STABILIZATION OF THE
FRACTURE
1.Temporary
.For example using gips
as temporary splinting.
2.Definitive (surgical)
.Can be with internal
fixation

(For

example

using plate and screw,

screw

or

external
indicated.

wires)
fixation,

or
as

REHABILITATION

Treatment designed to facilitate the process of

recovery from injury, illness or disease as normal
condition as possible.