Management of Open

Fracture
Definition open fracture
• A broken bone that is in communication through the skin with the
environment
Management aims
• To prevent infection
• Ensure fracture healing
• Restore function
Basic Principles of Open Fracture
Management in the Emergency Room
•Fracture management begins after initial trauma survey and resuscitation is complete
•Assessment
• soft-tissue damage
• neurovascular exam
•Antibiotics
• initiate early IV antibiotics and update tetanus prophylaxis as indicated
•Control bleeding
• direct pressure will control active bleeding
• do not blindly clamp or place tourniquets on damaged extremities
•Dressing
• remove gross debris from wound
• place sterile saline-soaked dressing on the wound
•Stabilize
• splint fracture for temporary stabilization
• decreases pain, further injury from bone ends, and disruption of clots
Initial Trauma survey
• Airway
• Breathing
• Circulation
• Disability
• Addressing any life threatening injury
Assessment and classification of open
fracture
• Before antibiotics to be given, we should classify the injury first and
the extensiveness of soft tissue damage
• Basically, we also check for peripheral pulses , sensation, circulation
of affected limbs or site.
Classification
• Gustillo anderson classification of open fracture
• Based on :
• 1. Size of wound
• 2. Amount of soft tissue injury
• 3. Presence or absence of neurovascular injury
• 4. Degree of contimination
Classification 1
• Clean wound less than 1 cm in diameter
• Simple fracture pattern with minimal comminution
• Minimal soft tissue injury
Classification 2
• Laceration more than 1 cm in diameter
• Moderate soft tissue damage
• No flaps, degloving or contusion
• Fracture pattern may be more complex
• Moderate contimination
Classification 3
• Open segmental fracture or a single fracture with extensive soft tissue
injury.
• Also included, injuries older than 8 hours
• >10 cm long
• Highly contiminated
• Usually comminuted
• IIIA, IIIB, IIIC, depend on soft tissue injury
Classification IIIA
• Severe soft tissue injury
• Adequate soft tissue coverage of the fracture is likely (despite high energy
trauma or extensive laceration or skin flaps)
Classification IIIB
• Inadequate soft tissue coverage with periosteal stripping
• Soft tissue reconstructive surgery is necessary
Classification IIIC
• Associated vascular injury that requires repair
• Reconstructive surgery for skin coverage
Anbiotics
• Tetanus toxoid should be given as prophylaxis
• In ED
• Zinnacef or cefuroxime (2nd Gen) were given to Gustilo 1, which is wound would
likely clean
• For Gustillo 2, where the wound be contaminated respective size of wound 1-
10cm we give Zinnacef and Flagyl (metronidazole)
• For Gustillo 3 we give 3 antiobiotics according degree of contamination and size
of wound more than 10cm , zinnacef, flagyl and gentamicin (gram +/- and active
against pseudomonas)
• Stat antibiotics should be given after assessment of injury
• At the time of debridement, gentamicin is added to second dose of first
antibiotics.
• Start antibiotics as soon as possible : less than 3 hours , 4.7 % infection rate
• More than 3 hours, 7.4% infection rate
Risk of Infection , Sorger 1999
Grade open fracture , Gustillo Anderson Risk of Infection (%)

1 0-12
2 2-12
3 9-55
Dressing and control bleeding
• Direct compression with reduce the bleeding
• Remove all the debris around the open fracture and irrigate the wound
• Irrigate the wound with normal saline
• If needed use compression bandaging with saline soaked dressing to
control the bleeding before entering operation theatre.

Stabilizing the fracture

• Use splint to stabilize the fracture
• Use POP back slab for further stabilization of fracture
• Aim of stabilize the fracture is to reduce pain
Basic Principles of Open Fracture
Management in the Operating Room
• Aggressive debridement and irrigation
• thorough debridement is critical to prevention of deep infection
• low and high pressure lavage are equally effective in reducing bacterial counts
• saline shown to be most effective irrigating agent
• on average, 3L of saline are used for each successive Gustilo type
• Type I: 3L
• Type II: 6L
• Type III: 9L
• bony fragments without soft tissue attachment can be removed
• Fracture stabilization
• can be with internal or external fixation, as indicated
• Staged debridement and irrigation
• perform every 24 to 48 hours as needed
• Early soft tissue coverage or wound closure is ideal
• timing of flap coverage for open tibial fractures remains controversial
• increased risk of infection beyond 7 days
• Can place antibiotic bead-pouch in open dirty wounds/ not done in Hospital Kuala Pilah
• beads made by mixing methylmethacrylate with heat-stable antibiotic powder
Aggressive debridement and Irrigation
• Aggressive Wound Debridement is the standard of care
• The most Important step is debridement
• Aim is to remove dead tissue and foreign body material to ensure
good blood supply
• Delay of debridement may increase risk of infection
• SUPERFICIAL DEBRIDEMENT
• Wound margins are excised to explore and identify entire zone of injury
• Extensile longitudinal incision can be made to visualize deep tissue and can be
extended till healthy tissue
• Non viable skin and subcutaneous tissue are to be excised
Deep debridement
• It is about muscle debridement
• The concept is when in doubt take it out
• In type I,II, and IIIA open fracture- all non vital and in doubt muscle can be
debrided
• IIIB and IIIC- removal of entire compartment may be needed
• Viability?
• Tendons?
• In open wounds tendons are subject to desiccation and hence it should be
covered with soft tissues if not with moist dressings
• Bone that should be removed? And preserve?
• One exception of strict removal of bone is when there is significant articular
attachment to the bone fragments
Irrigation
• Usual irrigation fluid used is normal saline
• High volume low pressure repeated lavage is performed. Better soft
tissue cleaning and promotes bone healing.
• Pulse lavage is more effective than bulb syringe with NS resulting in
100 fold decrease in St.Aureus in the wound
• There is no proper data for Irrigation, however based on Anglen
• 3L for type I
• 6L for type II
• 9L for type III

Boyd JI, Wongworawat MD. “High-Pressure Pulsatile Lavage Causes Soft Tissue Damage.” CORR 2004. 427: 13-17
Limb Salvage and Amputation
• Limb is nonviable as evidenced by
• irreparable vascular injury
• warm ischemia time >8 hrs
• severe crush injury with minimal remaining viable tissue
• Severely damaged limb may constitute a threat to patients life
• The severity of injury would demand multiple operative procedures and
prolonged reconstruction time
• Mangled extremity severity score of >7 accurately predicts amputation
• Score doubles for ischemia >6 hrs
• MESS( Mangled Extremity Severity Score) for prediction of amputation
• The outcome of injured limb is either salvage or amputation
• A score of > or equal to 7 is predicative of amputation
Skeletal Stabilization
• Done once vascular repair is completed and limb salvaged or once
irrigation and debridement is done
• Restoring the length, rotational, and angular alignment has many
benefits for healing of soft tissues
• Fracture reduction frees nerve conduits and helps in soft tissue
healing
• Minimizing motion of fragments also decreases further damage, pain
and permits mobilization of joints
• Extra osseous
• External fixation
• Internal fixation
External fixation
• Excellent stability obtained
• Reasonable anatomic reduction possible.
• Minimal additional soft tissue trauma
• Risk of infection-minimized.
• Ability to convert to internal fixation
Internal Fixation
• Plates and screws- to minimize complications IV anti staphylococcus
antibiotics should be started as soon as possible, sterile dressing,
meticulous debridement, copious irrigation and minimal stripping and
accurate anatomical reduction is to be done
• IM nail- currently the treatment of choice for grade I,II,IIIa, and IIIb
fractures as external-fixation devices leads to more malalignment,
nonunion, and delayed return to function
Wound Closure
• Wounds without skin loss: tension free primary closure after thorough
debridement. •
• Contraindications for primary closure •
• Delayed presentation >12 hrs.
• Delayed administration of antibiotics>12 hrs.
• Deep seated contamination
• Immunocompromised
• Nerve injury
• Inability to achieve tension free suture
• High risk of anaerobic contamination like farm yard injuries.
• Wounds with skin loss: healing by secondary intention. Delayed primary
closure, split skin grafts, free flaps
References
• Appley system of orthopedics and fractures
• Boyd JI, Wongworawat MD. “High-Pressure Pulsatile Lavage Causes
Soft Tissue Damage.” CORR 2004. 427: 13-17
• Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS 2001
• OrthoBullets
• Bach AW, Hansen ST Jr.: Plates versus external fixation in severe open
tibial shaft fractures. A randomized trial. Clin Orthop Relat Res. 1989
Apr;(241):89-94.