Management of compound fractures
Patients with open fractures may have multiple injuries;
a rapid general assessment is the first step and any life threatening conditions are addressed.
The open fracture may draw attention away from other more important conditions and it is
essential that the step-by-step approach in advanced trauma life support not to be forgotten.
When the fracture is ready to be dealt with, the wound is first carefully inspected;
1-arterial bleeding should be ligated
2- any gross contamination is removed .
3-the wound is photographed with aPolaroid or digital camera to record the injury
4-area then covered with a saline-soaked dressing to prevent desiccation. This is left
undisturbed until the patient is in the operating theatre .
5-The patient is given antibiotics, usually co-amoxiclav or cefuroxime, but clindamycin if the
patient is allergic to penicillin.
6- Tetanus prophylaxis is administered: toxoid for those previously immunized, human
antiserum if not.
7- The limb is then splinted until surgery is undertaken.
The limb circulation and distal neurological status will need checking repeatedly, particularly
after any fracture reduction maneuvers. Compartment syndrome is not prevented by there
being an open fracture
CLASSIFYING THE INJURY
Treatment is determined by
1- the type of fracture,
2- thenature of the soft-tissue injury (including the wound size) and
3- the degree of contamination.
Gustilo’s classification
of open fractures is widely used
Type 1 – The wound is usually a small, clean puncture through which a bone spike has
protruded. There is little soft-tissue damage with no crushing and the fracture is not
comminuted (i.e. a low-energy fracture).
Type II – The wound is more than 1 cm long, but there is no skin flap. There is no much
soft-tissue damage and no more than moderate crushing or comminution of the fracture
(also a low- to moderate-energy fracture).
Type III – There is a large laceration, extensive damage to skin and underlying soft tissue and,
in the most severe examples, vascular compromise. The injury is caused by high-energy
transfer to the bone and soft tissues. Contamination can be significant.
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Surgery
20/11/2016
There are three grades of severity. In type III A the fractured bone can be adequately covered
by soft tissue despite the laceration. In type III B there is extensive periosteal stripping
and fracture cover is not possible without use of local or distant flaps. The fracture is
classified as type III C if there is an arterial injury that needs to be repaired, regardless of
the amount of other soft-tissue damage.
The incidence of wound infection correlates directly with the extent of soft-tissue damage,
rising from less than 2 per cent in type I to more than 10 per cent in type III fractures.
PRINCIPLES OF TREATMENT
All open fractures, no matter how trivial they may seem, must be assumed to be contaminated;
it is important to try to prevent them from becoming infected. The four essentials are:
1. Antibiotic prophylaxis.
2. Urgent wound and fracture debridement.
3. Stabilization of the fracture.
4. Early definitive wound cover.
Debridement The operation aims to render the wound free of foreign material and of dead
tissue, leaving a clean surgical field and tissues with a good blood supply throughout. Under
general anesthesia the patient’s clothing is removed, while an assistant maintains traction on the
injured limb and holds it still. The dressing previously applied to the wound is replaced by a
sterile pad and the surrounding skin is cleaned. The pad is then taken off and the wound is
irrigated thoroughly with copious amounts of physiological saline.
The wound is covered again and the patient’s limb then prepped and draped for surgery.
It is advisable not to use tourniquet in this condition unless if there is sever bleeding or arterial
injury to deal with .
Wound excision The wound margins are excised, but only enough to leave healthy skin edges.
Removal of devitalized tissue: Devitalized tissue provides a nutrient medium for bacteria.
Dead muscle can be recognized by
a- its purplish colour, b-its mushy consistency,
c-its failure to contract when stimulated d-its failure to bleed when cut.
All doubtfully viable tissue, whether soft or bony, should be removed. The fracture ends can be
nibbled away until seen to bleed
Wound cleansing : All foreign material and tissue debris is removed by excision or through a
wash with copious quantities of saline. A common mistake is to inject syringefuls of fluid
through a small aperture – this only serves to push contaminants further in; 6–12 L of
saline may be needed to irrigate and clean an open fracture of a long bone. Adding
antibiotics or antiseptics to the solution has no added benefit .
Nerves and tendons : as a general rule it is best to leave cut nerves and tendons alone at the
time of the wound excision,to be sutured by delay primary suture ; though if the wound is
absolutely clean and no dissection is required – and provided the necessary expertise is
available – they can be Sutured at the time of wound excision .
Stabilization of the fracture : Stabilizing the fracture is important in reducing the likelihood of
infection and assisting recovery of the soft tissues. The stabilization of the fracture is
usually by external fixation
Wound closure : A small, uncontaminated wound in a Grade I or II fracture may (after
debridement) be sutured, provided this can be done without tension. In the more severe
grades of injury, immediate fracture stabilization and wound cover using split-skin grafts,
local or distant flaps is ideal, provided both orthopaedic and plastic surgeons are satisfied
that a clean, viable wound has been achieved after debridement.
Aftercare : In the ward, the limb is elevated and its circulation carefully watched. Antibiotic
cover is continued but only for a maximum of 72 hours in the more severe grades of injury.
GUNSHOT INJURIES
With high-velocity missiles (bullets, usually from rifles, travelling at speeds above 600 m/s)
there is marked cavitation and tissue destruction over a wide area. The splintering of bone
resulting from the transfer of large quantities of energy creates secondary missiles, causing
greater damage.
With low-velocity missiles (bullets from civilian hand-guns travelling at speeds of 300–600
m/s) cavitation is much less, and with smaller weapons tissue damage may be virtually
confined to the bullet track. However, with all gunshot injuries debris is sucked into the
wound, which is therefore contaminated from the outset.
Emergency treatment
:
As always, the arrest of bleeding and general resuscitation take priority. The wounds
should each be covered with a sterile dressing and the area examined for artery
or nerve damage. Antibiotics should be given immediately
.
Definitive treatment
:
Traditionally, all missile injuries were treated as severe open injuries, by exploration of the
missile track and formal debridement. However, it has been shown that low-velocity
wounds with relatively clean entry and exit wounds can be treated as Gustilo type I
injuries, by superficial debridement, splintage of the limb and antibiotic cover; the fracture
is then treated as for similar open fractures. If the injury is to soft tissues only with minimal
bone splinters, the wound may be safely treated without surgery but with local wound care
and antibiotics.
High-velocity injuries demand thorough cleansing of the wound and debridement, with excision
of deep damaged tissues and, if necessary, splitting of fascial compartments to prevent
ischaemia; the fracture is stabilized and the wound is treated as for a Gustilo type III
fracture. If there are comminuted fractures, these are best managed by external fixation.
The method of wound closure will depend on the state of tissues after several days; in some
cases delayed primary suture is possible but, as with other open injuries, close
collaboration between plastic and orthopaedic surgeons is needed .
Close-range shotgun injuries, although the missiles may be technically low velocity, are treated
as highvelocity wounds because the mass of shot transfers large quantities of energy to the
tissues.