Compound fracture-3 pdf - ابراهيم حسن

Compound fracture

Compound # are classified according to the severity of

tissue destruction into 3 types (Gustilo classification):

І- the wound is small, clean &usually

caused by bone spike (compound

from within).

П - the wound is >1cm with moderate

tissue damage (bone & soft tissue).

Ш- there is extensive skin, soft tissue, bone & neurovascular damage

with considerable contamination:

ШA- If the fracture can be covered by

soft tissue.

ШA

Ш B- If the # require

reconstructive surgery

for coverage.

G3B

Ш C- If there is arterial injury requiring repair

even if there is little tissue damage.

Management:

open fracture is an emergency.

At the scene: ensure clean airway, stop bleeding,

cover the wound, splint the # &transfer to hospital.

In the hospital: in the emergency room re-examine the

patient quickly then start resuscitation with IV line and

take blood sample for cross match.

The priority of

Ŗ should be for: Airway, Breathing &

Circulation then do further assessment checking the

level of consciousness, neck, back, abdomen, pelvis

and the limbs for wounds & #. After that, when the

patient is resuscitated and become more stable, you

can do more careful examination followed by the

required investigations including x-rays.

Local Ŗ of open fracture: start immediately

with broad spectrum AB &tetanus prophylaxis.

In the theater: clean the limb with soap &water, shave the skin

around the wound & sterilize it with antiseptic like chlorhexidine

or povidone iodine; then expose the wound and clean it with
physiological saline mixed with antibacterial agent several times.

Then start debridement:

Skin: only dead edges are excised till get healthy oozing skin.

Subcutaneous tissue: excise all dead subcutaneous tissues.

Muscles: all dead muscles should be excised bec. they are good

food for bacteria. A dead muscle is bluish in color (not red),

does not contract if pinched and if cut it will not bleed.

Bone: bone ends are cleaned, bone fragments are not removed

unless they are small and totally detached. Then do stabilize

the # with external fixator.

Blood vessels: large vessels are repaired, while small bleeders are ligated or clamped.

Nerves: approximate the nerve ends with sutures for later repair.

Wound closure: if the wound is small, clean and debrided within

few hours, you can close it, otherwise the wound should be left open

for daily dressing until it become clean with healthy granulation tissue
growth, then close it (secondary suture). Skin loss can be replaced by

skin graft (partial or full thickness), pedicle graft or free graft

(cutaneous, myocutaneous or osteomyocutaneous).

Complications of fracture

General complications

1- shock: is a generalized state of reduced tissue perfusion which if

persist, it will cause damage to vital organs. In # , the shock can be:

Neurogenic shock: due to pain, the blood will pool in the skeletal
muscles.

Ŗ→ splint the # & give anaelgesia like morphine or pethidine.

Hypovolemic shock:  is due to blood loss from bone ends, nearby soft
tissue &injured blood vessels e.g. in a simple femoral shaft #, there may
be 1- 1.5 liter of blood lost into the soft tissue of the thigh outside the
      circulation.

Ŗ → arrest the bleeding & restore the lost blood.

crush syndrome: may occur if a large bulk of muscles is crushed

or if a tourniquet has been left unreleased for > 6 hrs. After release, the

acid myohaematin (cytochrome C), resulting from muscle breakdown,
will be released into circulation &may block renal tubules or cause renal
artery spasm, both may lead to acute renal failure. So to avoid that, the
limb should be amputated above the level of the forgotten tourniquet &
before releasing it.

Ŗ of renal failure: ↓fluid &protein, ↑carbohydrate

intake, maintain electrolyte balance. Renal dialysis may be needed.

3- Venous thrombosis & Pulmonary embolism: incidence of

DVT after major trauma or surgery is 30% & that of PE is 5%

Causes of DVT: 1- Activation of factor 10 by thromboplastine

released from tissue damage. 2- Blood stasis. 3- Endothelial

damage.4- Increase number &stickiness of platelets.

Risk factors: 1- old patients. 2- cardiovascular disease.

3- Bed ridden patients. 4- hip surgery.

on &exercise of the patient.

arly mobilizati

: 1

Prevention

2- Elevation of affected limb. 3- Elastic bandage to prevent

blood pooling. 4- Anticoagulants like aspirin or heparin.

in body

ly there will be slight ↑

clinical

DVT

Established

temperature and pulse rate with swollen tender calf.

: venography or ultrasound scaning.

Diagnosis

of extensive DVT especially in thigh and pelvis:

Treatment

1-bed rest. 2-heparin IV 10 000 IU 6 hourly for 5-7 days or

according to partial thromboplastin time ( 1.5- 2 of the normal),

then shift to warfarin with the dose according to prothrombine

time for 3 months.

Pulmonary embolism: if massive, will cause sudden death.

If small, it may cause chest pain, dyspnea and haemoptysis.

4- Tetanus: tetanus organism require dead tissue to grow, so good
debridement is important in prevention. The exotoxin is carried to

the CNS via blood and lymphatics. Once it reach the anterior horn

cells, it will be fixed there and can not be neutralized by antitoxin.

CF: early tonic and later clonic muscle contraction, especially of the

jaw, face, those near the wound &later, those of the neck & back.

If the diaphragm and intercostal muscles are affected, the patient

may die because of asphyxia.

Prophylaxis: good wound toilet, active immunization using

toxoid &booster dose after injury (those who were not immunized,

are human antitoxin serum).

Ŗ of established tetanus: IV antitoxin, sedation, muscle relaxant

(diazepam), AB (penicillin) &if required, assisted ventilation.

5- Gas gangrene: caused by Clostridia perfringens(welchii), anaerobic
gram +ve rods growing only in tissue with low oxygen tension, so the
usual site is dirty wound with dead muscle that has been closed with
inadequate debridement. Clinically, within 24 hrs, the wound become
swollen, painful, brown discharge with specific smell, gas in the tissue,
rapid pulse, little fever and later, the patient may become toxic and
comatose.

Ŗ: excision of all dead tissue, IV AB, hyperbaric oxygen may

limit infection. In severe cases, amputation may required.

6- Fat embolism: is thought to be due to liberation into the

circulation

of fat globules larger than 10μm, the aggregation

of them may obstruct capillaries especially in the lungs.

CF: usually, a young adult, within 72 hrs from injury, gets

slight fever, rapid pulse, dyspnea, confusion, skin petechiae

and in severe cases, respiratory distress and coma.

Diagnosis: is suspected if blood Po

is < 60 mmHg.

Ŗ→ assisted ventilation, fluid balance, heparin to prevent

thromboembolism & steroid to ↓ pulmonary edaema.

7- Fever: absorption of #

haematoma may ↑body temp by 0.5˚C.