Open Fractures

Dr. KB LEE
Department of O&T
Queen Elizabeth Hospital
AADO
Introduction
„ Management of open fracture
„ Clinical cases
„ Summary
Management of Open Fracture
Open Fracture
„ Fracture communicates through a
traumatic wound to surrounding
environment
„ Resulting in contamination & soft tissue
envelope disruption
Open Fracture
„ A big wound not communicating with
fracture ≠ open fracture
„ Even a small wound communicating with
fracture ≡ open fracture (compound fracture)
Open Fracture
„ High energy
„ Outcome depends extent of soft tissue injury
„ Treatment of soft tissue trauma with
contamination Î Primarily important
„ Treatment of skeletal injury Î Secondary
Gustilo Classification (1976, 1984)
I < 1cm Clean wound, minimal comminution
II > 1cm Mod. contamination / Moderate comminution
III > 10cm High contamination / Soft tissue damage
(Including all segmental #, farmyard injuries, # in
contaminated environment, gunshot)

a Soft tissue crushed / flapped / lacerated,

comminuted #, adequate coverage
b Extensive soft tissue injury, periosteal stripping,
exposure of bone, inadequate coverage
c V. severe loss of coverage, vascular injury
Gustilo Classification:
Typing Pitfalls
„ Problem of inter-observer variance
„ Typing can only be attempted after initial
debridement and irrigation
„ Typing often Up-graded subsequently when
flaps necrosed, or skin graft failed - requiring
local or free flaps - Grade IIIB.

„ Does Typing reliably guide treatment??

„ Can Typing guide prognosis??
Classification:
Gustilo & Anderson
Type Size Energy of trauma Infection
(cm) (Soft tissue crush & rate (%)
fracture comminution)
I <1 Low energy 0-2

II 1-10 Moderate energy 2-5

III >10 High energy 5-50

Classification:
Gustilo & Anderson
Subclass Description Infection Amputation
rate (%) rate (%)
IIIA Adequate soft 5-10 0
tissue coverage
IIIB Periosteal stripping, 10-50 16
wound coverage
required
IIIC Repairable vascular 25-50 42
injury
Type III Open Fracture
„ It is not “a fracture with a wound”
It is “a wound resulting from high energy
trauma, complicated with a Fracture”
„ First priority is to deal with the Wound,
and then minimize complications arising
from the fracture.
Objectives of Open Fracture Mx
„ Prevent infection
„ Promote fracture healing
„ Restore function
 Principles of Management
„ ATLS: Save life first, then save limb
„ Prevent infection: Wound debridement & lavage,
IV / local antibiotics, Tetanus prophylaxis
„ Fracture stabilization: Temporarily & definite
„ Early soft tissue coverage: Initial flap preservation,
delayed 1° suture, secondary intention, skin graft, flap
„ Mx of bone defect: Shortening, bone graft / transport
„ Rehabilitation: to minimize disability & optimize
functional recovery
ATLS:
Save the Life First
„ Resuscitation: ABC
ATLS:
Then Save the Limb
„ Recognize & treat the limb threatening
conditions Vascular insufficiency

Traumatic amputation
Compartment syndrome
Limb Specific Management:
Initial Management
Take them seriously!
„ Make detailed assessment & documentation,
take clinical photo
„ Initial cleansing if possible
„ Sterile cover - do not open until in OT
„ Immediate systemic antibiotics
„ OT as soon as fasted enough for GA or regional
anesthesia - It is an Emergency! (But 6-hr rule
controversial)
„ Analyze needs, prioritize aims, plan, and plan
for the worst
 Limb Specific Management:
First Operation “EOT”
„ Assess and document wound location, size,
contamination - photo
„ Debridement and copious lavage (6 - 10 L.), discard
loose fragments
„ Preserve flaps - esp. where local flaps are not readily
available: distal 1/3 of tibia and beyond.
„ Stabilize fracture – Ext. Fix. or Nail
„ Do NOT close wound
„ Great demand on appropriate decision making
and surgical proficiency - experienced surgical
team makes a difference!
Prevent Infection:
Wound Debridement & Lavage
„ Remove all devitalized tissue, debis, loose
fragments & foreign body
„ NS / antiseptic irrigation:

copious pulsatile lavage (6-10 L)

„ +/- 2nd look debridement every 24-72 hrs until
completely clean
„ Wound left open & daily dressing

1st debridement 2nd debridement

Lavage
„ Wound irrigation is the key to prevent
infection
„ Decrease bacterial load and remove foreign
body
„ “Copious”, Pulsatile
„ Controversy: NS, antiseptic, antibiotic, soap
Prevent Infection:
IV Antibiotics
„ Broad spectrum cephalosporin (Gm +ve & -ve)
Î Zinacef
„ +/- Aminoglycoside (Gm - ve)
Î Gentamicin
„ +/- Metronidazole (anaerobes)
Î Flagyl

≠
No optimal regimen!
Depends on
wound condition !!
Prevent Infection:
Local Antibiotics
Antibiotic loaded beads:
1. High local concentration

2. Temporary spacer
Prevent Infection:
Tetanus Prophylaxis
„ As a routine
„ Previously immunized
Î toxoid booster
„ Not immunized
Î toxoid + immune globulin
Fracture Stabilization:
Optimize Fracture Healing
„ Reasonable reduction
„ Stable fixation
„ Dynamize and weight bear at appropriate
time
„ Bone graft
„ Bring in blood supply
Fracture Stabilization:
Temporarily
Aim:
1. maintain bony alignment & length

2. reduction of dead space

3. improve circulation & lymphatic drainage

4. facilitate wound care

5. pain control
Fracture Stabilization:
Temporarily
Standard: External Fixation
„ Quick & easy

„ Minimal invasive
Temporarily stabilization
„ Good stability

„ Prevent infection

Should leave room for

wound care & future reconstruction
Fracture Stabilization:
Temporary Ext. Fix. vs Nailing
„ Ext Fix generally more forgiving, esp. for tibia
„ More room for adjustments and revisions
„ Typing of open fracture not easy, a lot of inter-
observer differences - Big trouble if under-typed
and nailed
„ Much quicker if proficient, but long learning
curve
„ More prone to delayed and mal-union if Ext Fix
used as definitive treatment
„ But open femur # is safe with primary nailing
Fracture Stabilization:
Definite
„ Usually done after wound conditions
( infection & coverage ) stabilized
„ Exchange to internal fixation
(plate / IM nail) OR Î
Keep external fixation
„ Timing & method depends on fracture
pattern & wound conditions
Conversion of
Ext. Fix. to Reamed Nailing
„ Tibia - generally not later than one week
„ For I, II and IIIA #’s
„ One stage or “cooling” period
„ Better access for flap surgery
„ Less prone to delayed or mal-union
„ Generally more acceptable to patients
„ Shorter hospital stay
„ Only if fracture location and type amenable to
nailing
IM Nail Conversion
in Long Bone Fractures
„ When?
„ Less than 3wks without inflammation :
„ immediate internal fixation
„ More than 3wks :
„ limb temporarily stabilized in cast for 8-
10 days Î prevent infection
Reamed or Unreamed Nailing?
„ Controversial in terms of infection, nonunion &
re-operation rate
„ Theoretical advantage with unreamed -
preserving blood supply
„ More nail or screw breakage
„ Problems: Ex Fix > Unreamed > Reamed
„ Few bones large enough!
„ Reamed nailing generally safe for IIIA or below.
Early Soft Tissue Coverage:
Initial Flap Preservation
„ Esp. where local flaps are not readily
available: distal 1/3 of tibia and beyond
„ Don’t jeopardise blood supply by insertion
of pins, drains etc. thro’ the flap
„ No tension
„ Minimise soft tissue motion - to enhance
regeneration of microvasculature - skeletal
immobilisation
 Early Soft Tissue Coverage
„ Usually within 3 days to 1 week to prevent
nosocomial infection (main source of infection in
open #) and improve outcome
„ Balanced by soft tissue tension & infection
„ Methods:
- Delayed 1° closure
- Skin graft (PTSG, full thickness)
- Flap (local, free) bring in blood supply
Soleal flap
Vacuum Assisted Closure (VAC)
„ Accelerating wound healing by reducing
chronic edema, increasing local blood flow
and enhancing granulation tissue formation
„ Applied after each irrigation & debridement
until wound is clean (about 10-20 days)
„ Promising modality, but need additional
studies
 Management of Bone Defect
„ Depends on size & site of defect
Bone defect
Bone graft Bone transport

Shortening
Î
OR OR
Management of Bone Defect
Bone Graft
„ Autograft / allograft / artificial bone

„ Cortical / cancellous

„ Vascularised / nonvascularised
Bone Grafting
„ I & II #’s generally do not require bone graft
- dynamise at 6 - 12 weeks.

„ III #’s - YES, but not before 6 weeks.

„ No segmental defect - graft if no callus by 12w.
„ Segmental defect < 2cm, graft at 6 weeks
„ Segmental defect > 2cm, bone transport
Recombinant Human Bone
Morphogenetic Protein-2 (rhBMP-2)
„ Reduce secondary procedures, hardware
failure & wound infection
„ Faster fracture healing & wound healing
„ Need further studies
Management of Bone Defect
Bone transport Ilizarov
Rehabilitation:
Minimize Disability
„ Avoid immobilizing joints
„ Avoid transfixion of muscle or tendons
„ Early mobilization
„ Maintenance exercises
„ Psychological support
„ Prevent sores
Management Protocol
Complications
„ Infection
„ Delayed union
„ Non-union
Amputation:
Guideline
„ Nonviable limb
„ Nonfunctional limb
„ Life-theatening limb
„ Too extensive & prolonged reconstruction
„ MESS >7
Amputation:
MESS
MESS for limb salvage
„ <4 Î good prognosis

„ >7 Î poor prognosis

Open Fractures
Clinical Cases
Salvageable Limb
Case 1
Female / 25 yr / RTA (motorbike)
Limb threatening condition !
 Principles of Management
„ ATLS: Save life first, then save limb
„ Prevent infection: Wound debridement & lavage,
IV / local antibiotics, Tetanus prophylaxis
„ Fracture stabilization: Temporarily & definite
„ Early soft tissue coverage: Initial flap preservation,
delayed 1° suture, secondary intention, skin graft, flap
„ Mx of bone defect: Shortening, bone graft / transport
„ Rehabilitation: to minimize disability & optimize
functional recovery
Revascularization
Debridement
External fixation
 Principles of Management
„ ATLS: Save life first, then save limb
„ Prevent infection: Wound debridement & lavage,
IV / local antibiotics, Tetanus prophylaxis
„ Fracture stabilization: Temporarily & definite
„ Early soft tissue coverage: Initial flap preservation,
delayed 1° suture, secondary intention, skin graft, flap
„ Mx of bone defect: Shortening, bone graft / transport
„ Rehabilitation: to minimize disability & optimize
functional recovery
Primary Knee Fusion
With Hoffmann II
 Principles of Management
„ ATLS: Save life first, then save limb
„ Prevent infection: Wound debridement & lavage,
IV / local antibiotics, Tetanus prophylaxis
„ Fracture stabilization: Temporarily & definite
„ Early soft tissue coverage: Initial flap preservation,
delayed 1° suture, secondary intention, skin graft, flap
„ Mx of bone defect: Shortening, bone graft / transport
„ Rehabilitation: to minimize disability & optimize
functional recovery
Non-salvagable Limb
Case 2
M/54
„ Knocked down by a car
„ MESS=7
 Principles of Management
„ ATLS: Save life first, then save limb
„ Prevent infection: Wound debridement & lavage,
IV / local antibiotics, Tetanus prophylaxis
„ Fracture stabilization: Temporarily & definite
„ Early soft tissue coverage: Initial flap preservation,
delayed 1° suture, secondary intention, skin graft, flap
„ Mx of bone defect: Shortening, bone graft / transport
„ Rehabilitation: to minimize disability & optimize
functional recovery
Day 1, 2nd Debridement,
Two Pins Added
What next ?

„ Keep fixator, skin

graft, wait for
bone healing ?

„ BKA ?
MESS
„ Very high energy : 4
„ Age 54 : 2
„ Transient shock : 1
„ Limb ischaemia : 0

„ Total: 7 / 14
„ Amputation recommended for score of >= 7.
What next ?
„ Keep fixator, skin
graft, wait for bone
healing
„ BKA

„ Change to Ring
Fixation to buy
more time
 Principles of Management
„ ATLS: Save life first, then save limb
„ Prevent infection: Wound debridement & lavage,
IV / local antibiotics, Tetanus prophylaxis
„ Fracture stabilization: Temporarily & definite
„ Early soft tissue coverage: Initial flap preservation,
delayed 1° suture, secondary intention, skin graft, flap
„ Mx of bone defect: Shortening, bone graft / transport
„ Rehabilitation: to minimize disability & optimize
functional recovery
 Day 3

Hybrid Fixator
with tensioned wire
Soft tissue defect anticipated!
 Local antibiotics:
Gentamicin beads

Bone defect also anticipated!

Day 10: Complicated with Infection
despite Repeated Debridement

„ Agreed to BKA
Conversion to Nailing
Case 3
 M/51

Antero-lateral view, Right leg

RTA
Bilateral open fracture tibia .
Left side Grade II
Right side IIIB.

Antero-medial close-up view

Right leg
 Principles of Management
„ ATLS: Save life first, then save limb
„ Prevent infection: Wound debridement & lavage,
IV / local antibiotics, Tetanus prophylaxis
„ Fracture stabilization: Temporarily & definite
„ Early soft tissue coverage: Initial flap preservation,
delayed 1° suture, secondary intention, skin graft, flap
„ Mx of bone defect: Shortening, bone graft / transport
„ Rehabilitation: to minimize disability & optimize
functional recovery
Initial Treatment
„ Day 0: debridement, lavage, ex fix both
sides, bridging across the ankle.
„ Day 4: lavaged again
„ Day 6:
Left side converted to IM nail.
Right side: ex fix revised. Ex fix fixing distal
tibial segment instead of bridging across
ankle joint. Further lavage.
 Day 6: before revision of fixation

Antero-lateral view

Anterior view
Antero-medial view
 Day 6: after revision
of fixation

Small area of exposed bone

Anterior view
 Antero-medial view

Exposed bone

This wound communicates with posterior surface of tibia.

Close up view of exposed bone
Subsequent Development
„ Day 10: SSG of wounds.
„ SSG taken and all wounds became closed.
„ 4 week: Autogenous cancellous bone graft
onto antero-lateral aspect of fracture site.

„ Patient discharged to KH. Refused

Exogen treatment.
Opposite (Left) Tibia
Initial Management
„ Debridement, lavage, Ex fix on admission.
„ Repeat debridement and lavage on D2 &
D4
„ Conversion to AO IM Nail on Day 6
Wounds closed
 Left Leg

Day 9
Left Leg

11 weeks
 Right Leg

11 weeks
 4 months: Fracture in delayed union with atrophic fracture ends.

Right Tibia

4 months
Right Leg

4 months
Right Leg

4 months
4 Months
Right Leg
„ Fixator removed
„ Fracture grossly unstable: even the fibula
is not united yet
„ Pin tracts debrided and over-drilled
„ Application of short-leg cast with windows
for pin hole dressing
Right Leg
Pin tracts “rested”
for 4 weeks.

5 months

Resection of fibula,
IC nail fixation of
tibia with
compression.
 5 months

Right Leg

Started on Exogen
2 weeks

Right Leg 8 weeks 14 weeks

Right Leg

2 weeks 8 weeks 14 weeks

Right Leg

22 weeks
22 weeks
One and a half year
 Day 3 10 weeks 30 weeks
Left Leg
 Day 3 10 weeks 30 weeks
Left Leg
Conversion to Nailing
Case 4
M/23
„ Ex-member of Hong Kong Badminton
team
„ Works as Badminton coach
„ Student at City University
„ Sustained severe injuries when his
motorbike was hit by a car.
Open wounds at the left leg.
Initial debridement
and Hoffmann II
External Fixation
Before and after initial external fixation
Day 3, fixation revised
Injured limb supported
and raised on the fixator
frame to facilitate
nursing care, surgery,
and drainage.
Skin graft
4 weeks
Fixation removed (already the 9th operation).
Pin holes “rested” for 4 weeks.
8 weeks after injury

IC Tibial nail
inserted.
6 months
after nailing
1 year after injury
Two years after injury
„ IM Nail removed
„ 12 operations in total
„ Full range at the knee
„ Knee instability due to PCL rupture
(pending reconstruction)
„ Minimal pain at the injured limb
„ Resumed badminton coaching part-
time
„ Resumed university studies
2 years after injury
Infected Open Fracture
Case 5
M/50
„ Type IIIA open fracture of distal tibia
„ Also with fractures in the tarsals and
metatarsals
„ Crushed by metal board
Initial treatment
on Day 0
„ Debridement, Lavage
„ External fixation
„ iv Antibiotics
Day 2
„ Wound looked clean and healthy, not
much stripping of bone.
„ Reamed IM nail using Osteo IC tibial
nail, static lock
„ Wound debrided, lavaged, SSG
„ Clinical photo just before SSG ...
Day 11

„ ORIF of foot fractures

„ calcaneal via lateral incision;
„ navicular via medial incision
„ Foot and ankle quite swollen prior to
this, skin quite precarious on lateral side.
„ SSG on open wound had taken well.
Infection!

„ Redness and discharge started at

lateral foot wound, then the medial
wound,
„ Stitches taken off for drainage
„ then the wound over the patella tendon
became red as well.
„ MRSA
Day 23, Day 39

„ Wounds debrided and debrided

Progress

„ Patella tendon wound gradually got better

„ Foot wounds still bad
„ Foot wounds gradually healed up after
exposure and removal of some implants
„ By 8 weeks, just prior to discharging home,
collection found at antero-medial aspect of
fracture site!
Day 59
„ Incision and drainage of abscess
„ Incision at antero-medial aspect.
„ Abscess cavity extended to postero-
medial aspect of fracture,
communicating
10 weeks

„ Loosening of
distal fixation
detected,
fracture went
into valgus &
recurvatum
10 weeks
Subsequent Management
(11 weeks)

„ Removal of nail,
„ overreaming,
„ hybrid external fixation,
„ Debridement of wound and fracture site,
„ intramedulary gentamycin beads,
„ plating of fibula
After wound closure
2 May 2003
12 weeks
15 weeks
(3 weeks after hybrid fixation)
„ Autogenous cancellous bone graft laid
onto anterior aspect of inter-osseous
membrane at the level of the fracture
Exogen
„ Started on 4 weeks after hybrid fixation
„ Daily standard dose
18 weeks
(6 weeks after
hybrid)
11 weeks
after hybrid
11 weeks after hybrid

Pin tracts okay.

On touch down
walking.
“Early callus”
palpable along
antero-medial aspect
of tibia.
14 weeks
14 weeks
14 weeks
17 weeks after hybrid

„ External Fixator removed

„ Patient advised to keep 20% weight

bearing
23 weeks
 35 weeks
from hybrid
fixation
11 months
after injury

Stick walking 30 min, unaided 10 min.

43 weeks from
hybrid
fixation
13 months
after injury
Delayed Union
Case 6
Male / 16

Traffic Accident

Type II Open Wound

Single injury
Initial Management
(Day 0)
„ Debridement
„ Free fragments discarded
„ Lavage (9 litres of NS)
„ External fixation
„ Antibiotics
Day 2
„ Debridement

„ Lavage (9 L. of NS)
Day 5
„ Debridement
„ Lavage (9 L. of NS)
„ Removal of External fixator
„ G-K Tibial Nail - static lock
„ Soleal Flap + Skin graft
10 days after
nailing
8 weeks after
nailing
9 Weeks after Nailing
„ Postero-lateralbone graft
„ Autogenous cancellous
bone laid on the
interosseous membrane
„ To induce cross union
10 days after
bone graft
10 weeks after
bone graft
Dynamisation
performed
5 months after
nailing
(3 months after
bone graft).
3 months after
dynamisation
5 months after
dynamisation,

removal of
prox. screws
2 year 8 months
after injury.

Delayed union is common in

open fracture even after BG
 Soft Tissue Defect
requiring Flap Coverage
Case 7
M/64
„ DM, HT, Schizophrenia, Parkinson,
Chronic smoker
„ Live with family, walk unaided
„ RTA: knocked down by a taxi
Injury
Pictures

Diagnosis ?
Diagnosis
„ Open fracture dislocation of right ankle
1. Type IIIb: perosteal stripping without vascular
deficit
2. # medial & lateral malleolus
„ Closed extra-articular # of base of left 1st MC

„ Management Plan ?
 Principles of Management
„ ATLS: Save life first, then save limb
„ Prevent infection: Wound debridement & lavage,
IV / local antibiotics, Tetanus prophylaxis
„ Fracture stabilization: Temporarily & definite
„ Early soft tissue coverage: Initial flap preservation,
delayed 1° suture, secondary intention, skin graft, flap
„ Mx of bone defect: Shortening, bone graft / transport
„ Rehabilitation: to minimize disability & optimize
functional recovery
Day 0
„ Ankle: Debridement + External Fixation
„ Thumb: CR + K-wire + dynacast
Day 0
„ Intra-op: right knee haemathrosis noticed
„ No gross laxity
„ Better x-ray showed PCL injury
Day 1
„ Wound: soft tissue necrosis
„ 2nd look debridement
„ Cross knee external fixation for PCL
 Chest infection
Day 3 & Fever

„ Wound: purulent collection drained, necrosis

debrided until healthy viable tissue seen , non-
viable medial malleolus free fragment also
removed
„ Large soft tissue defect with bone & joint exposed
What next ?
What next ? Infection set in !

Joint exposed !

Bone exposed !
 Principles of Management
„ ATLS: Save life first, then save limb
„ Prevent infection: Wound debridement & lavage,
IV / local antibiotics, Tetanus prophylaxis
„ Fracture stabilization: Temporarily & definite
„ Early soft tissue coverage: Initial flap preservation,
delayed 1° suture, secondary intention, skin graft, flap
„ Mx of bone defect: Shortening, bone graft / transport
„ Rehabilitation: to minimize disability & optimize
functional recovery
Soft Tissue
Reconstruction Ladder
„ Delayed 1° closure X too much skin loss
„ 2° intention by granulation ?? too big & too long
„ Skin graft X bare bone exposed
„ Flap: Free ?? 64 yr old, DM, HT, schizophrenia,
chronic smoker, chest infection
„ Flap: Local- Random X not reliable
- Pedicled Options ?
Local Pedicled Flap
for Foot & Ankle Region
„ Supra-malleolar
„ Medial saphenous
„ Medial plantar
„ Medialis pedis
„ Peroneus brevis
„ Extensor brevis All are technically demanding
„ Cross-leg with variable result !
Reconstruction around
Distal leg, Ankle & Heel
„ Technically demanding
„ Limited option for local muscle flap & random
skin flap in distal LL, which sacrificing major
arteries
„ Free flap more classic BUT
1. lengthy operation
2. Microvascular expertise
3. Contraindication for microsurgery: old age,
heavy smoker, poor medical condition
Reverse Sural Flap
„ Fasciocutaneous flap depends on superficial
sural artery of peroneal artery
„ Pedicle: superficial & deep fascia, sural nerve,
short sapehnous vein & superficial sural artery
„ Flap proper: skin island , subcutaneous tissue &
fascia
„ For reconstruction of soft tissue defect around
distal leg, ankle, heel & dorsum of foot
Advantage
„ Great mobility & versatility with wide arc of
rotation (90°-180°): from distal leg to heel to
forefoot
„ Quick (2 hrs, one-stage), easy (minimal
expertise) & reliable (constant anastomosis)
„ Safe, without sacrificing important artery or
structure, no major donor morbidity
„ Excellent durability even for heel coverage
„ Suitable for all age group from pediatrics to
elderly
Back to our case: Day 5
„ Cross knee ext fix removed for better prop
up & sit out post-op in view of chest infection
„ Adjust ext fix for intra-op leg elevation
„ Prone position
„ No tourniquet
Wound debridement
Planning
„ A line at halfway between
Achilles tendon & lateral
malleolus, from ankle to
midline between two heads of
gastrocnemius
„ Mark the most distal point of
dissection: 7cm above tip of
lateral malleolus
„ Mark the pedicle & adjacent
fascia
„ Mark the skin island of flap
Identify the Pedicle
„ Skin incision over
pedicle
„ Skin undermined
to explore the
pedicle and
adjacent 1-2cm
fascia on each side
Fasciocutaneous Flap
Dissection
„ Identify & ligate the sural nerve & adjacent
short sapheouns vein at proximal margin
Pedicle Dissection
„ Dissect the flap including the deep fascia
covering gastrocnemius muslce
„ Pedicle dissected including adjacent
fascia, about 1-2 cm on each side
Flap transfer to cover defect
Donor site closure
„ Donor coverage: PTSG
„ Incision for pedicle: primary suture
„ Pedicle coverage: PTSG
Flap 5 week
Post injury 6 week
10 Weeks
High Successful Rate even with
Risk factors
„ Age>40
„ PVD
„ Venous insufficiency
„ DM
„ Heavy smoker
„ Poorly compliant patient
SUMMARY
Open Fracture
„ Fracture communicates through a
traumatic wound to surrounding
environment
„ Resulting in contamination & soft tissue
envelope disruption
Open Fracture
„ High energy
„ Outcome depends extent of soft tissue injury
„ Treatment of soft tissue trauma with
contamination Î Primarily important
„ Treatment of skeletal injury Î Secondary
Type III Open Fracture
„ It is not “a fracture with a wound”
It is “a wound resulting from high energy
trauma, complicated with a Fracture”
„ First priority is to deal with the Wound,
and then minimize complications arising
from the fracture.
Objectives of Open Fracture Mx
„ Prevent infection
„ Promote fracture healing
„ Restore function
 Principles of Management
„ ATLS: Save life first, then save limb
„ Prevent infection: Wound debridement & lavage,
IV / local antibiotics, Tetanus prophylaxis
„ Fracture stabilization: Temporarily & definite
„ Early soft tissue coverage: Initial flap preservation,
delayed 1° suture, secondary intention, skin graft, flap
„ Mx of bone defect: Shortening, bone graft / transport
„ Rehabilitation: to minimize disability & optimize
functional recovery
Complications
„ Infection
„ Delayed union
„ Non-union
Open Fracture Management

„ Analyze needs, prioritize aims,

plan, and plan for the worst
„ Take them seriously!
Thank You
The End
Principle of External Fixation
External Fixator

„ External device (outside the skin)

„ Stabilizes the bone fragments
through pins or wires connected
to bars, tubes or rings
Types of External Fixator

„ Pin fixators (Schanz pins / Steinmenn pins)

„ Ring fixators (tensioned wires)
„ Hybrid fixators (wires and pins)
Pin Fixators
AO Orthofix

Stryker: Hoffmann II
Ring & Hybrid Fixators
Stryker: Tenxor
AO Orthofix

Half pin

Tensioned wire
 Stryker:
Mini- Fixators Hoffmann Compact

AO Mini
Ilizarov
Ring Fixator
 Components
of External Fixator
Pin-to-Clamp
„ Pin / Wire Clamp-to-Rod
„ Clamp
„ Rod
Straight and U rods
Different Combinations !

Pin-to-Rod
Frame Classification
1 Unilateral
1A Unilateral uniplanar
1B Unilateral biplanar
2 Bilateral
2A Bilateral uniplanar
2B Bilateral biplanar (3D)
3 Modular
Frame Classification

Unilateral Bilateral
uniplanar uniplanar Modular

Unilateral Bilateral
biplanar biplanar (3D)
Safe Soft Tissue Corridor

„ Avoid
vessels,
nerves &
tendons
Advantages
• Provides low-risk stable fixation
- minimal additional soft tissue trauma
• Adjustable
- allowing translation, rotation, angulation, and axial
adjustments
• Provides access to the extremity
- for wound care and reconstructive surgery.
• Technically easy to perform
- apply quickly
Disadvantages
„ Bulk of the device
„ Discomfort
„ Need for daily pin care
„ Pin tract infection
„ Delay union/ nonunion
„ Malunion
„ Tethering of muscle & tendon
„ Limitation of the joint movement
Biomechanics of External Fixator

Stability of frame depends on

1. Pin size

2. Number of pins

3. Pin location

4. Bone-frame distance
Biomechanics of External Fixation

„ Pin Size
„ {Radius}4
„ Most significant factor in
frame stability
„ Larger pin Î ↑ stiffness
„ Too large Æ stress riser
„ Too small Æ ↑ local stress
because of instability
Biomechanics of External Fixation

„ Number of Pins
More pins Î more stable
Biomechanics of External Fixation

„ Pin Location
„ Avoid zone of injury or future
ORIF
„ Pins close to fracture as
possible
„ Pins spread far apart in each
fragment
Biomechanics of External Fixation

„ Bone-Frame Distance
„ Closer Æ better
Factors Affecting Construct Stiffness
Biomechanics of External Fixation
„ SUMMARY OF EXTERNAL FIXATOR STABILITY:

Can make a fixator more stable by:

1] Increasing the pin diameter.
2] Increasing the number of pins.
3] Increasing the spread of the pins.
4] Multiplanar fixation.
5] Reducing the bone-frame distance.
6] Predrilling & cooling during insertion (↓ thermal necrosis).
7] Radially preload pins.
8] 90° tensioned wires.
9] Stacked frames.

**but a very rigid frame is not always good.

How to improve stability of this frame
 •More pins
•More rods
•Better position of rods
•Bilateral biplanar frame

Much better
now !
Complications of Ext. Fix.

„ Pin loosening
„ Pin tract infection
• Malunion
• Delayed or non-union
• Neurovascular injury
• Fracture through the hole
• Failure of fixation
Application of External Fixation
„ Any fracture
„ Open fracture
„ Polytrauma
„ Comminuted metaphyseal fracture
„ Paediatric fracture
• Bone transport
• Limb lengthening
• Angular correction
• Soft tissue reconstruction
• Contractures