Ifran Saleh, MD

DEPT. ORTHOPAEDI & TRAUMATOLOGI

FACULTY OF MEDICINE UNIVERSITAS INDONESIA
CIPTO MANGUNKUSUMO HOSPITAL
 Emergency
Orthopaedic

Compartement Joint
Syndrome Dislocation
History of Open Fractures

• Treatment  amputation
• Mortality  75%
• Function in survivors poor
 Location and Initial
Degree of Health Status
Type of injury Extent of Contamination Treatment
Injury of The Patient
Status

High- The Soft

Energy Tissues
vs
Low-
Energy The Bone
 Management of Open Fractures

Operating
Secondary/Tertia
Accident ry Rehabilitation
Scene and Emergency Room for
Emergency Reconstruction
Transport Room
Procedure
Injury
protocols
(ATLS) Treatment of
Wound the wound
covered and
limb splinted

Antibiotics
Treatment of
the bone
Tetanus
Prophylaxis
 Goals

Prevent Restore Achieve

Infection Function Union
 Classification: Open Fractures
Gustilo and Anderson 1976, 1984

Tscherne and Oestern 1982

AO/OTA
The “Big 5” In Open Fracture Care

Treat as an
Emergency
Debridement
and Re-
Debridement
Stabilize Fracture and Soft
tissue

Early Closure

Antibiotics
Treat as an emergency

Status of chest,
General ATLS 1°survey ATLS 2°survey Tetanus
head,
cardiovascular
Status system

Do not expose
Saline dressing,
unnecessarily
Local (3–4x increase
alignment, and
splintage
in infection rate)

Distal Neurovascular
status
Extremity
Debridement and Re-Debridement

Debridement  Clinical assessment of tissue necrosis

Removal of all
Two Wound irrigation
necrotic or
devitalized tissue
Phases including bone

Gustillo → 10 Warm sterile

Beware pressure Remove all
Irrigation litres (minimal 6
litres)
Not absolute! saline or tap
water
systems foreign material

Sequential Skin Fat and fascia Muscle Bone

Re-debridement and secondary wound closure  difficult to

determine the viability of marginal tissue
Stabilize Fracture and Soft Tissue

Stabilize soft tissue and fracture

External Plan pins
Consider
temporary Understand
versus to mechanics
fixation completion

Internal Depending on
grade,
contamination,
fixation and delay
Anatomical site of injury
• Degree of contamination
Temporary vs • Status of the wound and
Definitive soft tissues
• Other associated injuries
Initial Stabilizer and treatment
External vs
• Experience of surgeon
internal Fixation
vs Combination and surgical team
• Implant availability
 Stabilize Fracture and Soft Tissue
External Fixation
Goal of External Fixation
Temporary Spanning
External fixator (Until
Definitive Fracture
soft-tissue stabilization Early Fracture Healing
Treatment
and change to another
fixation method)

Considering to External Fixator:

• Soft-tissue management
• Severe contamination
• Extensive bone loss
• Vascular injury
• Unstable Dislocation or fracture dislocation
• Complex periarticular fracture
• Polytrauma
 Stabilize Fracture and Soft Tissue
Intramedullary fixation

Considering to Intramedullary
Fixation:

• Supports use in open shaft

fractures
• IM better than external fixator for
definitive treatment
• Timing
• Reamed vs unreamed
 Stabilize Fracture and Soft Tissue
Plate fixation
Considering to Plate Fixation:

• Intraarticular and metaphyseal

fractures
• Upper extremity (forearm and
humerus)
• Femur in ARDS
Standard

MIPO

Plate techniques LISS

Locked

Periarticular
Early Closure

Delayed Close
Primary closure
primary closure SSG or cooperation
→ never (unless
→ Grade 1 & 2 local/free flap with plastic
articular)
(3) surgeons

Advance Dressings
Antibiotic pouches

Vacuum dressings

New dressings (silver)

Hydro-scalpel
Vacuum dressings
Vacuum dressings
 Free Flap In Open Fractures
Cover in 72 hours 72 hours – 3/12 ≥ 3/12

Number of 134 (25%) 167 (31%) 231 (44%)

patients (532)

Flap failure 1 (0.75%) 20 (12%) 22 (9.5%)

Infection 2 (1.5%) 29 (17.5%) 14 (6%)

10 x
Time to union 6.8 months 12.3 months 29 months
2x
Time in hospital 27 days 130 days 256 days
4x
Number of 1.3 4.1 7.8
anesthetics 4x
Antibiotics

Open fractures Extent of

Prophylactic
13.9–2.7% are wound and
antibiotic Injury
decrease in contaminated by degree of
therapy definition “early environment
sepsis rate contaminatio
proven treatment” n

Practice protocols
• Cephalosporin
• Aminoglycoside or alternative
gram negative coverage
• Penicillin (farm/soil/ischemia)
Take-home messages: the “big 5”
• Treat as an emergency

• Debridement and re-debridement

• Stabilize fracture and soft tissue

• Early closure

• Antibiotics
Thanks