OPEN FRACTURE

ASSSOCIATE PROFESSOR DR
HAMED SAYED ALHAWARY
,UMS.FSPK
 Objectives
Definition of an open fracture
Important points in history of an open fracture
Classification
Management:
Initial treatment
Importance of surgical debridement
Bone treatment initial & definitive
Soft tissue coverage
Factors affecting outcome
 Definition
Open fracture is a fracture where the skin
coverage overlying is breached
even a small puncture wound
Another name: compound fracture

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 History in open fractures
Mechanism of injury
Date, time, type, method of impact,
Consciousness
Size of wound
Amount of bleeding
Other injuries: often missed
Anti-Tetanus status
 Type of injury
Determines amount of energy and
Extent of soft tissue injury
 Type of injury
Fall: height is important
Sport: stronger impact
Heavy object falling: direct injury soft tissue
Road traffic accident (RTA): more severe
Car (MVA) , motorcycle, pedestrian
Assault & firearms: severe
 Mechanism of Injury
Try to determine if injury was caused by:
Low velocity
High velocity
Crushing under objects
 Mechanism of Injury
Field of injury:
Relatively clean
Contaminated soil
 Mechanism of Injury
Open injury from:
In-out: usually cleaner
Out-in: usually more contamination and dirt
 Mechanism of Injury
Penetrating Missiles
Low velocity < 300 m/s - damage along the tract
Comminution
High velocity: >300m/s - sever comminution
Comminution with wide soft tissue damage
Some fragment inside
Some flip inside
Vacuum phenomena - cavitation
 Signs of high energy injury
Segmental fracture
Bone loss
Compartment syndrome
Crush syndrome
Extensive de-gloving
 Examples
Low energy High energy

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 Approach clinical exam
General medical condition should be
evaluated to exclude shock and brain injury
Vital signs should be observed and followed
up
Look:
special attention is to be paid to wounds
 Approach clinical exam
Feel:
Sensory and motor deficits
Pulse distal to injury
Compartment syndrome
Tense compartment
Move:
With care, if necessary!
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 Approach clinical exam
Examination of the viscera
Rib fractures
Lung, liver and spleen
Pelvic fractures
Urinary bladder and urethra
Head and spinal injury
Neurological examination
 Management of open fractures
Initial management
Classifying the injury
Definitive treatment
 Initial management
it is essential that the step-by-step approach in
advanced trauma life support not be forgotten
Treat the patient, not the fracture! (A B C)
 Initial management
it is essential that the step-by-step approach in advanced
trauma life support not be forgotten
When the fracture is ready to be dealt with:
The wound is carefully inspected
Any gross contamination is removed
The wound is photographed
The area then covered with a saline-soaked dressing
The patient is given antibiotics
Tetanus prophylaxis is administered
The limb circulation and distal neurological status checked
repeatedly
 Grades of open fracture
Important to grade severity of open injuries
and soft tissue injuries
To treat according to guidelines
To have an idea about prognosis
Several classifications
Most widely used: Gustilo Classification
 Gustilo Classification
Grade 1:
Low-energy, minimal soft-tissue damage
(wound < 1cm)
Grade 2:
Higher energy, no flaps needed / no crushing
Moderate contamination
(wound > 1cm)
Grade 3:
High-energy, flaps needed / crushing
Significant contamination.
 Gustilo Classification
Sub-Types of Grade III:
Type 3A : Adequate soft-tissue cover
Can cover skin primarily

Type 3B: Inadequate cover

Can not cover skin primarily
May need skin graft or flap

Type 3C: Vascular injury

Requires vascular repair
 Gustilo Grade I
Low energy
Simple fracture
Skin open by fragment pressure
within out
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Wound < 1 cm
No / little contamination
 Gustilo Grade II
Higher energy
Laceration > 1 cm
No flap / No contusion
Minimal contamination
 Gustilo Grade IIIA
High-energy,
Adequate soft-tissue cover
Contamination
Comminution or segmental fracture
 Gustilo Grade IIIB
High-energy,
Extensive soft-tissue stripping
Inadequate cover,
Massive contamination
 Gustilo Grade IIIA or IIIB
An intra-operative decision
 Gustilo Grade IIIA or IIIB
Adequate soft tissue coverage
Gastilo Grade? IIIC
 Problem of open fractures
Infection skin is breached
Primary: from the field
Massive contamination
Debris and foreign bodies
Devitalized tissues
Secondary infection after internal fixation
Initial bacterial contamination
Proper debridement not done
Internal fixation is a foreign body
 Principles of treatment
All open fractures, no matter how trivial they may
seem, must be assumed to be contaminated

The basic guidelines:

Antibiotic prophylaxis
Urgent and proper wound and fracture debridement
Stabilization of the fracture ? External Fixation
Early definitive wound cover
 Primary surgery
The aims of primary surgery are:
Preservation of life and limb
Definitive injury assessment
Staged wound debridement
May need to repeat after 48-72 hours
Fracture stabilization
 Primary surgery Debridement
Trim skin edges
Remove foreign material
Remove all dead muscles and lacerated tissues
Remove fully detached small bone pieces
Saline wash: 5 Liters (washwashwash)
Delayed secondary closure
Primary surgery Debridement

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Alois Karlbauer
Alois Karlbauer
Alois Karlbauer
Alois Karlbauer
 Surgical Debridement
Surgical debridement demands meticulous
excision of all dead and devitalized tissues
Start from outside working inwards:
Skin
Fat
Muscle
Bone
Neurovascular

Alois Karlbauer
 Treatment guidelines
Gustilo I and II:
Can treat by primary internal fixation
Rate of infection low if follow guidelines

Alois Karlbauer
 Treatment guidelines
Gustilo IIIA
Usually defer internal fixation until soft tissue
condition allows
Gustilo IIIB
External fixation
Later, internal fixation
Gustilo IIIC
Vascular repair is a priority
External fixator
 Higher infection rate
Increased contamination:
Exposure to soil
Exposure to water
Exposure to fecal material
Exposure to oral material
Gross contamination
Delay > 12 hours
 Summary
Definition of open fracture
Important points in history of an open fracture
Gustilo classification
Management:
Importance of early surgical debridement
Bone treatment initial & definitive
Soft tissue coverage