classification and management of open fractures

CLASSIFICATION AND MANAGEMENT OF OPEN FRACTURES : 

CLASSIFICATION AND MANAGEMENT OF OPEN FRACTURES Dr Ramachandran MS., Dept of orthopedics, SMS Medical college,

Introduction : 

Introduction An open fracture is one in which a break in the skin and underlying soft tissue leads directly into or communicates with the fracture and its hematoma The term compound fracture is non-specific and hence not used When wound occurs in same limb segment as a fracture , the # must be considered open until proven otherwise.

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CLASSIFICATION OF OPEN FRACTURES

OVERVIEW : 

OVERVIEW Communication between health care professionals Formulating a treatment plan Decision on limb salvage Detailed audit of care to ensure optimal management

METHODS OF CLASSIFICATION : 

METHODS OF CLASSIFICATION GRADING SYSTEM – focus on severity of limb injury only Eg: Gustilo Anderson , Tscherne and Gotzen, Byrd and Spicer etc SCORING SYSTEM – focuses on limb injury and general health; also give ‘amputation score’. Eg: MESS , NISSA ,LSI, PSI etc COMPREHENSIVE SYSTEM – combines the above two systems Eg: AO system , Ganga hospital score

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GRADING SYSTEMS

GUSTILO ANDERSON SYSTEM : 

GUSTILO ANDERSON SYSTEM In 1976 , Gustilo and Anderson treated 1025 open fractures based on his grading system that offered prognosis about outcome of infected fractures In 1984, it was modified and was based on Size of wound Periosteal soft tissue damage Periosteal stripping Vascular injury Recently it has emerged that injured limbs are appropriately categorised by the system after wound excision (Yang EC, Eisler J.2003)

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Simple and hence it is widely used Poor interobserver reliability especially with inexperienced surgeons gun shot injuries , wounds in farm yards are always gradeIII

TSCHERNE SYSTEM : 

TSCHERNE SYSTEM This system includes compartment syndrome which is not included in other grading systems

BYRD AND SPICER : 

BYRD AND SPICER This system lacks sophistication and hence not widely used

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SCORING SYSTEMS

MANGLED EXTREMITY SEVERITY SCORE (MESS) : 

MANGLED EXTREMITY SEVERITY SCORE (MESS)

MESS Contd… : 

MESS Contd… * If ischemia time > 6 hrs, add 2 points.

MESS Contd… : 

MESS Contd… It was developed to identify those patients who will be benefited by primary amputation In retrospective analysis, the outcome of injured limb was either salvage or amputation A score of 7 or greater is predictive of amputation MESS is found to be specific but lacks some sensitivity which infers that score predicting limb salvage(<7) is more reliable than score predicting amputation (> or =7) (Bosse MJ JBJS 83A:412,2001)

OTHER SCORING SYSTEMS : 

OTHER SCORING SYSTEMS NISSSA – Nerve injury Ischemia Soft tissue injury Skeletal injury Shock Age , is more sensitive and more specific than MESS. LSI – Limb Salvage Index a.This index is applied to limbs with arterial injury b.Warm ischemia time together with scores for injured skin , muscle , bone , NV are added to give total score c. LSI > or = 6 and grade IIIc gustilo with major nerve injury are amputated

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COMPREHENSIVE SYSTEMS

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AO System : Skin lesions , muscle -tendon , NV , bone injuries are graded separately AO system allows better prediction of outcome when compared to Gustilo Due to its complexity not widely accepted Ganga hospital score : Includes additional criteria like age >65 , DM , cardio-respiratory disease , trauma chest/abdomen, farmyard/sewage contaminations, delay in debridement >12h

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MANAGEMENT OF OPEN FRACTURES

INITIAL MANAGEMENT : 

INITIAL MANAGEMENT ABC of initial management is addressed first Compressive dressings for extremity hemorrhage Rule out cervical injuries , chest , abdominal injuries , head injuries in polytrauma patients As soon as possible careful examination of wound is carried out and serial photographs of wound taken Atleast sketch diagrams of the limb and wound is made which is more informative than the descriptive paragraphs

Initial wound management : 

Initial wound management In emergency room : Don’t do digital exploration (to avoid infection and bleeding) Obvious FB are removed with forceps If patient will undergo formal debridement in<1 hour just do sterile saline dressing if not irrigate with 1 or 2l of NS Povidone dressing alters color and impairs osteoblast function (controversial) so better avoided Patients immunity to tetanus is determined IV antibiotics are given as soon as possible

Debridement and Irrigation : 

Debridement and Irrigation Timing - Debridement done as soon as possible Skin and wound preparation-dirt and debris removed by gentle scrub brush Sterile tourniquets kept ready but not used SUPERFICIAL DEBRIDEMENT: Traumatic wounds extended – to identify and explore the entire zone of injury and to access ends of bone fragments Skin incisions – extensile longitudinal incision to visualize deep tissue and can be extended till (N) tissue encountered Clearly Nonviable skin and subcutaneous tissue excised but of marginal viability may be left for later debridement Don’t detach skin and subcutaneous tissue from the fascia Any nonviable shredded fascia and even the marginally viable ones excised

Extensile longitudinal skin incision : 

Extensile longitudinal skin incision

Contd.. : 

Contd.. DEEP DEBRIDEMENT: Whereas skin tend to tear , fascia split or shred , muscle because of water content are subjected to hydraulic damage by fluid waves during injury In muscle debridement the concept ‘when in doubt take it out’ In type I,II and IIIa open # all non-vital and in doubt muscle can be debrided but IIIb and IIIc removal of entire muscle compartment may be needed so marginally viable ones are left for later re-debridement Viability of muscle checked by its color ,capacity to bleed, contractility and consistency(last 2 more reliable)

Contd.. : 

Contd.. Tendons , unless injured beyond repair should be preserved In open wounds tendons are subject to dessication and hence it should be covered with soft tissues if not with moist dressings In general bone devoid of soft tissue attachment removed and large ones are utilized provisionally for skeletal fixation and removed once fixation achieved One exception to strict removal of bone without soft tissue attachment ,is significant portion of articular surface attached to bone fragment

Contd.. : 

Contd.. IRRIGATION: After meticulous debridement irrigation of wound is done Most common irrigant used is NS and high volume , low pressure lavage repeated an adequate number of times to prevent infection Amount used varies , Anglen recommended 6 to 10l for grade II and III # Additives – antiseptics, antibiotics and surfactants can be used

Skeletal Stabilisation : 

Skeletal Stabilisation Once the vascular repair has been completed and limb salvaged or irrigation and debridement done , stabilisation of bone is next concern Restoring the length ,rotational and angular alignment has many benefits for healing of soft tissue fracture reduction unkinks NV conduits and helps in soft tissue healing minimising motion of fragments also decreases further damage, pain and permits mobilisation of joints

Contd.. : 

Contd.. METHODS OF SKELETAL STABILISATION: Extra osseous immobilisation –Eg: plasters ,weight bearing casts , splints and skeletal tractions Used in Low grade open fractures – Eg: grade I leg bone # (plasters) and open shaft femoral fractures (skeletal traction) External fixation – Used in high grade open fractures excellent access to wound dressing and surveillance possible Pin tract infections (not decreased by dressings; Egol et al), loosening , osteo-myelitis are some complications

Extra osseous immobilization- skeletal traction : 

Extra osseous immobilization- skeletal traction

External fixator : 

External fixator

Contd.. : 

Contd.. INTERNAL FIXATION: Plates and screws – to minimise complications IV anti staph antibiotics as soon as possible, sterile dressing , meticulous debridement , copious irrigation and minimal stripping and accurate anatomical reduction in extraperiosteal plate fixation to be done IM Nail- currently the treatment of choice for grade I,II,IIIa and IIIb fractures as ex-fix devices leads to more malalignment, nonunions, and delayed return to function and no substantial decrease in infection when compared with nails

Internal fixation – plates and screws : 

Internal fixation – plates and screws

IM Nail : 

IM Nail

Wound closure and coverage : 

Wound closure and coverage Wounds without skin loss : Tension free primary closure after thorough debridement Contraindications for primary closure are Delayed presentation >12hr Delayed administration of antibiotic >12hr Deep seated contamination Immunocompromised NV injury Inability to achieve tension free suture High risk of anaerobic contamination like farm yard injuries

Contd.. : 

Contd.. Wounds with skin loss: Healing by secondary intention Releasing or relaxing incision – donor region may require SSG in anatomic regions with less tissue mobility like leg and ankle Fascio-cutaneous flap or rotational flaps

Thank you : 

Thank you