this is only about management of open fractures. Kindly give your valuable suggestions

1. By Dr Shahid Latheef

2.  HIPPOCRATES – “ SURGEONS CAN ONLY
FACILITATE HEALING THEY CANNOT
IMPOSE IT”.

3.  ABCDE
 Compressive bandages - Open, actively bleeding
wounds.
 Associated injuries.
Spine , Chest & Pelvis
 A careful examination of the extremities to diagnose
fractures and dislocations

4.  Assess neurovascular status
 Documentation of wound
 Photograph
 IV antibiotics, Tetanus prophylaxis
Can I take pictures with my phone and send it to my
senior?

5.  Local irrigation with saline
 Sterile compressive dressing and splint
– Betadine soaked
 Repeat wound examinations associated with
higher infection rate
 Do not culture wound in casualty
Tscherne et al, Fractures with Soft Tissue Injuries. 1984

6. Pierre Joseph
Timing
 At the earliest
 Within 6 hours from time of injury

7. Retrospective Study
 47 Grade II/III open fractures
 Initial debridement
 Less than 5 hours - 7% infection rate
 More than 5 hours - 38% infection rate
Kindsfater et al, J Orth Trauma, Apr 1995,9(2) p121-7

8.  Remove foreign material
 Detection and removal of nonviable tissue
 Reduction of bacterial contamination
 Creation of wound that can heal without infection
and promote fracture healing
 Fasciotomy as indicated

9.  Not in CASUALTY but in THEATRE
 5 to 10 liters of saline
 Pulse lavage preferable
 Iodine/Hydrogen peroxide not beneficial
 Tourniquet used – may interfere with evaluation of
muscle viability

10. Extensile incision
 extend wound in longitudinal direction both
proximally and distally
 Expose: fracture, damaged tissue, and healthy
tissue
 “wound should be equal in length to the diameter
of the limb at that level”

11. Color, Consistency, Contractility, and Capacity to bleed
 Necrotic muscle is culture medium for
infection, especially anaerobic
 “when in doubt, take it out”

12. Tendons
 Left if clean, and preserve blood supply
 Cover properly
Bone
 If devoid of soft tissue attachments, must be
removed
 Soft tissue attachments to remaining bone must
be preserved

13.  Minimal contamination
 1st gen Cephalosporins
 Moderate contamination, higher energy
 Amikacin (5mg/kg) IV Q 24
 Soil contamination/severe contamination
 Penicillin
 Metrogyl

15.  Clinical decision
 Type I wounds
12 – 24 hours
 Type II and III wounds
2-3 days
 No role for prolonged use of antibiotics

16.  >10 Liters Normal Saline results in lower incidence
of infection
 Pulse lavage is more effective than bulb syringe
with NS resulting in 100 fold decrease in Staph
Aureus in the wound
Anglen et al, J Ortho Trauma,2008 :390-396

17.  Provides high local concentration of antibiotics in
the wound
 Prepared in the OR
 PMMA with Tobramycin made into bead shapes,
threaded on large non-absorbable suture, placed
directly in the wound and covered with
impervious dressing, creating “bead pouch”

18. Splint
 Good option if operative fixation not
required
 Synthetic splints preferred
External Fixation (Damage Control Orthopaedics in
polytrauma patients)
 Great option in contaminated wounds, or extensive soft
tissue injury
Internal fixation
 Usually appropriate if wound clean, and soft tissue
coverage available

19. • Easily and rapidly applied
• Excellent stability obtained
• Damage Control Surgery
• Reasonable anatomic reduction possible

20.  Risk of infection minimized
 Ability to convert to internal fixation when
wound is clean with adequate soft tissue coverage
available
 Facilitates bone transport/acute shortening

21.  Grade I to IIIA: Early –Internal fixation
 Late – External. Convert to
Internal fixation at the earliest
 Grade IIIB: External fixation. Convert to
Internal fixation when possible

22.  Nail preferrable
 Stable biological fixation – Plate or Nail
 Supplement with bone grafts

23.  Delayed Primary Closure
 Local Soft Tissue Flap
 Free Tissue Transfer
 Best if wound is covered or closed within 5-7 days
 Decreases infection rate

24. “Saving a functional
limb versus saving
the patient”
 Decision to be made early (48 – 72 hrs)
 Mangled Extremity Score
 Ganga Hospital Score

25. 1. Treat open fractures as emergencies.
2. Perform a thorough initial evaluation to diagnose
life-threatening and limb-threatening injuries.
3. Begin appropriate antibiotic therapy in the
emergency department or at the latest in the
operating room, and continue treatment for 2 to 3
days only.

26. 4. Immediately debride the wound of contaminated
and devitalized tissue, copiously irrigate, and
repeat debridement within 24 to 72 hours
5. Stabilize the fracture with the method determined at
initial evaluation.
6. Leave the wound open
(controversial).

27. 7. Perform early autogenous cancellous bone
grafting.
8. Rehabilitate the involved extremity
aggressively.

28.  Provide Airway and Urgent resuscitation
 Immobilise injured extremity and cover wound with sterile
dressing
 Prophylactic IV antibiotics
 Urgent optimum wound debridement
 External fixation for damage control, definitive internal
fixation at the earliest
 Early bone grafting
 Delayed wound closure with SSG/Flap

29.  GAS GANGRENE
 TETANUS
 THROMBO EMBOLIC
COMPLICATION
 LATE COMPLICATION
 DELAYED UNION
 NON-UNION
 MAL-UNION
 CHRONIC INFECTION

30.  Rockwood and Green’s fractures in adults- 6th
 Campbells Operative orthopaedis- 11th edn
 Text book of orthopaedics – Kulkarni
 Anglen et al, J Ortho Trauma,2008 :390-396
Dr Shahid Latheef
+917795664142