Download Management of compound fractures

Management of compound
fractures
Patients with open fractures may have multiple
injuries;
a rapid general assessment is the first step and
any life threatening conditions are addressed.
The open fracture may draw attention away from
other more important conditions and it is essential
that the step-by-step approach in advanced
trauma life support not to be forgotten.
When the fracture is ready to be dealt with, the
wound is first carefully inspected;
1-arterial bleeding should be ligated
2- any gross contamination is removed .
3-the wound is photographed with aPolaroid or digital camera to
the injury record
4-area then covered with a saline-soaked dressing to prevent
desiccation. This is left
undisturbed until the patient is in the operating theatre .
5-The patient is given antibiotics, usually co-amoxiclav
or cefuroxime, but clindamycin if the patient is
allergic to penicillin.6- Tetanus prophylaxis is administered:
toxoid for those previously immunized, human
antiserum if not.7- The limb is then splinted until surgery
is undertaken.
The limb circulation and distal neurological status
will need checking repeatedly, particularly after any
fracture reduction maneuvers. Compartment syndrome
is not prevented by there being an open fracture
CLASSIFYING THE INJURY
Treatment is determined by 1- the type of fracture, 2- the
nature of the soft-tissue injury (including the wound
size) and 3- the degree of contamination. Gustilo’s classification of
open fractures is widely used
Type 1 – The wound is usually a small, clean puncture
through which a bone spike has protruded. There is
little soft-tissue damage with no crushing and the
fracture is not comminuted (i.e. a low-energy
fracture).
Type II – The wound is more than 1 cm long, but
there is no skin flap. There is no much soft-tissue
damage and no more than moderate crushing or
comminution of the fracture (also a low- to
moderate-energy fracture).
Type III – There is a large laceration, extensive
damage to skin and underlying soft tissue and, in the
most severe examples, vascular compromise. The
injury is caused by high-energy transfer to the bone
and soft tissues. Contamination can be significant.
There are three grades of severity. In type III A the
fractured bone can be adequately covered by soft tissue
despite the laceration. In type III B there is extensive
periosteal stripping and fracture cover is not
possible without use of local or distant flaps. The fracture
is classified as type III C if there is an arterial
injury that needs to be repaired, regardless of the
amount of other soft-tissue damage.
The incidence of wound infection correlates
directly with the extent of soft-tissue damage, rising
from less than 2 per cent in type I to more than 10 per
cent in type III fractures.
PRINCIPLES OF TREATMENT
All open fractures, no matter how trivial they may
seem, must be assumed to be contaminated; it is
important to try to prevent them from becoming
infected. The four essentials are:
• Antibiotic prophylaxis.
• Urgent wound and fracture debridement.
• Stabilization of the fracture.
• Early definitive wound cover.
Debridement
The operation aims to render the wound free of foreign
material and of dead tissue, leaving a clean surgical
field and tissues with a good blood supply
throughout. Under general anesthesia the patient’s
clothing is removed, while an assistant maintains traction
on the injured limb and holds it still. The dressing
previously applied to the wound is replaced by a
sterile pad and the surrounding skin is cleaned. The
pad is then taken off and the wound is irrigated thoroughly
with copious amounts of physiological saline.
The wound is covered again and the patient’s limb
then prepped and draped for surgery.
It is advisable not to use tourniquet in this condition unless if there is
sever bleeding or arterial injury to deal with .
Wound excision The wound margins are excised, but
only enough to leave healthy skin edges.
Removal of devitalized tissue: Devitalized tissue
provides
a nutrient medium for bacteria. Dead muscle can be
recognized by a- its purplish colour, b-its mushy
consistency, c-its failure to contract when stimulated and
d-its failure to bleed when cut. All doubtfully viable
tissue, whether soft or bony, should be removed. The
fracture ends can be nibbled away until seen to bleed
Wound cleansing : All foreign material and tissue debris
is removed by excision or through a wash with copious
quantities of saline. A common mistake is to inject
syringefuls of fluid through a small aperture – this only
serves to push contaminants further in; 6–12 L of
saline may be needed to irrigate and clean an open
fracture of a long bone. Adding antibiotics or
antiseptics to the solution has no added benefit .
Nerves and tendons : as a general rule it is best to leave
cut nerves and tendons alone at the time of the wound
excision,to be sutured by delay primary suture ; though if
the wound is absolutely clean and no dissection is
required – and provided
the necessary expertise is available – they can be
Sutured at the time of wound excision .
Stabilization of the fracture :
Stabilizing the fracture is important in reducing the
likelihood of infection and assisting recovery of the soft tissues.
The stabilization of the fracture is usually by external fixation
Wound closure :
A small, uncontaminated wound in a Grade I or II
fracture may (after debridement) be sutured, provided
this can be done without tension. In the more severe
grades of injury, immediate fracture stabilization and
wound cover using split-skin grafts, local or distant flaps is ideal,
provided both orthopaedic and plastic
surgeons are satisfied that a clean, viable wound has
been achieved after debridement.
Aftercare :
In the ward, the limb is elevated and its circulation
carefully watched. Antibiotic cover is continued but
only for a maximum of 72 hours in the more severe
grades of injury.
GUNSHOT INJURIES
With high-velocity missiles (bullets, usually from
rifles, travelling at speeds above 600 m/s) there is
marked cavitation and tissue destruction over a wide
area. The splintering of bone resulting from the transfer
of large quantities of energy creates secondary missiles,
causing greater damage.
With low-velocity
missiles (bullets from civilian hand-guns travelling at
speeds of 300–600 m/s) cavitation is much less, and
with smaller weapons tissue damage may be virtually
confined to the bullet track. However, with all gunshot
injuries debris is sucked into the wound, which is
therefore contaminated from the outset.
Emergency treatment :
As always, the arrest of bleeding and general resuscitation
take priority. The wounds should each be
covered with a sterile dressing and the area examined
for artery or nerve damage. Antibiotics should be
given immediately
.
Definitive treatment:
Traditionally, all missile injuries were treated as severe
open injuries, by exploration of the missile track and
formal debridement. However, it has been shown that
low-velocity wounds with relatively clean entry and
exit wounds can be treated as Gustilo type I injuries,
by superficial debridement, splintage of the limb and
antibiotic cover; the fracture is then treated as for
similar open fractures. If the injury is to soft tissues
only with minimal bone splinters, the wound may be
safely treated without surgery but with local wound
care and antibiotics.
High-velocity injuries demand thorough cleansing
of the wound and debridement, with excision of deep
damaged tissues and, if necessary, splitting of fascial
compartments to prevent ischaemia; the fracture is
stabilized and the wound is treated as for a Gustilo
type III fracture. If there are comminuted fractures,
these are best managed by external fixation.
The
method of wound closure will depend on the state of
tissues after several days; in some cases delayed primary
suture is possible but, as with other open
injuries, close collaboration between plastic and
orthopaedic surgeons is needed .
Close-range shotgun injuries, although the missiles
may be technically low velocity, are treated as highvelocity
wounds because the mass of shot transfers
large quantities of energy to the tissues.