Download Open Fracture Management

Open Fracture Management
Paul Fawson
1st Year Resident
Goals
1)
2)
3)
4)
5)
6)
7)
8)
Treat all frx as an emergency
Thorough exam of life threatening injuries
Begin abx
Debride type II-III frx
Stabilize the frx
Leave wound open for 5-7 days
Early autogenous cancellous bone grafting
Rehab the jacked-up extremity
Classification
• Type I- < 1 cm. Moderately clean puncture, little
soft tissue damage, no crushing injury, little
comminution. Simple, transverse, or oblique frx
• Type II- > 1 cm, no extensive soft tissue damage,
slight/moderate crushing injury, moderate
comminution and contamination.
• Type III- Extensive soft tissue damage,
comminution, and contamination.
– IIIA- Adequate soft tissue coverage
– IIIB- Loss of soft tissue
– IIIC- Arterial injury that needs repaired
H&P
• Preliminary Exam performed in the ER
• History and Physical
• Location?
– Farm? Water contact to wound?
Sterile Dressing
• Cover the Wound with Sterile dressing to
prevent further contamination
Antibiotic Therapy
• Immediate, appropriate and effective
antibiotic therapy.
• > 70% of open frx are contaminated at time of
injury.
• Gram – and aerobic gram + are most common
– S. aureus, S. epidermitis, P. Aeruginosa,
streptococcus, Enterobacteriaceae, B. fragilis
Antibiotic Therapy
• Type I- Start 2.0 g of Cephalosporin
(Cephazolin) upon admission
– Then 1.0 g q 6-8 hours for 48-72 hours
• Type II-III- Ceph + aminoglycoside
• Add 10 million units of penicillin if frx
occurred on a farm.
• 3-7 days only
• 3-7 days again with delayed procedures.
Debridement
• Debridement of wound with copious intermittent
lavage.
– 5,000-10,000 mL of NS or DW
– 2,000 mL bacitracin-polymyxin solution??
• Small puncture wounds and lacerations should be
extended for adequate exposure.
• Discard any small or large fragments or fragments
of devitalized, unattached cortical bone.
• Don’t put back bone found from the scene into
the pt.
Soft Tissue Reconstruction
• Early is recommended if a clean, stable wound
has been achieved.
• This is the key to reduce infection in type III
• Keep wound moist until complete coverage in
5-7 days.
Stabilization of Fracture
• Osseous stability reduces the risk of infection
and protects the integrity of the remaining
soft tissue
• External
– Ease of application with minimal operative trauma
– Maintenance of access to the wound
– Good option for type III
Stabilization of Fracture
• Intramedullary nailing with reaming
– Not recommended with open tibial frx. A large
study showed 6% infx rate with IM nail compared
to 0-1% infx rate in open frx management
• Plate and screws
– Indicated for displaced intra-articular and
metaphyseal frx of LE.
Splints and casts
• Plaster cast can be used for a stable, isolated
type I frx until wound is healed. After this,
immobilized in a cast
• Avoid circular cast in acute stage.
Coverage and Closure of Wound
• Goal is safe, early closure of wound in 7-10
days.
• Type I-IIIA, delayed primary closure in 5-7 days
• IIIB-IIIC, multiple debridements required
• Clinical decision to determine is infection is
still present.
Compartment Syndrome
• 3-9% of open tibial frx found to have
compartment syndrome
• Recommends decompressive fasciotomies to
all 4 leg compartments.
Bone grafts
• Blood flow is imperative
• Autogenous cancellous bone grafting is
indicated with loss of bone or marked
comminution after wound has healed (2-3
weeks)
• Type III- delay grafts to 6 weeks after wound
heals.
Amputation
• 2 absolute indications for primary amputation
– A type IIIC with disruption of post tib nerve and…
– IIIC with loss of soft tissue, massive
contamination, severe comminution, or massive
loss of bone.
• Or type IIIC remained untreated for > 8 hours.
• Delayed amputation is more $$$ and tends to
be a more proximal amputation vs primary
amputation.
References
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
I . BEHRENS, FRED, and SEARLS, KATE: External Fixation of the Tibia. Basic Concepts and Prospective Evaluation. J. Bone and Joint Surg. , 68B(2): 246-254, 1986.
2. BLICK, S. S. ; BRUMBACK, R. J. ; POKA, ATTILA; BURGESS, A. R. ; and EBRAHEIM, N. A.: Compartment Syndrome in Open Tibial Fractures. J.
Bone and Joint Surg. , 68-A: 1348-1353, Dec. 1986.
3. BONDURANT, F. J. ; COTLER, H. B. ; BUCKLE, R. : MILLER-CROTCHETT, P. ; and BROWNER, B. D. : The Medical and Economic Impact of Severely
Injured Lower Extremities. J. Trauma, 28: 1270-1273, 1988.
4. BONE, L. B. ; JOHNSON, K. D.; WEIGELT, JOHN; and SCHEINBERG, R. : Early versus Delayed Stabilization of Femoral Fractures. A Prospective
Randomized Study. J. Bone and Joint Surg. , 71-A: 336-340, March 1989.
5. BUNKIS, JURIS; WALTON, R. L. ; and MATHES, S. J. : The Rectus Abdominis Free Flap for Lower Extremity Reconstruction. Ann. Plast. Surg.,
11: 373-380, 1983.
6. CAUDLE, R. J. , and STERN, P. J. : Severe Open Fractures of the Tibia. J. Bone and Joint Surg. , 69-A: 801-807, July 1987.
7. CHAPMAN, M. W. : The Role of Intramedullary Fixation in Open Fractures. Clin. Orthop. , 212: 26-33, 1986.
8. CHAPMAN, M. W. , and MAHONEY, MICHAEL: The Role of Early Internal Fixation in the Management of Open Fractures. Clin. Orthop. , 138:
120-131, 1979.
9. CHAPMAN, M. W. ; GORDON, J. E. ; and ZISsIM0S, A. : Compression-Plate Fixation of Acute Fractures of the Diaphyses of the Radius and Ulna.
J. Bone and Joint Surg. , 71-A: 159-169, Feb. 1989.
10. CIERNY, GEORGE, III: BYRD, H. S. ; and JONES, R. E. : Primary versuDeslayed Soft Tissue Coverage for Severe Open Tibial Fractures. A
Comparison of Results. Clin. Orthop. , 178: 54-63, 1983.
1 1 . DELLINGER, E. P. ; MILLER, S. D. ; WERTZ, M. J. ; GRYPMA, MARTIN; DROPPERT, BETH; and ANDERSON, P. A. : Risk of Infection after Open
Fracture of the Arm or Leg. Arch. Surg. , 123: 1320-1327, 1988.
12. DELLINGER, E. P. ; CAPLAN, E. S. ; WEAVER, L. D.; WERTZ, M. J. ; DROPPERT, B. M.; HOYT, NANCY; BRUMBACK, ROBERT; BURGESS, A.; POKA,
ATTILA; BENIRSCHKE, S. K.; LENNARD, E. S.; and LoU, M. A. , SR.: Duration of Preventive Antibiotic Administration for Open Extremity
Fractures. Arch. Surg. , 123: 333-339, 1988.
13. GUSTILO, R. B. , and ANDERSON, J. T. : Prevention of Infection in the Treatment of One Thousand and Twenty-five Open Fractures of Long Bones.
Retrospective and Prospective Analyses. J. Bone and Joint Surg. , 58-A: 453-458, June 1976.
14. GUST1LO, R. B.; GRUNINGER, R. P.; and DAVIS, TRACY: Classification of Type III (Severe) Open Fractures Relative to Treatment and Results.
Orthopedics, 10: 1781-1788, 1987.
15. GUSTILO, R. B.; MENDOZA, R. M.; and WILLIAMS, D. N.: Problems in the Management ofType III (Severe) Open Fractures. A New Classification
of Type III Open Fractures. J. Trauma, 24: 742-746, 1984.
16. KARLSTROM, GORAN, and OLERUD, SVEN: Percutaneous Pin Fixation of Open Tibial Fractures. Double-Frame Anchorage Using the Vidal-Adrey
Method. J. Bone and Joint Surg. , 57-A: 915-924, Oct. 1975.
17. KLEMM, K. W. , and BORNER, M.: Interlocking Nailing of Complex Fractures of the Femur and Tibia. Clin. Orthop., 212: 89-100, 1986.
18. LANGE, R. H. ; BACH, A. W.; HANSEN, S. T. , JR.; and JOHANSEN, K. H.: Open Tibial Fractures with Associated Vascular Injuries. Prognosis for
Limb Salvage. J. Trauma, 25: 203-208, 1985.
19. LAWRENCE, R. M.; HOEPRICH, P. D. ; HUSTON, A. C.; BENSON, D. R.; and RIGGINS, R. S.: Quantitative Microbiology of Traumatic Orthopedic
Wounds. J. Clin. Microbiol. , 8: 673-675, 1978.
References
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
20. LHOWE, D. W. , and HANSEN, S. T.: Immediate Nailing of Open Fractures of the Femoral Shaft. J. Bone and Joint Surg. , 70-A: 812-820, July
1988.
21. MCCRAW, J. B. , and ARNOLD, P. G.: McCraw and Arnold’s Atlas of Muscle and Musculocutaneous Flaps. Norfolk, Virginia, Hampton Press,
1986.
22. MCCRAW, J. B.; FISHMAN, J. H. ; and SHARZER, L. A.: The Versatile Gastrocnemius Myocutaneous Flap. Plast. and Reconstr. Surg. , 62: 15-23,
1978.
23. MCGRAW, J. M. , and LIM, E. V. A. : Treatment of Open Tibial-Shaft Fractures. External Fixation and Secondary Intramedullary Nailing. J. Bone
and Joint Surg. , 70-A: 900-91 1 , July 1988.
24. MATHES, S. J. ; MCCRAW, J. B. ; and VASCONEZ, L. 0. : Muscle Transposition Flaps for Coverage of Lower Extremity Defects. Surg. Clin. North
America, 54: 1337-1354, 1974.
25. MAY, J. W. ; GALLICO, G. G. , III; JUPITER, J. ; and SAVAGE, R. C. : Free Latissimus Dorsi Muscle Flap with Skin Graft for Treatment of Traumatic
304 R. B. GUSTILO, R. L. MERKOW, AND DAVID TEMPLEMAN Chronic Bony Wounds. Plast. and Reconstr. Surg. , 73: 641-649, 1984.
26. MOED, B. R. ; KELLAM, J. F.; FOSTER, R. J.; TILE, MARVIN; and HANSEN, S. T.: Immediate Internal Fixation of Open Fractures of the Diaphysis
of the Forearm. J. Bone and Joint Surg. , 68-A: 1008-1017, Sept. 1986.
27. NEALE, H. W. ; STERN, P. J.; KREILEIN, J. G.; GREGORY, R. 0.; and WEBSTER, K. L.: Complications of Muscle-Flap Transposition for Traumatic
Defects of the Leg. Plast. and Reconstr. Surg., 72: 512-515, 1983.
28. OLERUD, SVEN, and KARLSTROM, GORAN: The Spectrum of Intramedullary Nailing of the Tibia. Clin. Orthop., 212: 101-112, 1986.
29. PATZAKIS, M. J. ; HARVEY, J. P. , JR. ; and IVLER, DANIEL: The Role of Antibiotics in the Management of Open Fractures. J. Bone and Joint Surg.,
56-A: 532-541, April 1974.
30. PATZAKIS, M. J. ; WILKINS, J. ; and MOORE, T. M. : Considerations in Reducing the Infection Rate in Open Tibial Fractures. Clin. Orthop. , 178:
36-41, 1983.
31 . PONTEN, BENGT: The Fasciocutaneous Flap: Its Use in Soft Tissue Defects of the Lower Leg. British J. Plast. Surg., 34: 215-220, 1981.
32. RITTMANN, W. W. ; SCHIBLI, M. ; MATTER, P. ; and ALLGOWER, M. : Open Fractures. Long-Term Results in 200 Consecutive Cases. Clin. Orthop.,
138: 132-140, 1979.
33. ROMMENS, P. , and SCHMIT-NEUERBURG, K. P. : Ten Years of Experience with the Operative Management of Tibial Shaft Fractures. J. Trauma,
27: 917-927, 1987.
34. ROSENSTE1N, B. D. ; WILSON, F. C. ; and FUNDERBURK, C. H. : The Use of Bacitracin Irrigation to Prevent Infection in Postoperative Skeletal
Wounds. J. Bone and Joint Surg. , 71-A: 427-430, March 1989.
35. ROTH, A. I.; FRY, D. E.; and POLK, H. C. , JR.: Infectious Morbidity in Extremity Fractures. J. Trauma, 26: 757-761 , 1986.
36. TAKAMI, HIR0SHI; TAKAHASHI, SADAO; and AND0, MASASHI: Microvascular Free Musculocutaneous Flaps for the Treatment of Avulsion Injuries
of the Lower Leg. J. Trauma, 23: 473-477, 1983.
37. TEMPLEMAN, D. C. ; SWEENY, CHRISTOPHER T. ; CHAPMAN, M. W. ; GUSTILO, R. B.; KYLE, R. F. ; BRAY, R. J. T. ; and GORDON, J. E. : Critical
Analysis of the Management of Open Femur Fractures at Two Regional Trauma Centers. Read at the Annual Meeting of The American Academy
of Orthopaedic Surgeons, Las Vegas, Nevada, Feb. 13, 1989.
38. TOLHURST, D. E. : Surgical Indications for Fasciocutaneous Flaps. Ann. Plast. Surg. , 13: 495-503, 1984.
39. VELAZCO, A. ; WHITES1DES, T. E. , JR. ; and FLEMING, L. L. : Open Fractures of the Tibia Treated with the Lottes Nail. J. Bone and Joint Surg.,
65-A: 879-885, Sept. 1983.
References
• 40. WEILAND, A. J. ; MooRE, J. R. ; and HOTCHKISS, R. N. :
Soft Tissue Procedures for Reconstruction of Tibial Shaft
Fractures. Clin. Orthop. , 178: 42-53, 1983.
• 41. WISS, D. A.: Flexible Medullary Nailing of Acute Tibial
Shaft Fractures. Clin. Orthop., 212: 122-132, 1986.
• 42. WORLOCK, PETER; SLACK, RICHARD; HARVEY, LEN; and
MAWHINNEY, ROD: The Prevention of Infection in Open
Fractures. J. Bone and Joint Surg. , 70-A: 1341-1347, Oct.
1988.
• 43. WRIGHT, J. K. , and WATKINS, R. P.: Use of the Soleus
Muscle Flap to Cover Part of the Distal Tibia. Plast. and
Reconstr. Surg. , 12: 957-958,1981.