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Nailing compound fractures when / safety evidence DR.G.S.KULKARNI MIRAJ
HISTORY of open fractures American Civil War Mortality 26% France – Russian war Amputee
Nailing in open fractures 1. Improved technique debridement. 2. Use of AB bead pouch and Rod 3. Vaccume assisted closure 4. Newer designs of nails & plates. 5. Perioper. AB
Corner stone of Open fracture-Debridement 1.Wound - Extend longitudinally- 2.Exploration Fasciotomy 3.Debridement 4.Irrigation 5.AB Beads 6.VAC – not a substitute
Adv. nailing in open # 1.Early stabilization of open fracture controls pain,swelling, mobility inflammation 2. Mobility-Further soft tissue damage 3. Early mobilization of jt & pt. 4 CPM
IMN Adv. 1.Biomechanically superior, maintain L, alignment and rotation 2.Early wt. bearing 3.Less rate of secondary surgery
Adv. of immediate IF Unkinks A,V and lymphatics, improves circulation at fracture zone
Ext. Fix –meta-analysis Adv : union - 94 % infection - 16% chro. Osteo - 4% -Giamondis JBJS, Br. 2006
Complication of Ext. Fix 1.Pin loosening 2.Pin tract inf. 32 % 3.Mal-union 4.Exchange nailing- inf to 30% 5. “Non-union machine “
IMN IMN is a safe, effective method for open fracture I, II, III A & B S.Malvin JAAOS, Feb 2010
Reamed V/s Unreamed Reaminng-- Adv 1. larger diameter – better fracture stability 2. Implant failure less 3. Reaming deposit B.G. 4. Periosteal blood supply ++
Reaming. Metaanalysis failed to show an increased risk of re-operation No increased rate of infection or nonunion - Bhandari Et al JBJS B 2001 :
Multicentric level 1 study open fractures 460 Reamed210 Unreamed196 Does not support superiority of either. SPRINT Group JBJS Am 2008 Debate is ongoing
Reamed Disadv - 1. Reduced intramedullary blood supply, but Periosteal blood supply Thermal necrosis a) use sharp reamers, increment by 0.5 mm b) gentle reaming –back & forth
Poor result of IMN 1.Inadequate debridement 2.Inappropriate soft tissue closure 3.Thermal necrosis 4.Severe contamination + late arrival These are contra-indications
Literature 143 cases of open tibial shaft fractures.Primary IMN has Favourable results. Deep infection – 3 % - Koker & Tornetta JOT 2007
Exchange ex fix to IMN Safety period 10 days till soft tissue recovery < 14 days ( Varies from 7 to 28 days) Shorter period reduces infection rate - JS Melion et al JOT Feb 2010
Do not do primary IMN Severe contamination Inadequate debridement Delayed arrival AB Rod + Ex. Fix 7-10 days IMN
JAGRUTI M DAY 1 Debride A-B Rod AO Ex Fix 1st VAC
JAGRUTI MANCHAREKAR DAY 1 DAY 5
JAGRUTI M After 3 changes of VAC, 2 nd Skin graft DAY 9
JAGRUTI M After 1 yr
VAC & I.F. OF OPEN FRACTURE With VAC it is possible to nail or plate IIIB open # as VAC is an excellent interval coverage
Almost no role of plaster splint or plaster cast with window in open fracture.
External Fixator in Open #s Advantages 1. Pins away from fracture zone 2. No additional open surgery 3. Access to wound dressing and plastic surgery 4. Early mobilisation
External Fixator Disadvantages : 1.Pin tract infection 2.Risk of infection of later ORIF 3.Soft – tissue impaling stiff jt. 4.Pin loosening Ex fix as a definative treat not favoured
Nailed on day 1 of injury
Amar Sawant 15 days old
AMAR SAWANT Amar Sawant
AMAR SAWANT Amar Sawant
Hebbal Hasan Open fracture+ pilon IMN on day 1
Hebbal Hasan Both united
CONCLUSION Corner stone of fracture debridement IMN is a safe, effective method Two stage nailing –I) AB rod II) ILIMN a) severe contamination b) delayed arrival
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