1. Open Fractures Principles of Management
Majdi Hashem, MD
Assistant professor of orthopedic
Consultant orthopedic and spine
Course organizer
Reproduced courtesy of Prof Mamoun Kermli

2. Historical fact … until WW I
Treatment of open fractures was “Amputation”
Mortality rate ~ 75%
Function in “survivors” was poor
Alois Karlbauer

3. Objectives Definition of an open fracture
Important points in history of an open fracture
Classification
Management:
Initial treatment
Importance of surgical debridement
Bone treatment initial & definitive
Soft tissue coverage
Factors affecting outcome

4. Definition
Open fracture is a fracture where the skin coverage overlying is breached
even a small puncture wound
Another name: compound fracture

5. History in open fractures
Mechanism of injury
Date, time, type, method of impact, …
Consciousness
Size of wound
Amount of bleeding
Other injuries: often missed
Anti-Tetanus status

6. Type of injury Determines amount of energy and
Extent of soft tissue injury

7. Type of injury Fall: height is important Sport: stronger impact
Heavy object falling: direct injury – soft tissue
Road traffic accident (RTA): more severe
Car (MVA) , motorcycle, pedestrian
Assault & firearms: severe

8. Mechanism of Injury Try to determine if injury was caused by:
Low velocity
High velocity
Crushing under objects

9. Mechanism of Injury Field of injury: Relatively clean
Contaminated soil

10. Mechanism of Injury Open injury from: In-out: usually cleaner
Out-in: usually more contamination and dirt

11. Mechanism of Injury Penetrating Missiles
Low velocity < 300 m/s - damage along the tract
Comminution
High velocity: >300m/s - sever comminution
Comminution with wide soft tissue damage
Some fragment inside
Some flip inside
Vacuum phenomena - cavitation

12. Signs of high energy injury
Segmental fracture
Bone loss
Compartment syndrome
Crush syndrome
Extensive de-gloving

13. Examples
Low energy High energy
A. Karlbauer

14. Approach – clinical exam
General medical condition should be evaluated to exclude shock and brain injury
Vital signs should be observed and followed up
Look:
Special attention is to be paid to wounds

15. Approach – clinical exam
Feel:
Sensory and motor deficits
Pulse distal to injury
Compartment syndrome
Tense compartment
Move:
With care, if necessary!

16. Approach – clinical exam
Examination of the viscera
Rib fractures
Lung, liver and spleen
Pelvic fractures
Urinary bladder and urethra
Head and spinal injury
Neurological examination

17. Management of open fractures
Initial management
Classifying the injury
Definitive treatment

18. Initial management
it is essential that the step-by-step approach in advanced trauma life support not be forgotten
Treat the patient, not the fracture! (A B C)

19. Initial management
it is essential that the step-by-step approach in advanced trauma life support not be forgotten
When the fracture is ready to be dealt with:
Inspect wound
Remove gross contamination
Photograph the wound
Cover with a saline-soaked dressing
Splint
Give antibiotics
Give Tetanus prophylaxis
Check limb circulation and distal neurological status repeatedly

20. Grades of open fracture
Important to grade severity of open injuries and soft tissue injuries
To treat according to guidelines
To have an idea about prognosis
Several classifications
Most widely used: Gustilo Classification

21. Gustilo Classification
Grade 1:
Low-energy, minimal soft-tissue damage
(wound < 1cm)
Grade 2:
Higher energy, no flaps needed / no crushing
Moderate contamination
(wound > 1cm)
Grade 3:
High-energy, flaps needed / crushing
Significant contamination.

22. Gustilo Classification
Sub-Types of Grade III:
Type 3A : Adequate soft-tissue cover
Can cover skin primarily
Type 3B: Inadequate cover
Can not cover skin primarily
May need skin graft or flap
Type 3C: Vascular injury
Requires vascular repair

23. Gustilo Grade I Low energy Simple fracture
Skin open by fragment pressure within – out
Wound < 1 cm
No / little contamination

24. Gustilo Grade II Higher energy Laceration > 1 cm
No flap / No contusion
Minimal contamination

25. Gustilo Grade IIIA High-energy, Adequate soft-tissue cover
Contamination
Comminution or segmental fracture

26. Gustilo Grade IIIB High-energy, Extensive soft-tissue stripping
Inadequate cover,
Massive contamination

27. Gustilo Grade IIIA or IIIB
An intra-operative decision

28. Gustilo Grade IIIA or IIIB
? Adequate soft tissue coverage

29. Gastilo Grade?
IIIC

30. Problem of open fractures
Infection – skin is breached
Primary: from the field
Massive contamination
Debris and foreign bodies
Devitalized tissues
Secondary infection after internal fixation
Initial bacterial contamination
Proper debridement not done
Internal fixation is a foreign body 30

31. Principles of treatment
All open fractures, no matter how trivial they may seem, must be assumed to be contaminated
The basic guidelines:
Antibiotic prophylaxis / Anti-tetanus
Urgent and proper wound and fracture debridement
Stabilization of the fracture – ? External Fixation
Early definitive wound cover

32. Primary surgery The aims of primary surgery are:
Preservation of life and limb
Definitive injury assessment
Staged wound debridement
May need to repeat after hours
Fracture stabilization

33. Primary surgery – Debridement
Trim skin edges
Remove foreign material
Remove all dead muscles and lacerated tissues
Remove fully detached small bone pieces
Saline wash: 5 Liters (wash–wash–wash)
? Delayed secondary closure

34. Primary surgery – Debridement
/ Principles of Fracture Treatment

35. Alois Karlbauer

36. Alois Karlbauer

37. Alois Karlbauer

38. Alois Karlbauer

39. “Dilution is the solution to pollution”
Alois Karlbauer

40. Surgical Debridement
Surgical debridement demands meticulous excision of all dead and devitalized tissues
Start from outside working inwards:
Skin
Fat
Muscle
Bone
Neurovascular
Leaving dead tissue
invites infection
Alois Karlbauer

41. Treatment guidelines Gustilo I and II:
Can treat by primary internal fixation
Rate of infection low – if follow guidelines
Alois Karlbauer

42. Treatment guidelines Gustilo IIIA Gustilo IIIB Gustilo IIIC
Usually defer internal fixation until soft tissue condition allows
Gustilo IIIB
External fixation
Later, internal fixation
Gustilo IIIC
Vascular repair is a priority
External fixator

43. Higher infection rate More contamination (may change grade II to III):
Exposure to soil
Exposure to water
Exposure to fecal material
Exposure to oral material
Gross contamination
Delay > 12 hours

44. Case example - 1 26y male, motorbike accident, stable Gustilo Type?
Management:
Swab taken
Antibiotics, anti- tetanus
Debridement, skin closure
External fixator
Later on, Intramedullary nail
IIIA / IIIB
Tadashi Tanaka, Chiba, Japan

45. Case example - 1
Tadashi Tanaka, Chiba, Japan

46. Case example - 2
32y old, sever car accident, hit by a truck on bridge and car fell into canal

47. Case example - 2 Sever contamination, commination, and crushing
Un-salvaged after several attempts

48. Summary Definition of open fracture
Important points in history of an open fracture
Gustilo classification
Management:
Importance of early surgical debridement
Bone treatment initial & definitive
Soft tissue coverage