Principles of management of open fractures

definition

• Osseous disruption in which a break in skin and underlying soft tissue communicates directly with the fracture and its hematoma.
• Wound in same limb segment as # considered as open until proven otherwise.

classification

• Most common used Gustilo and Anderson.

Grade I wound

Grade II laceration>1 cm w/o extensive soft tissue damage, flap

Grade IIIA >10cm wound extensive soft tissue injury but adequate soft tissue coverage

Grade IIIB significant soft tissue loss with exposed bone requires soft tissue transfer

Grade IIIC Assoc vascular injury that requires repair for limb preservation

goals of management

• Prevention of infection
• Appropriate management of bone & soft tissue with resultant bone healing
• Restoration of function of injured extremity

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• Initial management as per ATLS protocol
• Injured extremity assessed for extent of wound, soft tissue injury & contamination. NVB is checked.
• Tetanus prophylaxis. (0.5 ml toxoid).

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• Administer IV antibiotics
• Type I : Cephalosporin
• Type II : Cephalosporin + Aminoglycoside
• Type III : Cephalosporin + Aminoglycoside + Penicillin

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• All debris, devitalized tissue, loose cortical bone fragments removed. Dissection continued to viable edges (color, consistency, contractility).
• Irrigation with low pressure saline (I 3L, II 6L, III 10L).
• Closure of wounds (delayed primary).

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• Fracture stabilization
• Extra osseous: low grade
• External fixation: high garde, dirty wounds, extensive soft tissue injury
• Internal fixation: if wound clean, tissue coverage available.

Complications

• EARLY: compartment syndrome, crush syndrome, infection & sepsis, DVT & embolism
• LATE: osteomyelitis and non-union