Open Fractures: DR Gourav Ramuka

Open fractures
Dr Gourav Ramuka
Definition
 An open fracture is one in which a break in the skin
allows for direct communication of the fracture site or
fracture hematoma with the elements external to the
usual protection of the skin.
Mechanism of injury
• Open fractures occur as a result of direct high energy
trauma either from Road traffic collisions or falls from
height.
• These fractures can also occur indirectly, such as a high-
energy twisting type of injury.
 The prognosis in open fractures is determined primarily
by the amount of devitalized soft tissue and the level and
type of bacterial contamination. The interplay of these
two factors, rather than the fracture pattern alone, is the
primary determinant of the outcome.
 Outcome subsequently hinges on viable soft-tissue
coverage, neurovascular integrity, prevention of infection,
and healing of the fracture.
 Poor tissue oxygenation and devitalization of the
surrounding tissues including the bone provide a perfect
medium for infection and bacterial multiplication.
 When left open – prone to nosocomial infection such as
pseudomonas species and gram negative bacteria
Current recommendations for acute management of
open fractures mirror the military model:
 Provide airway management and urgent resuscitation.
 Immobilize the injured extremity and apply sterile
dressing to the wound.
 Administer early intravenous antibiotics.
 Perform urgent operative wound debridement and
irrigation, leave the wound open, and stabilize unstable
skeletal injuries.
 Perform repeated debridements, as needed.
 Delay wound closure/coverage.
Initial assessment
1. History and mechanism of injury
2. Neurovascular status
3. Size of skin wound
4. Muscle crush or loss
5. Periosteal stripping or bone loss
6. Fracture pattern, fragmentation
7. Contamination
8. Compartment syndrome.
Antibiotics
Tetanus prophylaxis
 timing
 initiate in emergency room
 two forms of prophylaxis
 toxoid
 0.5 mL, regardless of age
 immunoglobulin
 < 5 years old receive 75 U
 5-10 years old receive 125 U
 >10 years old receive 250 U
 toxoid and immunoglobulin should be given intramuscularly with two
different syringes in two different locations
 guidelines for tetanus prophylaxis depend on 3 factors
 complete or incomplete vaccination history (3 doses)
 date of most recent vaccination
 severity of wound
Extremity Stabilization & Dressing
 stabilization
 splint, brace, or traction for temporary stabilization
 decreases pain, minimizes soft tissue trauma, and prevents

disruption of clots
 dressing
 remove gross debris from wound, do not remove any bone
fragments
 place sterile saline-soaked dressing on wound
The objectives of debridement (and
irrigation) are as follows:
 Extension of the traumatized wound to allow
identification of the zone of injury.
 Detection and removal of foreign material, especially
organic foreign material.
 Detection and removal of nonviable tissues.
 Reduction of bacterial contamination.
 Creation of a wound that can tolerate the residual
bacterial contamination and heal without infection.
Irrigation
 Supplements systemic debridement by removing foreign
material and decreasing bacterial load.
 on average, 3L of saline are used for each successive
Gustilo type
Type I: 3L
Type II: 6L
Type III: 9L
 NS normally used for irrigation.
 Antibiotic solution has no advantage than soap for
irrigation
Debridement
 Adequate debridement is the single most factor in
attainment of good result in treatment of open fractures.
 Systemic debridement
 Removal of gross contaminants and debris
 From superficial to deep structures
 All necrotic tissues should be excised.
 Use of tourniquet should be minimised.

 Muscle viability is assessed by 4’C
1. Contractibility
2. Colour
3. Consistency
4. Capacity to bleed
 When it is difficult to determine the viability of all

tissues at the time of initial debridement, repeated
debridement at 24-48 hr interval can be employed to
eliminate devitalized tissues.
Timing of debridement and irrigation
 Most guidelines recommend debridement within 6 hrs. If
clean Primary closure.
 Serial debridement may be necessary every 24-48hrs if

debridement is delayed until the wound viability is
ensured.
 If clean within 2-3 days delayed Pr. Closure

.
 Later Secondary closure (Flaps) or healing by Secondary
intentions (scarring)
Primary surgery
 Timing :
 Surgical emergency
 Operating within 6-8hrs of injury –contaminated wounds
not treated within this time will have sustained bacterial
multiplication to result in early infection.
Primary surgery
 Fracture stabilization:
 As soon as primary wound care is completed,
treatment should proceed to fracture reduction and
fixation.
Fixation Options ??
External Fixation Vs Internal Fixation
Relative Indications for External
Fixation in Open Fractures
 Severe contamination any site,
 Periarticular fractures
– Definitive
• Distal radius
• Elbow dislocation
– Relative
• Knee
• Ankle
• Elbow
• Wrist
• Pelvis
Advantages of Ext Fixation:-
 Can be applied relatively easily and quickly
 It provides relatively stable fracture fixation
 There is no further damage done if applied correctly
 It avoids implantation of hardware in open wound.

Disadvantages
 Major problems with external fixation are related to pin
tract infection, malalignent ,delayed union, poor patients
compliance.
 Tubular fixactors may not be the choice of fixation but

Ring fixators may be an option in open diaphyseal
fractures.
Relative Indications for Internal
Fixation in Open Fractures
 1)Periarticular fractures
– Distal/proximal tibia
– Distal/proximal femur
– Distal/proximal humerus
– Proximal ulnar radius
– Selected distal radius/ulna
– Acetabulum/pelvis
2) Diaphyseal fractures
– Femur
– Tibia
– Humerus
– Radius/ulna
Primary Closure
 If it is to be done, the following criteria must be met:-
1.The original wound must have been fairly clean, and not
have occurred in a highly contaminated environment.
2.All necrotic tissue and foreign material have been

debrided.
3.Circulation to the limb is essentially normal.
4.Nerve supply to the limb is intact.

5.The patient's general condition is satisfactory and
allows careful postoperative assessment.
6.The wound can be closed without tension.
7.Closure will not create a dead space.
8.The patient does not have multisystem injuries.

Delayed primary closure
 Closure before the 5th day is termed delayed primary
closure.
 As long as closure is achieved before the fifth day, wound

strengths at 14 days are comparable with those in
wounds closed on the first day.
 Leaving the wound open minimizes the risk of anaerobic

infection, and the delay allows the host to mount local
wound defensive mechanisms that permit safer closure
than is possible on the first day.
 Current standard of care for all open fracture wounds is
to be left open initially.
 Delayed closure is accomplished within 2-7days
 VAC assisted wound closure is presently recommended

for temporary management of open fracture wounds.
Complications
 Hypovolemic shock
 Compartment syndrome
 Fat embolism
 ARDS
 Neurovascular injuries
 Infection
Thankyou
Ref :
 Rockwood and green’s fractures in adult
 Cross III WW, Swiontkowski MF. Treatment principles in
the management of open fractures. Indian journal of
orthopaedics. 2008 Oct;42(4):377.

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Open fractures

 decreases pain, minimizes soft tissue trauma, and prevents

 Use of tourniquet should be minimised.

 When it is difficult to determine the viability of all

 Serial debridement may be necessary every 24-48hrs if

 If clean within 2-3 days delayed Pr. Closure

 It provides relatively stable fracture fixation

 There is no further damage done if applied correctly

 It avoids implantation of hardware in open wound.

 Tubular fixactors may not be the choice of fixation but

2.All necrotic tissue and foreign material have been

3.Circulation to the limb is essentially normal.

4.Nerve supply to the limb is intact.

6.The wound can be closed without tension.

7.Closure will not create a dead space.

8.The patient does not have multisystem injuries.

 As long as closure is achieved before the fifth day, wound

 Leaving the wound open minimizes the risk of anaerobic

 Delayed closure is accomplished within 2-7days

 VAC assisted wound closure is presently recommended

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