Open Fractures and Nerve Injury

Question 1

What are the different types of open fracture?

Answer 1

• 1 - <1cm wound and clean
• 2 - 1-10cm wound anc clean
• 3A - >10cm wound and high energy, bnut with adequate soft tissue coverage
• 3B - >10cm wound and high-energy, but with inadequate soft tissue coverage
• 3C - all injuries with vascular injury

Question 2

What are the classifications of peripheral nerve injury?

Answer 2

• Neuropraxia (Class I)
  
  • Temporary interruption of conduction without loss of axonal continuity.
  • Physiological block of nerve conduction in the affected axons.
  • Mildest type of peripheral nerve injury
  • Endoneurium, perineurium and epineurium are intact.
  • No wallerian degeneration.
  • Conduction normal except in specific area of injury.
  • Recover is full.
  • EMG shows fibrillation potentials and positive sharp waves.
• Axonotmesis (Class II)
  
  • Involves loss of the relative continuity of the axon and it’s covering of myelin, but preservation of the connective tissue framework of the nerve (epineurim and perineurium are preserved)
  • Wallerian degeneration distal to injury.
  • Sensory and motor deficits distal to injury.
  • No nerve conduction distal to site of injury (3-4 days after injury).
  • EMG shows fibrillation potentials and positive sharp waves (2-3 weeks post injury).
  • Axonal regeneration and recovery possible without surgery.
• Neurotmesis (Class III)
  
  • Total severance or disruption of the entire nerve fibre.
  • Wallerian degeneration distal to site of injury.
  • Connective tissue lesion may be partial or complete.
  • Sensory-motor problems and autonomic function defect are severe.
  • EMG and NCV findings are axonotmesis.
  • Surgical intervention necessary.

Question 3

Management of open fractures

Answer 3

• Antibiotics and dressings
  
  • Administer prophylactic IV antibiotics immediately to patients with open fractures
  • Consider saline-soaked dressing covered with an occlusive layer
  • Do not irrigate open fractures of long bones, hindfoot or midfoot before debridement
• Debridement, fixation and cover
  
  • Surgery to achieve debridement, fixation and cover should be performed concurrently between orthopedics and plastic surgery
  • Debridement
    
    • Immediately for contaminated open fractures
    • Within 12 hours for high energy that are not contaminated
    • Within 24 hours for all other open fractures
  • Fixation and definitive soft tissue cover
    
    • At same time if list allows
    • Within 72 hours if not
• Amputation
  
  • If limb is source of life-threatening, uncontrollable bleeding
  • If attempted preservation would pose unacceptable risk to life
  • If limb is deemed unsalvagable
• Pain relief
  
  • IV morphine is first line
  • If no IV access intranasal route for diamorphine or ketamine
• Photographic documentation may be required in relation to local policy