What is the definition of an open fracture?
There is a direct communication between the external environment and the fracture
usually through a break in the skin,
e.g. fragments of bone from a fractured pelvis penetrating the rectum
What are the most common open fracture sites?
Fingers and tibial shaft account for over 50%
What is the gustilo grading for open fractures?
Type - 1 low energy, wound is less then 1cm, clean, often bone piercing skin from inside
Type - 2 moderate soft tissue damage, wound is less than 10 cm, no soft tissue flap or avulsion
Type - 3 - high energy - extensive soft tissue damage, severe fracture, wound is greater than 10cm
What are the grades ABC for grade 3 gustilo open fracture?
A = soft tissue damage +++ but not grossly contaminated
B = periostel stripping, extensive muscle damage, heavy contamination
C = Asoc, neurovascular complication
What is the epidemiology of open tibial shaft fractures?
Which surgeons are involved in open fractures?
Orthopaedic and plastic surgeons
What is the primary surgical treatment for open fractures?
Surgical debridement and skeletal stabilisation
This treatment takes place at a specialist centre whenever possible
What are the stages of severe open fracture treatment?
IV antibiotics (cefuroxime and coamoxiclav) - clindamycin if there is a penicillin allergy
Vascular and neurological status of the limb is assessed regularly
Restore circulation if there is vascular compromise (using shunts) - 6 hour rule
Surgery for compartment syndrome
Surgery if the wound is contaminated by marine, agricultural or sewage matter
Plan of management for soft tisssue and bone is documented by plastics and Orthopaedic surgeons
Appropriate transfer to specialist cnetre if necessary
Co amoxiclav and gentamicin are administered at wound excision and are continued for at least 72 hours or definitive wound closure - whichever is sooner.
Vacuum foam dressings are not to be used as definitive wound nagement in open fractures,
What are the example soft tissue injrueis in open fractures?
Skin loss - direct tension free closure is not possible following wound excision
Muscle injury that requires excision of devitalised muscle
Injury to one or more major arteries of the leg
Wound contamination with marine, aggicultural or sewage material
What are fracture patterns of the tibia?
Besides antibiotics, what other prophylactic treament may be necessary for open fractures?
When does the 6 hour rule apply for open fracture?
Marine or farmyard environment
The 6 hour rule does not apply for solitary open fractures - 24 hours otherwise
Treatment of the open fracture may include fixation (permanent or temporary)
Split skin grafting, myofasciocutaneous, fasciotunaeous, rotation, free flaps
What are the factors that affect amputation rate?
Shock (measured by blood pressure)
Injury mechanism (measurement of energy)
When is amputation necessary?
Insensate foot or limb
Irretrievable soft tissue or bony damage
Other life threatening injuries
Recquires dual consultant decision