Briefly on open fractures

Open fractures are always assumed to be infected, and a small puncture wound is as liable as a laceration towards infection.
The most useful classification for open fracture is the Gustillo's classification :

a) Type I


It is essentially a low energy fracture.
There is only little soft tissue damage.
The wound is small (<1cm), and is clean
There is no comminution.

b) Type II


It is a moderate energy fracture, with not much of soft tissue damage.
Wound, though is > 1cm, it is clean.
There is moderate amount of comminution.

c) Type III

This is a high energy fracture, with extensive damage to the skin, soft tissue, and neurovascular structures.
Wound is contaminated in this case.
There are 3 subtypes :

IIIA : Fractured bone can be adequately covered by tissue

IIIB : Fractured bone cannot be covered by tissue, with periosteal stripping and severe comminution


IIIC : Regardless of the extent of soft tissue injury, there is arterial damage

Management

1) At the scene

Provide temporary stabilization of the fracture.
Splint the limb, then cover the wound with clean dressing or sterile material.

2) At hospital

Rapid general assessment for any life-threatening injuries.
Tetanus prophylaxis given (TT for those previously immunized, and human anti-serum for those who do not)
Wound is inspected, washed and dressed. Ideally it should be photographed to avoid frequent undressing of the wound for inspection.
Wound is inspected for site, size, contamination, neatness, communication with fracture, state of soft tissue, vessels and nerves.
Antibiotics prophylaxis is given :

A combination of benzylpenicillin and flucoxacillin (or 2nd generation cephalosporins) every 6 hourly for 48 hours. If there is heavy contamination, add gentamicin or metronidazole.
To continue the antibiotics for 4-5 days.

3) Prompt wound debridement


The purpose of wound debridement is to make sure that the wound is devoid of foreign materials or dead tissues, and to maintain a good blood supply throughout.
All ragged margins of the skin is excised as well, to maintain a healthy skin edges.
Besides, the wound has to be washed by generous amount of normal saline.

4) Definite stabilization of fracture

Aim is to reduce the risk of infection and to promote soft tissue healing.
The mode of fixation depends on : degree of contamination, duration from injury to operation and degree of soft tissue damage.
If there is no obvious contamination, and the time lapsed is < 8 hours, all open fractures up to grade IIIA can be managed as in closed injuries (cast splintage, internal/external fixation)
However, any open fractures which are more severe required both plastic and orthopedic surgeons (usually external fixation with circular frame works)

5) Definite wound cover

A small, type I open fracture can be sutured after debridement, provided that it can be done without tension.
For all other wounds, you have to wait until the dangers of tension and infection has passed (usually requires 2-3 days).
Then the wound is closed by : delayed primary closure, secondary closure, skin grafting or tissue flaps.

Category: Orthopedics Notes