Advanced Treatment of Open Fractures by Habeeb Almajidi.pptx

Advanced Treatment of Open Fracture

1. Advanced treatment of open fractures Done by STUDENT : HABEEB HAMEED ALI ABDULRAHMAN Supervised by Dr. GHAZI AL- AREEQI

2. PREFACE TO OPEN FRACTURE To talk about the advanced treatment of open fracture, we have to have full knowledge and information about conventional medical methods of treating open fractures. because, the steps of treatment of open fracture have not changed as a whole but the way of performing it have changed variously depending on countries and ability of health system.

3. AIM OF ADVANCED STUDIES OF OPEN FRACTUTRE TREATMENT Reduction of INFECTIONS 1 Selection of best time of wound closure 2 Establishing new & best accurate methods for decontamination 3 Reduction of hospitalization time 4

4. Summary it is a fractures with direct communication to the external environment. Diagnosis is made clinically by assessing the size and nature of the external wound as well as obtaining radiographs of the bone at the location of the soft tissue injury. Treatment depends on location of fracture but generally requires immediate IV antibiotics and urgent irrigation and debridement followed by surgical fixation as needed .

5. Significance Open fractures are fractures in which the bone has violated the skin and soft tissue. Because of their severity, open fractures are associated with complications that can result in 1-increased lengths of hospital stays, 2-multiple operative interventions, and even 3-amputation (average amputation lifetime healthcare costs over $500,000.). One of the factors thought to influence the extent of these complications is exposure and contamination of the open fracture with environmental microorganisms, potentially those that are pathogenic in nature

6. Epidemiology Incidence common 30.7 per 100,000 persons per year Demographics average age is 45 years old Anatomic location tibia and finger phalanx are most common

7. Etiology Pathophysiology mechanism of injury high-energy trauma "inside-out" open fractures The risk of a fracture being open is related to 1- the amount of soft-tissue coverage in that region of the body and to the amount of energy imparted to that region. For example, the tibia has a long medial aspect that is subcutaneous, and therefore, it is “easier” for trauma to the lower leg to expose the bone and fracture site. Conversely, the femur is surrounded by thick muscle layers circumferentially and, therefore, is less likely to be exposed after a similar amount of force to the thigh . Associated conditions often associated with additional injuries (30%) compartment syndrome the presence of an open wound does not preclude the occurrence of compartment syndrome in the injured limb

8. Etiology Pathophysiology If the open fracture was caused by penetrating trauma, direct injury to major neurovascular structures may be more likely, thereby affecting the prognosis for limb function. Direct inoculation of the tissue is a basic issue in the pathophysiology of open fracture management. Furthermore, bacteria can colonize wounds at later stages of care, being introduced into the wound at subsequent dressing changes or repeat debridements prior to definitive wound closure. Gustilo and Anderson reported that 50.7% of their 158 patients had a positive wound culture upon initial evaluation.[5] Another 31 patients that were initially culture-negative had a subsequent positive culture at the time of their definitive closure Devitalized tissue results from the energy imparted to the body. A crushing injury can impair the local immune response, with local ischemia playing a large role in this process. Ischemia may also occur by direct trauma to the large vessels and/or microcirculation. Important indirect causes of ischemia include increased myofascial  compartment pressures, increased vascular permeability, and the use of vasoconstrictive medications during resuscitation.

9. Classification Gustilo classification  Tscherne classification  The  Gustilo open fracture classification  system is the most commonly used classification system for  open fractures . It was created by Ramón Gustilo and Anderson, and then further expanded by Gustilo, Mendoza, and Williams NOTE............ It is important to note that the severity of the injury may not be fully appreciated at the time of initial evaluation, and therefore, classification should be based on the intraoperative findings.

10. Orthopaedic Trauma Association classification The Orthopaedic Trauma Association (OTA) published a fracture and dislocation classification compendium, according to which open fractures are categorized on the basis of five main variables: skin injury, muscle injury, arterial injury, contamination, and bone loss

11. ORTHOPEDIC TRAUMA CLASSIFICATION Skin injury is quantified as follows : Laceration with edges that approximate Laceration with edges that do not approximate Laceration associated with extensive degloving Muscle injury is quantified as follows : No appreciable muscle necrosis, some muscle injury with intact muscle function2. Loss of muscle but the muscle remains functional, some localized necrosis in the zone of injury that requires excision, intact muscle-tendon unit3. Dead muscle, loss of muscle function, partial or complete compartment excision, complete disruption of a muscle-tendon unit, muscle defect does not reapproximate

12. ORTHOPEDIC TRAUMA CLASSIFICATION Arterial injury is quantified as follows : No major vessel disruption Vessel injury without distal ischemia Vessel injury with distal ischemia Contamination is quantified as follows : None or minimal contamination2. Surface contamination (not ground in) Contaminant embedded in bone or deep soft tissues or high-risk environmental conditions (barnyard, fecal, dirty water, etc) Bone loss is quantified as follows : None Bone missing or devascularized bone fragments, but still some contact between proximal and distal fragments Segmental bone loss

13. Follow..... To date, relatively few studies have been done comparing the Gustilo-Anderson and OTA classification systems with regard to prediction of treatment outcomes (eg, infection, limb amputation, need for soft-tissue coverage, or limb salvage). In a retrospective study aimed at examining this question, Hao et al found the OTA system to be better than the Gustilo-Anderson system at predicting postoperative complications and treatment outcomes in patients with open long-bone fractures.[8] Interobserver reliability appears to be comparable for the two systems

14. Presentation History obtain information regarding mechanism, location, and timing of injury arthrotomy  Open fractures occur in many ways, and the location and severity of the injury are directly related to the location and magnitude of the force applied to the body. Clearly, this involves a broad spectrum of clinical scenarios. In the most benign form, an open fracture may involve a very small wound caused by a sharp bone spike, creating a small, minimally contaminated hole in the overlying skin. The opposite end of the spectrum may involve high-velocity gunshot wounds, vehicular trauma, or industrial accidents with associated tissue crushing and devitalization .

15. Presentation Physical exam inspection assess soft-tissue damage the size and nature of the external wound may not reflect the damage to the deeper structures neurovascular if concern for vascular insult, ankle brachial index (ABI) should be obtained normal ratio is > 0.9 vascular surgery consult and angiogram is warranted if ABI < 0.9        provocative tests consider saline load test or CT scan if concern for traumatic arthrotomy some studies now show CT scan more sensitive than saline load test for the knee  

16. Ongoing workup of open fracture

17. Laboratory Studies Laboratory tests are typically not directly important for the acute care of an open fracture. However, many patients with open fractures will have other injuries that require appropriate laboratory investigation, and Advanced Trauma Life Support (ATLS) guidelines should be followed for workup of the traumatized patient Acute bacterial culture of open fracture wounds, before or shortly after initial debridement, is of little clinical utility. Organisms isolated in the acute phase of treatment do not correlate well with clinical infections that result from open fractures. Therefore, the routine use of cultures at this stage of care is of little benefit to the patient and is not cost-effective

18. Imaging Studies Radiographs indications X-RAYS examination is mandatory. Remember the ‘rule of twos’ • Two views – A fracture or a dislocation may not be seen on a single X-ray view, and at least two views ( anteroposterior and lateral) must be taken. • Two joints – In the forearm or leg, one bone may be fractured and angulated. Angulation, however, is impossible unless the other bone is also broken, or a joint dislocated. The joints above and below the fracture must both be included on the X-rays. • • Two limbs – In children, the appearance of immature epiphyses may confuse the diagnosis of a fracture; X-rays of the uninjured limb can be used for comparison. • Two injuries – Severe force often causes injuries at more than one level. Thus, with fractures of the calcaneum or femur it is important also to X-ray the pelvis and spine. • Two occasions – Some fractures are notoriously difficult to detect soon after injury, but another X-ray examination a week or two later may show the lesion.

19. Imaging Studies Radiographs ...... CT & MRI Computed tomography (CT) and magnetic resonance imaging (MRI) provide further detail of bone and soft-tissue injury, but they often are not immediately needed for the acute management of an open fracture . indications peri -articular injuries evaluation for traumatic arthrotomy of the knee Ul trasonography The use of ultrasonography (US) to assess tissue perfusion, myofascial compartment pressure monitoring, and perhaps magnetic resonance angiography

20. Treatment Nonoperative 1-Urgent IV antibiotics, 2-Tetanus prophylaxis, 3-Extremity stabilization and dressing indications initial treatment for all open fractures a soft tissue wound in proximity to a fracture should be treated as an open fracture until proven otherwise mutlidisciplinary training of open fracture management has been associated with decreased timing to antibiotic administration        antibiotic type indicated by injury pattern and location

21. Treatment operative Preface Urgent surgical intervention typically follows and involves both soft-tissue and bone management. Adjuncts to the care of open fractures have evolved and often involve delivery of antibiotics or metabolically important substances to the local fracture environment .

22. Treatment operative 1-I&D , 2-Temporary fracture stabilization, 3-Local antibiotic administration 4-Soft tissue coverage   indications consider I&D as soon as possible, may be beneficial within 6 hours in terms of decreasing infection risk ideal time of soft tissue coverage controversial, but most centers perform within 5-7 days outcomes infection rates of open fracture depend on zone of injury, periosteal stripping and delay in treatment incidence of fracture related infection range from <1% in grade I open fractures to 30% in grade III fractures 5-Definitive reconstruction and fracture fixation indications once soft tissue coverage is obtained and an adequate sterility is achieved outcomes definitive treatment with internal fixation leads to significantly decreased time to union, improved functional outcomes, and decreased time in the hospital compared to those definitively fixed with external fixation

23. *Gravity Irrigation (minimum 6 litres)

24. Technique……… Antibiotics Broad coverage for gram-positive organisms with the addition of gram-negative coverage for higher-grade injuries has become the most common choice for initiation of antibiotic therapy after open fracture. Timing initiate as soon as possible              studies show increased infection rate when antibiotics are delayed for more than 3 hours from time of injury continue for 24 hours after initial injury if wound is able to be closed primarily continue for 24 hours after final closure if wound is not closed during initial surgical debridement (48 hours for type III wounds)

25. Technique……… Antibiotics Types Gustilo type I and II 1st generation cephalosporin        clindamycin or vancomycin can also be used if allergies exist Gustilo type III 1st generation cephalosporin + aminoglycoside some institutions use vancomycin + cefepime farm injuries, heavy contamination, or possible bowel contamination add high dose penicillin for anaerobic coverage (clostridium)              special considerations fresh water wounds fluoroquinolones or 3rd or 4th generation cephalosporin saltwater wounds doxycycline + ceftazidime or a fluoroquinolone

26. Technique……… Tetanus prophylaxis Timing initiate in emergency room or trauma bay Forms of prophylaxis …. two 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

27. Technique 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 little evidence to support aggressive irrigation or irrigation with antiseptic solution in the ED, as this can push debris further into wound

28. NOTE ! The devices if EX. & INT. Fixation did not get advanced by change or adding to that much but more in its flexabilty and accuracy

29. Technique I&D, temporary fracture stabilization, local antibiotic administration and soft tissue coverage             Irrigation and debridement despite the great effectiveness of antibiotics, no principle is more important in the care of an open fracture than aggressive irrigation and débridement timing recent meta-analysis (GOLIATH study) have recommended debridement within 24 hours to minimize risk of infection for type III fractures within 12 hours for type IIIB open tibia fractures staged debridement and irrigation perform every 24 to 48 hours as needed

30. Technique Should we use antibiotics through which performing Irrigation and debridement??!!! Theories range from decreased penetrance secondary to an interruption in the blood supply to an increased penetrance related to local inflammatory mediators In either case, the use of antibiotics is not a substitute for thorough surgical débridement . Antibiotics are adjuvants best used in conjunction with surgical management.

31. When we can perform Irrigation and debridement??!!! It is recommended that débridement of open fractures be accomplished urgently, 1-once the patient’s medical condition has been stabilized, 2-once life threatening emergencies have been surgically or medically addressed, and 3-once appropriate surgical resourcesare available , including 1-An adequately trained and qualified operating room staff, . 2-appropriate assistance ,and 3-an adequately prepared surgeon . Neither emergent surgical intervention in the absence of physiologic stability nor prolonged elective delay is supported by the available literature or otherwise warranted in the management of open fractures.

32. Technique technique incision extend wound proximally and distally in line with extremity to adequate expose open fracture irrigation low-pressure bulb irrigation vs. high-pressure pulse lavage studies have shown that low pressure bulb irrigation is less expensive than high pressure pulse lavage and has no difference in infection rates or union rates      saline vs. saline with castile soap vs. antibiotic solution studies have shown that saline with castile soap had decreased primary wound healing problems when compared to antibiotic solutions on average, 3L of saline are used for each successive Gustilo type ( i.e 9L for type III)

33. Technique Debridement   thorough debridement of devitalized tissue is critical to prevent deep infection bony fragments without soft tissue attachments should be removed Temporary fracture stabilization  technique performed at the time of initial debridement external fixation is temporary initial treatment of choice for majority of high energy open fractures of the lower extremity

34. Technique Local antibiotic administration indications significantly contaminated wounds with large soft tissue defects large bony defects technique beads made by mixing methylmethacrylate with heat-stable antibiotic powder  vancomycin and tobramycin most commonly used

35. Soft tissue coverage timing early soft tissue coverage or wound closure is ideal      timing of flap coverage for open tibial fractures remains controversial, < 7 days is desired increased risk of infection beyond 7 days  odds of infection increase by 16% for each day beyond day 7   early studies demonstrated increased infection with delay beyond 72 hours, however recent studies do not support this finding (LEAP study) studies have not shown any statistical difference between rate of infection when ORIF is performed before fasciotomy closure, at fasciotomy closure, or after fasciotomy closure technique can proceed with bone grafting after wound is clean and closed negative-pressure wound therapy may be utilized during debridement until definitive coverage can be achieved (increased risk of infection if open >7 days

36. Technique Definitive reconstruction and fracture fixation no critical bone defect open reduction and internal fixation or intramedullary treatment depending on fracture location and morphology critical bone defect technique Masquelet technique ("induced-membrane" technique)      2 stage technique 1st stage : I&D, cement spacer and temporizing fixation 2nd stage : placement of bone graft into "induced membrane" and definitive fixation Studies show optimal time frame for bone grafting to be 4-6 weeks after placement of cement spacer distraction osteogenesis vascularized bone flap/transfer

37. Complications Surgical site infection incidence fracture related infection ranges from <1% in grade I open fractures to 30% in grade III fractures Osteomyelitis incidence ranges between 1.8% to 27% depending on the bone involved and grade/fracture type. the tibia is the most common site of post-surgical osteomyelitis following surgical treatment of open fractures risk factors include: blast mechanism of injury    acute surgical amputation delay in defintive soft tissue coverage greater than 7 days higher grade Gustillo -Anderson classification . Neurovascular injury Compartment syndrome

38. Long term Monitoring The frequency of follow-up is driven by various factors. The wound may have to be monitored closely in the early phases of healing. The particular fractures and chosen methods of fixation will determine the need for radiographic and clinical reexamination. ( See images .)

39. PROGNOSIS *To minimize risk of infection, debridement recommended to be performed within 24 hours for all type III fractures and within 12 hours for type IIIB open tibia fractures *Contamination with dirt and debris and devitalization of the soft tissues increase the risk of infection and other complications *Infection rates higher in open injuries due to blunt trauma compared to penetrating trauma

40. FUTURE DIRECTIONS Current research is addressing these critical issues. While culture methods are of limited value, culture-independent molecular techniques are being developed to provide informative detection of bacterial contamination and infection. Other advanced contamination and infection-detecting techniques are also being investigated. New hardware-coating methods are being developed to minimize the risk of biofilm formation in wounds, and immune stimulation techniques are being developed to prevent open fracture infections

41. Critical Issues Despite these established treatment paradigms, infections and infection-related complications remain a significant clinical burden. To address this, improvements need to be made in our ability to detect bacterial infections, effectively remove wound contamination, eradicate infections, and treat and prevent biofilm formation associated with fracture fixation hardware

42. References ORTOBULLTS ACADEMY WEBSITE Journal of American Academy of Orthopedics Surgeons 2020 OrthoInfo website ( Authorized by AAOS) ResearchGate website ( The AO/OTA-classification of Open fractures ( Medscape Medical Encyclopedia

43. THANK YOU Done by: HABEEB HAMEED ALI ABDULRAHMAN