COMPOUND FRACTURES principles and management

Open grade fracture principles of management

1. Compound Fractures

2. Overview
Classification
Debridement
Stabilization
Soft tissue cover
Complications
….finally !

3. Classification
(Gustilo & Anderson, 1976 )
Type I Puncture wound, clean
Type II Laceration
No tissue loss or
contamination
Type III extensive damage &contamination
a ) soft tissue cover possible
b ) soft tissue recon –flaps / graft
c ) added arterial injury

4. Type I –most deceptive !
puncture wound, clean

5. Type II
Laceration >1cm
No tissue loss, skin flaps
or
contamination

6. Type IIIa
extensive damage &contamination
a ) soft tissue cover possible

7. Type IIIb –soft tissue
recon
Soft tissue loss
Periosteal stripping
Bone exposure

8. Type IIIc, most challenging
…when in doubt amputate !

9. Management @ site
Stop haemorrhage
-pressure
Clean wound
-plenty of water
Cover with clean cloth
Splint
Do not try to push fragments into
the limb !

10. In casualty…
Body fluid isolation
-gown, gloves, glasses
IV access, correct shock
Tridot, HbsAg, Biochemistry
X-ray

11. Debridement
Fr :meaning removal of dead and
devitalised tissue
War wounds

12. Debridement, cont’d
Steps: c/s of site, blood
-antibiotics
-tourniquet application
Tourniquet ?
-pneumatic
-Eschmarc bandage

13. Debridement, cont’d
Plenty of water, saline,
Ringer lactate
Antibiotic scrub ( Providone iodine )
Scour for debris
2
nd
look in 48 hrs

14. Fracture stabilisation
External fixation
Internal fixation
-interlocking nails
-plate & screws

15. Case study
12yr old boy
RTA,
run over
by
school bus

16. Irrigate with water
in OT,
6-10
liters

17. …excise all dead tissue
Skin,
muscle,
tendons &
bone
…to this !

18. Soft tissue cover : groin flap

19. External fixation
Stabilise # from outside
Compound fractures
Risk of infection reduced
Soft tissue reconstruction

20. Ex Fix -types
Pin and Rod assemblies
Dynamic axial fixator
Ilizarov ( ring ) Fixator

21. Pin and Rod assemblies
Schanz pins
Rods
Clamps
Uniplanar
Multiplanar more
stable

22. Ex Fix : principles
For a stable construct
-2 pins as close to # as possible
-proximal & distal pins as far as
possible
-rod close to limb
-rod to rod connectors will
strengthen assembly

23. Ilizarov ( ring ) Fixator
GA Ilizarov
Kurgan

24. Ouch ! …

25. Ilizarov ( ring ) Fixator
principle –bone loss

26. Ilizarov, case study

27. Dynamic axial fixator
Clamps on a rail
Stable
Versatile
-compression
-distraction
-fragment
transport

28. DAF cont’d

29. Hybrids
Combine ext & Int
fixations

30. Soft tissue cover
Reconstructive ladder
“ the Ortho Plastic approach”
Split skin grafts
Local flap
Distant flap
Free tissue transfer

31. Skin grafts
Split skin graft
( Thriesh )
do not include
dermis
Full thickness
( Wolff )

32. Local flaps
Muscle
Myocutaneous
Faciocutaneous
needs SSG

33. Distant flaps
Cross leg flap
Groin flap

34. Free flaps
Tissue harvested with artery &
venae commitentes
Skin & facia / muscle / composite
Anastomosis at recipient site
Microvascular technique

35. Philosophy :
function before ego !

36. Epiphyseal injuries
Children
Weakest point is the physis
Growth disturbance

37. Classification ( Salter Harris )
Type 1 –transverse thru plate
Type 2 –with triangular
metaphyseal fragment
Type 3 –split in physis and
goes along the plate

38. Classification ( Salter Harris )
Type 4 –splits physis
extends to metaphysis
Type 5 –crushing of growth plate

39. Course
Types 1 & 2 no disturbance
3 may grow normally
( early recognition and reduction )
4 & 5 high risk of growth arrest