KIRU OPEN FRACTURES Ani.pptx its about fracture

about fractures

1. “Comprehensive Approaches to Managing Open Fractures” Dr. S Kirushanth (Registrar – Surgery)

2. Initial management

3. According to ATLS principles C (Overt bleeding) ABDE Identify limb-threatening injuries Vascular injuries to limb Compartment syndrome (10% open fracture can have compartment Xn ) If there is doubt about an open fracture, it is safer to proceed as though open until proven otherwise ALWAYS!!!!! 1. Life 2. Limb 3. Function

4. Antibiotic (first most important intervention in reduction of future wound infection)

5. Phase 2 At the time of definitive skeletal stabilization and soft tissue coverage Teicoplanin 800mg (if not been given within the past 12h) PLUS Gentamicin 3mg/kg (If not been given within the last 16h) (This will provide cover for organisms selected out from initial prophylaxis & Nosocomical pathogens) No further post-operative antibiotics are required

6. Thromboprophylaxis

7. Imaging X Rays - Two views obtained should be orthogonal to each other Include joints above and below the injured segment. Angiography – Should not delay emergency revascularization of an ischemic limb Immediate surgical exploration and shunting is indicated if hard signs of vascular injury persist after any necessary restoration of limb alignment and joint reduction.

8. SALVAGE? AMPUTATE?

9. Multiple scoring systems……!!!!!

10. Most commonly used scoring system worldwide <6 – Salvagable >7 – Amputation The disadvantage is that it gives more emphasis on limb ischaemia but less importance to soft tissue injury.

11. Subsequent Management?

12. Wound Debridement

13. Timing of wound debridement I mmediate WD I mmediate WD within 12 hours of injury Within 24H WD

14. Timing of wound debridement I mmediate WD I mmediate WD within 12 hours of injury Within 24H WD

15. Timing of wound debridement I mmediate WD I mmediate WD within 12 hours of injury Within 24H WD

16. Timing of wound debridement I mmediate WD I mmediate WD within 12 hours of injury Within 24H WD

17. Who should do wound Debridement? Wound debridement should be done by the most experienced senior plastic and orthopedic surgeons working together

18. Principles of WD

19. Muscle  viability four ‘C’s ; Color (pink not blue), C ontraction C onsistency (devitalized muscle tears in the forceps during retraction) C apacity to bleed. Devitalized muscles need to be excised. Bone Gently deliver the bone ends through the wound Clean edges. Then nibble the bone ends until capillary bleeding (punctate bleeding) from exposed cortical surfaces ( paprika sign ) Loose fragments of bone which fail the ‘tug test’ are removed Bone fragments that do not dislodge with viable soft tissue attachments are left Low- pressure lavage with a high volume of 0.9% saline completes the wound excision.. (3L – 12L)

20. Management / Reconstruction of bone and Soft tissues

21.   So, ideally, open fractures should be managed in a single sitting , with cleaning of the wound, wound debridement, fracture fixation and soft tissue closure This immediate definitive treatment has been termed ‘fix and flap’ However, immediate stabilization and cover is only possible if surgeons with orthopedic and plastic surgical expertise are both present at the time of initial surgery. “This should result in the lowest free flap failure and deep infection rates (No time for wounds to become colonized)”

22. Management of Soft tissues (Primarily sutured (after debridement), provided this can be done without tension) Both orthopedic and plastic surgeons are satisfied with a clean, viable wound achieved after debridement

23. Management of Soft tissues (Primarily sutured (after debridement), provided this can be done without tension) Both orthopedic and plastic surgeons are satisfied with a clean, viable wound achieved after debridement

24. Management of Soft tissues (Primarily sutured (after debridement), provided this can be done without tension) Both orthopedic and plastic surgeons are satisfied with a clean, viable wound achieved after debridement

25. The definitive soft tissue coverage cannot be achieved at the time of initial debridement in the following instances, Unable to achieve a clean, viable wound after debridement (e.g. – severe contamination) No plastic surgical expertise is available Patients is not physiologically well enough to tolerate prolonged surgery and will require temporization of their injuries ( Damage Control Orthopaedic )

26. Management of bone

27. (Primarily Internal fixation) “This is because open fractures are only contaminated and not infected”

28. After care

29. SOURCES The Standards for the Management of Open Fractures of the Lower Limb – BAPRAS, BOA 2020 Classification and management of acute wounds and open fractures- Surgery International Article Apley and Solomon’s System of Orthopedics and trauma(10 th edition) https:// surgeryreference.aofoundation.org /orthopedic-trauma/adult-trauma/further-reading/principles-of-management-of-open-fractures

30. Thank you