KIRU OPEN FRACTURES from Bapras guideline

About open fracture by new BaPRAs guideline

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

2. Definition
•A fracture, where the fracture hematoma communicates with the
external environment via a traumatic violation of the soft tissue and
skin
Open fractures are associated,
•High-energy trauma
•Thus, associated systemic injuries
•Significant soft tissue injury
•High risk of infection due to contamination

4. Initial management

5. •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

6. 1. Gross contamination is removed manually (no
washing)
2. Photographed
3. The limb is re-aligned
4. Covered with a sterile saline-soaked dressing
5. Splinted

7. A ‘mini debridement’ of the open
fracture in the emergency room
does not aid treatment.
(Lavage through the open wound
serves to drive particulate debris
further in !!!!)
Antiseptics in the dressing should not be used !!

8. Assessment of the limb
Distal neurovascular status should be
assessed & documented
(and repeated after each intervention –
e.g. – splinting)
IF ABSENT -
REALIGNMENT
Look for features of
compartment syndrome
Analgesics

9. Antibiotic
(first most important intervention in reduction of future wound infection)
•Majority of deep infections were caused by nosocomial organisms, most being
resistant to the initial antibiotic prophylaxis aimed at environmental flora
Two-phase antibiotic protocol
•co-amoxiclav (1.2 g) 8-hourly intravenously (iv) or
•an intravenous cephalosporin, e.g.ceftriaxone 2 g daily
•Penicillin allergy –IV Clindamycin 900mg 8-hourly (+ Gentamicin 3mg/kg single
dose for presumed Gustilo grade III fractures)
•Known or high risk of MRSA –IV Teicoplanin 800mg daily (Extra loading dose
after 12h)
Phase 1 – within 1 hour of injury

10. •Singe dose of IV Gentamicin 3mg/kg should be added to the above (Unless
the patient has already received gentamicin within the past 16h)
•Further dose of co-amoxiclavintraoperativelyif,
•Major blood loss (>10% of blood volume)
•If the procedure lasts for more than 3 hours
•Do not give additional doses of once-daily antibiotics unless it has been
more than 16h from the last dose
•Following wound excision phase 1 should be continued for 24h
At first wound excision on induction of anaesthesia

11. •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

12. Thromboprophylaxis
58% of patients with major trauma develop venous thromboembolism
Risk population
•Advanced age
•obesity
All patients must be considered for thromboprophylaxis.
•Low molecular weight heparin (i.e. enoxaparin) is preferred
Although caution is needed where patients are coagulopathic or there may be bleeding from
associated vascular, intracranial, or visceral injuries

13. 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.

14. Tetanus Prophylaxis
If given with 5 year
No further
immunization needed
Given 5 – 10 years
Booster dose is given
Not given within 10
years
1. Vaccine
+
2. Immunoglobulin

15. SALVAGE? AMPUTATE?

16. Multiple scoring systems……!!!!!
The most widely used scoring systems are
•Mangled Extremity Severity Score (MESS)
•Mangled Extremity Syndrome Index (MESI)
•Predictive Salvage Index (PSI)
•Limb Salvage Index (LSI)
•Ganga Hospital Open Injury Severity Scoring (GHOISS)

17. 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.

19. Do not base the decision on whether to perform limb
salvage or amputation on an injury severity tool score.
Ideally, decisions regarding salvage or primary amputation of a
severely injured limb should be made jointly by an orthopedic and
plastic surgeon with appropriate experience of limb salvage surgery
and with careful counselling of the patient their family members
about likely outcome with the two treatment option.

20. Subsequent Management?

21. Gustilo’s classification of open fractures into three types is widely
used for this purpose (Gustilo et al., 1984)
If the limb can be salvaged, subsequent treatment is determined by
the
Type of fracture,
Nature of the soft-tissue
injury
(including the wound size)
Degree of contamination.

29. Wound
Debridement

30. Timing of wound debridement
If any limb threatening
condition(GA IIIc)
Highly
contaminated
open fractures
(Marine,
agricultural and
sewage
contamination)
High-energy open
fractures (likely
Gustilo–Anderson
classification type
IIIA or type IIIB) that
are not highly
contaminated
All other
open
fractures
(Type I & II)
Immediate WD
Immediate WD
within 12 hours of injury
Within 24H WD

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

32. Principles of WD
•Dressings applied in the emergency room should only be removed when the patient is
in the operating theatre.
•After induction à a ‘prewash’ of the limb is performed with a soapy chlorhexidine
solution
•After the prewash à the patient is then transferred to the operating table and limb
prepped & draped for surgery in the standard manner (No betadine on wound)
•Tourniquet use is determined by surgical preference
•Gentamycin single dose of 3mg/kg is given at the time of WD (not on admission)

33. Debridement should be from systematically in
turn from superficial to deep, layer by layer,
peripheral to central.
Non-viable skin à excised to leave edges that
bleed from the dermis
Subcutaneous fat à needs wider excision
compared to skin
Wound extension? à always along fasciotomy
lines. This incision does not disturb skin
perforators (important for flap cover later).
Subcutaneous
Tissue
Deep Fascia
Muscle
Bone

34. •Muscle à viability four ‘C’s;
•Color (pink not blue), •Contraction
•Consistency (devitalized muscle tears in the forceps during retraction)
•Capacity 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)

35. Management / Reconstruction of
bone and Soft tissues

36. Wound
Debridement
Clean surgery

37. •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)”

38. Management
of Soft tissues
Soft tissue Management
GA Type IGA Type IIGA Type III
immediate fracture
stabilization and primary
soft tissue cover
Local/Distal flapSSG
(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

39. •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)

40. Definitive soft tissue coverage cannot be achieved
Fracture is temporarily stabilized externally and dress with a temporary
impervious dressing
Second look procedure for definitive coverage or closure should be performed
within 72 hours and not later than 5 days
Gentamicin 3 mg/kg dose is combined with either vancomycin 1 g or teicoplanin
800 mg on induction of anesthesia

41. Management of bone
If there is
1. No obvious contamination
2. Minimal contamination
3. Definitive wound cover can be achieved at the time of
debridement
open fractures of all types can be treated as for a
closed injury.

42. Bone Fixation
GA Type IGA Type IIGA Type III
If your happy with your
wound debridement and
tissue cover can be
achieved
Internal fixation
(Primarily Internal fixation)
“This is because open fractures are only
contaminated and not infected”

43. Definitive soft tissue coverage cannot be achieved
External fixation can be used as a temporary measure
The external fixator may be exchanged for internal fixation at the time of definitive wound
cover as long as:
(1) The delay to wound cover is less than 7 days
(2) Wound contamination is not visible.

44. After care

45. In the ward, the limb is elevated and its circulation carefully watched.
Antibiotics are continued accordingly
Optimize general condition of patient (Hb, Nutrition, etc.)
Start rehabilitation

47. 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(10th edition)
•https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/further-
reading/principles-of-management-of-open-fractures

48. Thank you