MANAGEMENT OF OPEN FRACTURES FINAL.pptx by Marian Afful-Eshun

Management of open fractures, presented by Marian Afful-Eshun, Resident in surgery , Cape Coast teaching hospital, Ghana

1. MANAGEMENT OF OPEN FRACTURES PRESENTED BY MARIAN AFFUL-ESHUN

2. OUTLINE INTRODUCTION HISTORY EPIDEMIOLOGY ETIOLOGY AND MECHANISM OF INJURY TYPES OF OPEN FRACTURES CLASSIFICATION OF OPEN FRACTURES PRINCIPLES OF MANAGEMENT COMPLICATIONS RECENT ADVANCES AND GUIDELINES IN MANAGEMENT CONCLUSIONS REFERENCES

3. INTRODUCTION Fracture: is a complete or incomplete break in the continuity of a bone with soft tissue injury. Open fracture: is a fracture where the fracture hematoma communicates with an epithelial surface. Open fractures are known orthopedic emergencies due to risk of associated infections and healing problems . They may present as part of a spectrum in multiply injured/poly traumatic patients in a third of cases and hence carry significant morbidity and subsequent disability if not managed appropriately. The initial management of open fractures usually affects the ultimate outcome

4. HISTORY Until world war 1, treatment for open fractures was amputation and this was associated with a high mortality rate, with function in survivors being poor. Management has evolved , with 4 era of management being described 1. Era of life preservation 2. Era of limb preservation 3. Era of antibiotics and infection control 4. Era of restoration of function

5. EPIDEMIOLOGY Globally open fractures account for about 3% of all fractures, with estimation 11-30 per 100,000 population annually. It is higher in males than females( 2-4:1), particularly in the 20-40 year age group. The most commonly affected bones are : tibia 45-65% Femur 10-15% Fibula 10-12%(mostly with tibia) Upper limb 10-15%

6. EPIDEMIOLOGY In the united states between 3.5 to 6 million fractures occur annually and about 3% of it is estimated to be open fractures. In a study on epidemiological patterns and initial management of open fractures in a sub-urban teaching hospital by David Oyoh in Delta State University, published in July, 2019, it was established that open fractures are common in the age group of 20-49yrs, 63% being males and 37% females. Road traffic accidents were identified to be the commonest cause of open fractures In a study by Tolgu et al, on treatment outcome of open tibia shaft fracures between Feb 2012 to July 2012 at KBTH, it was established that 81% of the patients were males within the age range of 20-40yrs, with the main cause of the fractures being vehicular, followed by assaults and gun shots.

7. CCTH 2022-2024 In ccth between 2022 to 2024 a total of 301 open fractures were recorded.

8. ETIOLOGY AND MECHANISM OF INJURY HIGH ENERGY TRAUMA Road traffic accidents- most common cause in young adults Fall from heights –common in construction injuries Assaults –sharp object injuries Crush injuries-heavy object compressions Penetrating mesiles /gunshots- high velocity projectiles causing extensive bone and soft tissue damage Industrial/agricultural accidents- machinery related injuries

9. LOW ENERGY 1. Osteoporotic bones, bone infections, or bone tumors are usually leads weak bones and minor trauma or force could easily cause these bones to break. This is usually seen commonly in adult females with osteoporotic bones

10. TYPES OF OPEN FRACTURES INTERNALLY OPEN/INSIDE –OUT OPEN FRACTURES: Caused by sharp fracture fragment which pierces the overlying soft tissue and skin/ epithelium from within outward. Common in low to moderate energy injuries , especially in sharp oblique or spiral fractures of long bones eg tibia.

11. TYPES OF OPEN FRACTURES EXTERNALLY OPEN/OUTSIDE- IN OPEN FRACTURES: occurs when an external object penetrates the skin/epithelial surface and underlying soft tissue and impacts the bone. Seen in high energy trauma.

12. CLASSIFICATION OF OPEN FRACTURES In the setting of open fractures there are two common classifications that are used in practice: Gustilo Anderson classification Mangled Extremity Severity Score Other classifications : Oestern and Tscherne classification AO/OTA classification

13. GUSTILO-ANDERSON CLASSIFICATION Was proposed in 1976 by Dr. Ramon Gustilo and John Anderson and revised in 1984. This classification is aimed at guiding treatment decisions and predict infection risk and outcome. Classification is done definitively after debridement in theater Parameters that are considered for the Gustilo -Anderson classification are Size of wound Extent of soft tissue damage Degree of contamination Fracture pattern Periosteal stripping and bone exposure Neurovascular status

14. GUSTILO-ANDERSON CLASSIFICATION TYPE WOUND SIZE SOFT TISSUE INJURY FRACTURE PATTERN CONTAMINATION VASCULAR INJURY COVERAGE REQUIREMENT Type I <1cm Minimal soft tissue damage Simple, low energy minimal none Primary closure possible Type II >1cm and <10cm Moderate soft tissue damage, no extensive flaps or avulsion Moderate comminution moderate none Primary closure possible

15. GUSTILO-ANDERSON CLASSIFICATION TYPE WOUND SIZE SOFT TISSUE INJURY FRACTURE PATTERN CONTAMINATION VASCULAR INJURY COVERAGE RECQUIREMENT TYPE IIIA >10CM Extensive soft tissue damage, no flap needed Severe comminution Moderate to severe none Adequate Soft tissue for closure TYPE IIIB >10cm Extensive soft tissue loss, periosteal stripping, bone exposed Severe comminution Severe contamination none Requires flap for coverage TYPE IIIC Any size Any degree of soft tissue damage Any pattern Any level Major vascular injury requiring repair Soft tissue and vascular repair required

16. GUSTILO ANDERSON CLASSIFICATION

17. GUSTILO ANDERSON CLASSIFICATION

18. GUSTILO ANDERSON CLASSIFICATION

19. GUSTILO ANDERSON CLASSIFICATION

20. GUSTILO ANDERSON CLASSIFICATION any size

21. MANGLED EXTREMITY SEVERITY SCORE

22. MANGLED EXTREMITY SEVERITY SCORE MESS is a trauma scoring system designed to aid decision-making in the management of severely injured limbs, whether to attempt limb salvage or proceed with amputation. Was developed by Johann W. Johansen et al and introduced in 1990 in the journal of orthopaedic trauma based on data from 193 lower extremity injuries in trauma patients. Purpose of MESS in management of open fractures: 1.Provides structured ,objective method to assess the severity of limb trauma 2.Helps to predict limb viability and likelihood of successful salvage 3.Guides in triaging, particularly in mass casualty and poly trauma settings 4.Emphasises the importance of ischaemia time, mechanism of injury and physiological response

23. Mangled extremity severity score The components of MESS: skeletal/soft tissue injury Limb ischemia Shock Age of patient

24. Mangled extremity severity score TYPE CHARACTERISTICS INJURIES POINTS Skeletal/soft tissue group 1 Low-energy Stab wound, closed simple fx , small caliber gun shot wounds 1 2 Medium energy Open or multiple level fxs , dislocations, moderate crush injuries 2 3 High energy Shotgun blast(close range), high velocity gunshot wounds, crush injury 3 4 Very high energy High energy trauma +gross contamination, soft tissue avulsion 4 Shock group 1 Normotensive hemodynamics BP stable in field and in operation theatre 2 Transiently hypotensive BP unstable in field but responsive to IV fluids 1 3 Prolonged hypotension Systolic < 90 mmhg in field and responsive to iv fluids only in operation theatre 2

25. MANGLED EXTREMITY SEVERITY SCORE TYPE CHARACTERISTICS INJURIES POINTS Ischemia group 1 none A pulsatile limb without signs of ischemia 2 mild Pulse reduced or absent but perfusion normal 1 3 moderate Pulseless, parasthesia , diminished capillary refill 2 4 advanced Pulseless, cool, paralyzed and numb without capillary refill 3 Age group 1 <30yrs 2 >30-<50yrs 1 3 >50yrs 2

26. MANGLED EXTREMITY SEVERITY SCORE 6 OR LESS CONSISTENT WITH A SALVAGEABLE LIMB 7 OR GREATER AMPUTATION GENERALLY IS THE EVENTUAL RESULT NB: the MESS is not a verdict- it’s a tool. Surgical judgement remains paramount

27. PRINCIPLES OF MANAGEMENT The successful management of open fractures hinges on early, systematic, and multidisciplinary intervention aimed at saving life first, before saving the affected limb. 1.Initial evaluation, exclusion of life threatening injuries and resuscitation 2. Initial fracture management: Clinical image, sterile wound cover , splinting , elevation of limb , imaging, blood investigations 3 . analgesia 4 . Antibiotic and tetanus prophylaxis 5 . Urgent wound a fracture debridement 6 . Stabilization of fracture 7 . Early definitive wound cover 8 . Rehabilitation

28. Initial evaluation and resuscitation This is aimed at saving life. The ATLS protocol is employed in this assessment. This includes: primary survey with initial resuscitation secondary survey

29. ATLS PROTOCOL: PRIMARY SURVEY Seeks to identify immediate life threatening injuries A Airway with cervical spine protection B Breathing C Circulation with external hemorrhage control D Disability or neurological status E Exposure and Environment – remove clothing, keep warm. NB: catastrophic hemorrhage may be controlled before the airway, designated by the C-ABC sequence; however, death is ultimately caused by cerebral anoxia, regardless of whether the anoxia is a result of airway obstruction, respiratory failure or shock. Hence, the goal of resuscitation is to preserve the perfusion of the brain with oxygenated blood.

30. Adjuncts to primary survey Vital signs Pulse oximetry End-tidal carbon dioxide Arterial blood gases Urinary output Urethral catheter (unless contraindicated) Nasogastric tube (unless contraindicated

31. Secondary Survey The secondary survey is a detailed, head-to-toe evaluation to identify all injuries not recognized in the primary survey The components of the secondary survey are: 1.the history 2.physical examination ‘ 3. further diagnostic tests 4 . re-evaluation .

32. Initial fracture management A clinical picture of the wound is taken to record the injury the wound is first carefully inspected; any gross contamination is removed, the area is then covered with saline-soaked sterile dressing to prevent desiccation. This is left undisturbed until the patient is in the operating theatre. Limb is immobilized with a splint and elevated to reduce swelling Imaging studies are done to access the full extent of the fracture

33. Imaging X- rays are the first line imaging in all open fractures. Assess bone alignment, fracture pattern, joint involvement and presence of foreign bodies CT scan: may be indicated in complex or intra-articular fractures( eg tibial plateau, acetabulum), where there is suspected bone loss. This is usually necessary for pre- op planning. Doppler USG: done to assess vascular integrity in suspected arterial injury ( eg when there is absent distal pulses) CT: angiography: vascular injury evaluation ( esp in GA IIIC or mangled limbs) MRI: not usually done in acute phase, done for suspected ligamentous, nerve or other soft tissue injury.

34. I maging Trauma series of imaging should also be done: c spine, chest and pelvic x rays, abdominopelvic ultrasound etc. The imaging request should include: the patients name, age, hospital number, indication for the imaging, mechanism of injury, clinical examination findings, site and description of the injury. The urgency of the investigation should also be stated on the request. Requesting doctors details

35. Pain control Analgesics are administered to control pain Paracetamol opiods NSAIDS Regional blocks

36. Tetanus prophylaxis Clostridium tetani spores may enter the circulation through wounds and cause tetanus which is a life threatening condition. Prompt prophylaxis is a standard of care in all open injuries Consider all farm injuries, gunshots, crush injuries and GA III fractures as tetanus prone Recommended doses: Tetanus toxoid(Td): 0.5ml IM Tetanus immunoglobulin: 250-500iu IM Tetanus immunoglobulin given within 24hrs of injury is best for protection

37. Antibiotic prophylaxis Emperical antibiotics given within 4 hours based on common organisms helps to reduce risk of infection. Gustilo Type Typical organisms Recommended antibiotics Type I and II Gram positive( eg staph aureus) 1 st generation cephalosporin ( eg iv cefazolin, clindamycin in penicillin sensistivity Type III Gram positive and gram negative 1 st generation cephalosporin+ aminoglycoside Feacal /farm contaminated wounds Include anaerobes Metronidazole or penicillin

38. Urgent wound and fracture debridement and irrigation Gustilo et al in 1984: adequate debridement is the single most important factor in the attainment of a good result in the treatment of an open fracture . The treatment for open fractures is surgical debridement and external fixation. In general the goal is to render the wound free from foreign material and of dead tissue that would serve as a breeding ground for bacteria. Many surgeons prefer to use a tourniquet as this provides a bloodless field. However, this induces ischemia in an already badly injured leg and can make it difficult to recognize which structures are devitalized . A compromise is to apply the tourniquet but not to inflate it during the debridement unless absolutely necessary

39. Wound and fracture debridement The ff principles must be followed during debridement : Wound is usually irrigated with distilled water or normal tap water before scrubbing and draping is done. 2. Excision of wound margins: enough to leave healthy bleeding edges 3.Wound extension: this provides adequate exposure for thorough cleansing. Safest way is to do it along fasciotomy incision lines to avoid damage to perforator vessels that can be use to raise flaps for bone cover if need be. 4. Delivery of the fracture: This is to ensure adequate examination of the fracture surfaces. This is done by bending the limb in a manner in which it was forced at the time of injury

40. Removal of devitalized tissue: Muscles: dead muscle can be recognized by its purplish color , its mushy consistency , its failure to contract when stimulated and its failure to bleed when cut. Tendons: if cleanly lacerated, tag ends with non absorbable suture for later repair, when wound is clean and ready for coverage

41. Nerves: inspect for laceration, contusion or avulsion. If completely transected, tag both ends with a non absorbable suture for later repair. Blood vessels: arteries if transected, temporary shunt( eg argyle shunt) can be placed in between the two ends for limb salvage. Definitive repair is done if limb is viable and contamination is manageable. Large caliber veins can be repaired and small ones ligated. All doubtfully viable tissue, whether soft or bony, should be removed. The fracture ends can be curetted or nibbled away until seen to bleed.

42. I rrigation Washing the wound with large volumes of fluid will remove macro contaminants and clots than can obscure the view of deeper levels of contamination or damaged tissue. It also serves to diminish the residual bacterial contamination of the remaining tissue. Up to 9 litres of fluid can be used for irrigation (3L for GA I, 6L for GA II, 9 L GA III) The method of irrigation and choice of irrigant solution has been subjects of debate

43. Many studies have recommended the ff : Routine use of normal saline as irrigant The use of antibiotics and antiseptic solutions should be limited because of lack of evidence of efficacy and potential risk of chemical irritation to tissues. Low pressure methods of irrigation are recommended as high pressures(above 50psi) could cause damage to soft tissue and bone It is not advisable to inject fluid through a small aperture using a syringe – this only serves to push contaminants further in

44. Study on open wound irrigation The FLOW study (fluid lavage of open wounds) is one of the most significant randomized control trials on irrigation in open fracture management. FLOW investigators, Bhandari M, Jeray KJ, Petrisor BA, et al. A trial of wound irrigation in initial management of open fracture wounds. New England Journal of Medicine. 2015 This study was a RCT involving 2447 patients. Purpose was to compare high pressure vs low pressure vs gravity flow irrigation and soap vs normal saline irrigation in open fractures Findings: no significant difference rates between pressure methods, but saline was superior to soap in reducing complications Conclusion: gravity irrigation with normal saline is effective as high pressure systems and may reduce tissue damage and complications

45. Fracture stabilization Fracture stabilization is necessary for early functional motion of the extremity . The stability imparted also helps minimize ongoing trauma to soft tissues and provides a stable scaffold for tissue healing. The choice of fracture fixation is based on the following factors Location and pattern of fracture Time from injury to surgery Level of contamination Quality of local soft tissue Overall health of patient Presence and nature of associated injuries

46. Fracture stabilization External fixation is the preferred choice of skeletal stabilization. It may be temporary or permanent. The surgeon must however take caution not to insert the fixator pins into potential flaps needed by the plastic surgeon. The external fixator may be exchanged for internal fixation at the time of definitive wound cover as long as the delay to wound cover is less than 7 days, wound contamination is not visible and internal fixation can stabilize the fracture. If there is no obvious wound contamination and definitive wound cover can be achieved at the time of debridement, open fractures can be fixed internally or externally depending on the individual characteristics of the fracture and wound.

47. Wound management and closure Definitive wound coverage is a crucial step in the management of open fractures. The main aim is to achieve durable soft tissue cover that : Protects underlying bone and implants Prevents infection Allows for soft tissue healing and bony union Soft tissue repair in open fractures, should be conceived as a reconstructive ladder escalating from the simplest to the most sophisticated procedures. Soft tissue coverage should be considered only after debridement is complete

48. Timing of wound closure In 1976 Godina published his landmark study looking at the results of 532 patients showing lower rates of flap failure, infection and non –union if coverage was performed within 72hrs. This is known as Godina”s principle. If after initial debridement, surgeon is not convinced of the level of decontamination , return to surgery for a ‘second look’ should be done within 48–72 hours, and not later than 5  days, with a definitive fracture stabilization and wound cover plan in mind. Open fractures do not fare well if left exposed for long periods, and multiple returns to theatre for repeated debridement can be  self-defeating The choice of wound coverage depends on the size, location and complexity of the wound as well as vascular status of the surrounding tissue

49. WOUND RECONSTRUCTION LADDER

50. Primary closure A small uncontaminated wound in a GA type I or II may be sutured after adequate debridement and irrigation, provided this can be done without tension. Delayed primary closure can be done within 3 to 5 days if level of decontamination after initial debridement is not certain.

51. Split thickness skin graft Ideal for superficial defects Indications: Clean granulating wound bed after serial debridement. Superficial soft tissue loss without exposed bone, tendon, or implant Stable fracture already internally or externally fixed. NB: delayed split thickness skin graft can be done within 5-10days after debridement to allow granulation and infection control.

52. Flap reconstruction: for deep and complex defects. Indications Exposed bone, tendons joints or implants Large soft tissue defects > 6-8cm When primary closure or STSG is not feasible Failed prior grafts or wound breakdown Flap choice depends on location, size and zone of injury

53. FLAPS Local flaps Tissues adjacent to the wound are harvested and advanced, rotated or transposed to cover an adjacent defect. Typically based on direct cutaneous artery and vein or random pattern blood supply. Regional flaps Are harvested from the same anatomical region but not directly adjacent and transferred on a vascular pedicle to cover the defect. Maintains a named artery and vein during transfer eg gastrocnemius flaps used for anterior knee or proximal tibia wounds, soleus flaps for defects of the middle third of the tibia .

54. Mangled extremity Can pose life threatening complications such as hypovolemic shock, rhabdomyolysis, arrhythmias, acute renal failure , sepsis etc. Decision to do a limb salvage management or amputate can be challenging in some scenarios though there are protocols to guide this decision Always weigh the benefits of limb salvage against the risk of prolonged treatment, repeated surgeries and poor function as the goal is to optimize the patients survival, independence and quality of life. The following potential scenarios may arise in managing mangled extremities: Immediate amputations attempted salvage with early amputation Successful salvage Unsuccessful salvage with late amputation

55. Mangled extremity when to consider salvage: Anatomically intact nerve Can reconstruct vascular supply: proximal injury, warm ischaemia <6hrs Moderate soft tissue injury or loss Moderate bone loss Functional distal joints Young patients

56. Mangled extremity Absolute indications for amputation: Warm ischemia > 6hrs with non- reconstructible arterial injury Crushed limb with complete loss of neurovascular structures Complete traumatic amputation with prolonged ischemia or gross contamination Non viable limb: cold, pulsesless , insensate with rigor or necrosis Severe life threatening sepsis from limb infection( eg gas gangrene, nectrotizing fasciitis) Uncontrollable hemorrhage despite surgical attempts Extensive soft tissue and bone loss that makes reconstruction impossible Avulsion or segmental loss of major vessesls and nerves in ahemodynamically unstable patient

57. Mangled extremity relative indications for amputation: These depend on functional, systemic or logistic factors: 1.MESS>/= 7 with multiple poor prognostic features 2.Severe associated injuries with poor overall survival odds( polytrauma , severe head injury) 3.Poor patient physiological reserve(elderly, comorbidities eg DM, HPT,HIV etc ) 4.Multiple failed attempts at salvage with infection or poor healing 5.Non– reconstructible limb after prior failed vascular repair 6.Poor rehabilitation potential-non compliance, low functional demand, psychiatric comorbidity 7.Patient preference after thorough counselling

58. TRAUMATIC AMPUTATION AND LIMB REATTACHMENT INDICATIONS: Clean-cut injuries ( eg sharp guillotine- type injuries Traumatic amputations in children(better healing and neuroplasticity) Thumb, fingers or hand amputation Proximal amputations eg arm and forearm CONTRAINDICATIONS: Crush injuries with extensive soft tissue damage Long warm ischemia time (>6hrs) Severe comorbidities Prolonged delay to surgery without proper preservation

59. Preservation of amputated part Clean in saline and wrap in sterile gauze Place in plastic bag and immerse the bag in ice water(4dc) Avoid direct contact between tissue and ice to prevent frost biteinjury Cold ischemia time limits: Muscle containing parts- <6hrs(warm), <12hrs(cold) Non muscle parts(fingers): upto 24hrs with cold preservation

60. Surgical principles of reattachment Debridement: remove all non viable tissue while preserving as much length and structure as possible Bone shortening and fixation: bones are shortened to relive tension and allow vascular and nerve repair. Internal fixation using k wires or mini plates and screws. Vascular repair: arteries and veins are repaired using microvascular techniques. Arterial inflow is established before venous drainage. Tendon repair: flexor and extensor tendons are repaired using core sutires and epitendinous sutures Nerve coaptation : precise alignment of nerve ends( epineural repair), early repair leads to better functional recovery. Skin closure: primary closure if possible. Consider grafts or flaps in cases of soft tissue loss.

61. Post operatively: monitor vascular patency: color, capillary refill, temperature Immobilize in functional position using splint or cast Anticoagulation to prevent thrombosis Infection prevention with antibiotics

62. Rehabilitation Immediate objectives of rehabilitation are to prevent muscle atrophy, prevent joint stiffness and improve circulation in the extremity. The ultimate objective is to restore the extremity to the greatest degree of function.. A well organized rehabilitation program initiated early will help return the patient to functional status This involves physiotherapy and occupational therapy, prosthesis

63. Advances in surgical management of open fractures Negative pressure wound therapy: enhances granulation tissue formation, reduces edema and helps in wound contraction Local antibiotic carriers eg gentamycin coated nails, calcium suloahte beads reduce deep infections Stem cell and biologic therapies Mesecnchymal stem cells studied for enhanced osteogenesis and angiogenesis Use of bone morphogenic protiens like BMP-2 in non union and segmental defects

64. Complications of open fractures SYSTEMIC COMPLICATIONS: SHOCK FAT EMBOLISM ARDS SEPSIS

65. LOCAL COMPLICATIONS OF OPEN FRACTURES: EARLY LATE URGENT LESS URGENT Local visceral injury Myositis ossificans Delayed union Vascular inury Fracture blister malunion Nerve injury Plaster sores Non union Compartment syndrome Pressure sores osteoarthritis haemarthrosis Nerve entrapment Chronic osteomyelitis infection Ligament injury Avascular necrosis Gas gangrene Tendon injury Growth disturbance Complex regional pain syndrome( algodystrophy ) Joint stiffness Muscle contracture

66. MALUNION NON-UNION

67. CHRONIC OSTEOMYELITIS

68. MYOSITIS OSSIFICANS

69. conclusion Open fractures occur on a daily basis and may associated with other life threatening injuries therefore management of patients should be given a holistic approach. Antibiotic and tetanus prophylaxis must be initiated early and tailored to the wound and setting Early and effective debridement remains the cornerstone of management Fracture stabilization and timely soft tissue cover are essential to prevent infection and promote healing Management is directed at getting the patient back to functional capacity and hence multidesciplinary approach must be employed in management: orthopedics, plastics, infectious dx specialist, physiotherapy, occupational therapy Open fracture care is not just about fixing ones- its about restoring life

70. references Apley”s system of orthopaedic AO principles of fracture management Millers review orthopaedics Medscape Ortho bullets Pub MED Post Graduate Medical Journal, Ghana College of physicians and Surgeons

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