open injury and open fracture management

Open fracture management

1. BY. DR.HARDIK BHALIYA(R2) DR.PRAMOD CHAKALABI(R1) MENTOR DR.SANKET SUTARIYA SIR(ASSISTANT PROFESSOR) OPEN FRACTURE CLASSIFICATION AND PRINCIPLES & MANAGEMENT OF OPEN INJURY

2. Introduction An open fracture is defined as an injury where the fracture and the fracture hematoma communicate with the external environment through a traumatic defect in the surrounding soft tissues and overlying skin. It should be emphasized that the skin defect may not lie directly over the fracture site and may lie at a distant site. It may communicate with the fracture under degloved skin. Hence any fracture associated with a wound in the same region must be considered to be an open injury until proven otherwise by surgical exploration.

3. The wound may be distant and there may be no direct exposure of the fracture Any wound, no matter how small or distant from the fracture, must still be considered indicative of an open fracture.

4. Apart from severe bone and soft tissue involvement, these injuries have other risk factors such as Skin degloving, soft tissue crushing, contamination with dirt and debris and injury to neurovascular structures. Hence they are associated with a high risk of complications, Recent developments such as advances in the management of polytrauma, the availability of powerful antibiotics, refinement of the techniques of radical debridement, bone stabilization,and early soft tissue reconstruction have helped to improve the outcome. The present challenge of the trauma surgeon is not simply salvage of the limb but the restoration of maximal function . Patients with a disfigured or painful limb are often very dissatisfied with the results of treatment and may opt for amputation at the end of a prolonged treatment regime.

5. Open fractures can occur in low-velocity injuries due to the sharp ends of the fractured bone piercing the skin and soft tissues but more often they are the result of high-energy injuries. The size and nature of the external wound may not reflect the damage to the deeper structures Frequently small lacerated wounds are associated with extensive occult degloving with severe soft tissue damage and bone comminution.

6. The severity of the skin wound often has no bearing on the extent of damage to deeper tissues. An open tibial diaphyseal fractures with a small skin wound (A) was associated with significant bone and soft tissue damage (c). A C One must also be aware that the extent of injury to the soft tissues and bone may not be fully exposed on day 1 and the actual “ zone of injury ” may be revealed only over the next few days

7. This has important implications in choosing the timing and nature of soft tissue reconstruction. It should also be understood that an open injury is just not a simple combination of a fracture and a wound. Additional factors such as contamination with dirt and debris and devitalization of the soft tissues increase the risk of infection and other complications.

8. Open fractures need Prompt diagnosis appropriate intravenous antibiotics meticulous injury zone excision (debridement) fracture stabilization second look soft-tissue cover after soft-tissue recovery

9. Assessment Every open injury is an orthopedic emergency and the success of treatment depends on a thorough initial evaluation and management that starts at the emergency room thorough evaluation as per ATLS protocols( airway,breathing,and circulation). There may be a number of injuries that are missed and there is a role for fast whole-body CT scanning which helps to identify injuries to the head, neck, spine,chest, and pelvis. An estimate of the blood loss must be undertaken quickly, if necessary, resuscitation measures immediately instituted. Inadequate resuscitation is an important cause of avoidable deaths and later comorbidities such as infection, delayed wound healing, and pulmonary complications. Acidosis, hypothermia,and coagulopathy often present in patients with open injuries and these must be identified and corrected quickly.

10. Once the patient is stabilized it is important that the circumstances of the accident and the patient’s history are meticulously documented. Documentation starts with a thorough history which includes details of the accident, the time of injury, any loss of consciousness , and other evidence of head injury, temporary or partial paralysis, the probable velocity of injury, the use of seat belts and helmets Witnesses and accompanying family members may provide useful information regarding the nature of the injury. resuscitative measures undertaken at the scene of the accident, and ask for the condition of the patient during Transport Ask for any COMORBIDITIES

11. resuscitation with crystalloid solutions was associated with lower rates of renal impairment and mortality. It was considered that losses into the interstitial space occurred due to edema formation that required additional fluid replacement. Therefore infusion of a combination of crystalloid and blood in a 3:1 ratio was recommended. in the subgroup of trauma patients, a significant improvement in the overall survival rate was observed in the group administered crystalloid. Crystalloid fluid is therefore considered to be the first treatment choice More recently, newer products with higher molecular weights have become available that should be more efficient in maintaining fluid in the intravascular space. There is further evidence however that in cases of severe hemorrhagic shock, increased capillary permeability allows these molecules to leak into the interstitium, worsening tissue edema and oxygen delivery

12. Traditionally, target hemoglobin concentrations of 10 g/L have been advocated , Randomized trials in selected normovolemic intensive care patients showed that maintenance of hemoglobin concentrations between 7 and 9 g/L resulted in equivalent outcomes to maintenance of hemoglobin concentrations above 10 g/L . transfusion requirement has been shown to constitute an independent risk factor for mortality in trauma.

13. Examination The patient should be adequately undressed so that any bruising and contusions in other parts of the body that might indicate more significant injury can be seen. This is especially important in patients who are not fully conscious or under the influence of alcohol. All constrictive clothing must be removed and the vascularity and movements of all four limbs must be examined An injured limb that is grossly deformed or shortened must be gently reduced and splinted so that vascularity is not compromised . Photographic documentation of the wound should ideally be undertaken. This is important as a good visual documentation surpasses any written description and will be of immense value during follow-up examinations

14. Tenting of the skin by sharp bone fragments or dislocated joints may lead to avascularity and further loss of skin and these fractures must be considered as impending open fractures even when no wound is present

15. In the emergency room examination of the wound should include the size and location of the wound, the orientation of the wound, to define if it is longitudinal, transverse or irregular, the depth of the wound and whether bone, tendons, and muscle are exposed. Attention should be paid to the status of the skin adjacent to the wound. If there is extensive damage or contusions to the skin around the wound there may be significant skin avascularity and therefore skin loss during debridement

16. the wound must be quickly covered with a sterile dressing . Probing or further handling of the wound may in fact be disadvantageous as it may provoke unnecessary bleeding and increase the chances of secondary contamination and nosocomial infections Significant bleeding may be controlled by application of a compression dressing and firm bandages with elevation of the limb. The surgeon should not attempt to blindly clamp a bleeding vein or artery in the emergency room as this may result in the unplanned clamping of an adjacent major neurovascular structure and lead to permanent and irreversible neurologic deficit Uncontrollable bleeding from a wound can be arrested with the help of a tourniquet .

17. Signs of Vascular Injury Hard Signs Absent or significant difference in pulsations compared to normal side. Severe bleeding from the wound. Expanding and pulsatile hematoma. Bruit or thrill. Associated Signs Associated numbness and neurologic deficit. Difference in skin temperature distal to injury. Absence of venous filling. Absence of pulse-oximeter reading .

18. If pulses are absent, one must re-examine the limb after the limbs are anatomically aligned and splinted as shortening and angulation of the fractured skeleton may result in kinking and occlusion of the vessels. investigations such as arterial doppler or a CT angiogram may be necessary. Documentation of the distal neurologic status is the next step. Both touch sensation and pinprick testing can be used to examine distal dermatomes and motor movements can also be tested.

19. Antibiotics Once the limb is properly splinted, bleeding has been controlled and the wound is covered with a wet saline dressing appropriate intravenous antibiotics should be administered The antibiotic therapy should be considered therapeutic and not prophylactic and it must be instituted as early as possible In addition, the patient’s tetanus status must be documented and supplementary injections given Gustilo type I & II injuries ( In the absence of organic or sewage contamination) IV cephalosporins Gustilo type III injuries A dd aminoglycoside With gross organic contamination Add Penicillin, with or without metronidazole

20. Intravenous Antibiotic Therapy for Open Fractures Give antibiotics as soon as possible (within 1 hours ). Agent of choice co- amoxiclav (1.2 g 8 hourly), or a cephalosporin(e.g., cefuroxime 1.5 g 8 hourly), continued until first debridement(excision). At the time of first debridement , co-amoxiclav (1.2 g) or a cephalosporin (such as cefuroxime 1.5 g) and gentamicin (1.5 mg/kg) should be administered and co- amoxiclav /cephalosporin continued until soft tissue closure or for a maximum of 72 hours, whichever is sooner. Gentamicin 1.5 mg/kg and either vancomycin 1 g or should be administered on induction of anesthesia at the time of skeletal stabilization and definitive soft tissue closure . These should not be continued postoperatively. Ideally start the vancomycin infusion at least 90 minutes before surgery. True penicillin allergy (anaphylaxis) clindamycin (600 mg IV pre-op/ qds ) in place of co-amoxiclav/cephalosporin. Lesser allergic reaction to penicillin (rash, etc.) a cephalosporin is considered to be safe and is the agent of choice.

21. Intravenous Antibiotic Therapy Evidence Supports Evidence Does Not Support Intravenous antibiotics at the earliest, preferably in the emergency room. • Use of metronidazole and aminoglyosides in severely contaminated wounds. • Equivalent efficacy of oral to parenteral antibiotics during the follow-up (when necessary). Prolonged and continuous use of antibiotics. • Continuing antibiotics as long as the drains are in. • Continuation of the empirical antibiotic regime till wound drainage is present. • Prophylactic antibiotics to prevent pin tract infections. • Antibiotic therapy as a substitute for debridement in presence of necrotic and contaminated material

22. Role of Cultures Infection is the major complication that leads to the need for secondary procedures, nonunions, failure of flaps, and even amputations. This fact stimulated surgeons to try to identify the bacteria that cause wound contamination. However studies have shown poor correlation between the presence of positive cultures and subsequent rate of clinical infection. There is disparity between the organisms grown on the initial wound swabs and the organisms grown subsequently. after the development of wound infection The commonly isolated organisms from established infection are Staphylococcus aureus, Pseudomonas, and Escherichia coli. These organisms are frequently due to hospital contamination and are never isolated from the environment where the accidents occur. The practice of obtaining routine cultures from the wound either pre- or post-debridement is no longer advocated.

23. Radiographic Imaging and Other Diagnostic Studies An anteroposterior and lateral radiograph of the injured bone with inclusion of the joints above and below is the minimum that is required Radiographic clearance of the cervical and thoracolumbar spines must be undertaken when necessary The presence of air in the subcutaneous tissues, intramuscular planes, and joint cavities and the visualization of foreign bodies are indicative of open injuries. The presence of air in the subcutaneous tissues in puncture wounds or small lacerations indicates severe degloving of the skin . Radiographic evidence of severe mud contamination, shattered glass, or metal pieces suggests significant contamination In the absence of life-threatening injuries, a CT scan may prove helpful particularly in intra-articular fractures

24. Mangled Extremity Severity Score (MESS) A score of >7 has been reported to predict amputation accurately in both retrospective and prospective studies

25. Ganga Hospital Open Injury Score (GHOIS) score ≤ 14 are advised salvage . • score ≥17 usually end up in amputation. • score 15 and 16 fall into gray zone where decision is made on patient to patient basis. Advantages of Ganga Hospital Open Injury Score Specifically designed for Type 3b injuries . • Assesses severity of injury to skin, muscle, bone separately. • Total score predicts amputation . • Individual score provides guidelines for reconstruction. • Scoring includes comorbidities which influences outcome. • Better interobserver agreement compared to Gustilo classification.

26. score 1 Wound without skin loss and not exposing the fracture score 2 wound without skin loss but exposing the fracture site score 3 wound with skin loss and not over the fracture site Score 4 wound with skin loss and over the fracture site , score 5 circumferential wound with bone circumferentially exposed.

27. score 1 transverse /oblique fractures / butterfly fragment involving less than 50% of circumference score 2 the presence of a large butterfly fragment involving more than 50% of circumference score 3 extensively comminuted or segmental fractures without loss of bone score 4 primary or secondary loss of bone of <4 cm score 5 loss of > 4 cm

28. score 1 partial injury to musculotendinous units Score2 complete but repairable injury to musculotendinous units score 3 irreparable injury to musculotendinous units involving one or more muscles in a compartment or complete injury to nerve score 4 loss of one entire compartment score 5 loss of two or more compartments or subtotal amputation.

29. Treatment Options Debridement and Lavage Debridement is an active surgical procedure and not just wound washing. All foreign material and tissues that are contaminated or suspected to be avascular are systematically removed so that whatever is left behind is vascularized living tissue, devoid of contamination A secondary aim of debridement is also to minimize risk factors for infection such as dead space or hematoma so that the incidence of infection is reduced. No obvious advantage in performing debridement within 6 hours compared to debridement performed between 6 and 24 hours after injury . The effect of delaying debridement >24 hours is however not yet clear. Timing???

30. Factors Increasing Risk for Infection Local Factors Systemic Factors • Organic, farm yard, or sewage contamination. • Poor debridement with retention of foreign debris and nonviable tissues. • Inadequate skeletal stabilization. • Presence of dead space. • Debridement later than 24 hours. • Presence of shock and ARDS • Comorbid factors like age above 65 years, metabolic disorders like diabetes mellitus, history of smoking. • Compartment syndrome and hypovascular tissues. • Prolonged hospital stay and exposure to resistant organisms. • Poor nutrition.

31. Lavage Lavage is used before and after debridement as it clears the debris and hematoma and provides optimal exposure and reduces contamination and the bacterial count Adequate quantity of fluid must be used for lavage. Typically at least 9 L of fluid are used for Type Ill B fractures No advantage in adding antiseptic solutions or antibiotics to lavage fluid . Use of hydrogen peroxide, alcohol solution, povidone iodine,and other chemical agents may impair osteoblast function , inhibit wound healing and cause cartilage damage. High-pressure lavage,which was once popular, is now not used as it has not shown any advantage. It may also have the disadvantage of damaging tissues such as periosteum and tendon sheaths and it may also push dirt and debris deeper into the tissues

32. Debridement Principles Must be performed by an experienced team and as early as possible. Orthoplastic approach with involvement of plastic surgeons even at the time of index surgery. Steps Pre-debridement photographs are taken in different angles. In heavily contaminated wounds, thorough washing with copious amounts of saline is advisable before draping the limb. Utilize specially made trolleys for washing the wound before draping and mesh trays of different sizes with outlet tubing for lavage after draping. A soft brush may be used to aid cleaning of dirt particles and debris Use of tourniquet allows a clear, bloodless field. Skin and Fascia Wounds must be longitudinally extended to provide adequate visualization of deeper structures. Margins must be trimmed to bleeding dermis to create a clean wound edge. Gentle handling of the skin and prevention of degloving are essential. All avascular fascia must be excised .

33. Muscle s All muscles in the compartment must be evaluated for viability (“4 C” Color, Consistency, Contractility, Capacity to bleed) and debrided . Bone Bone ends and medullary cavity must be carefully examined for impregnated paint, mud, and organic material. All fragments without soft tissue attachment must be excised . Lavage Completion Deflate tourniquet and evaluate viability of all retained structures. Assess loss of tissues and document with photograph for future reference and planning. Decide on method and timing of wound closure or coverage and bone stabilization. Document sequence of reconstruction. In very severe tissue loss VAC may be used as a bridging procedure till the patient is fit for flap cover .

34. Superficial Debridement The length of incision depends upon the nature of injury. Typically longer incisions are required for more severely contaminated wounds and wounds over a joint to allow proper inspection of all parts of the joint. Extension of skin incisions must be done without separating the skin from the deep fascia as this may decrease viability and increase hematoma formation. Debridement of the skin must be undertaken without a tourniquet as the extent of skin resection is usually decided by the presence of bleeding skin edges debridement of the fascia which is nonviable ,detached, shredded,or even doubtfully nonviable must be excised

35. Deep Debridement An aggressive approach to muscle debridement must be adopted as retained necrotic muscle is a major growth medium for bacteria and greatly increases the risk of anaerobic infection muscle viability is assessed by the four C’s: Contractability, Color, Consistency, and Capacity to bleed The decision to retain or discard damaged bone is done on the basis of vascularity and whether the fragments are from the diaphysis , metaphysis , or the articular margins . Retained avascular bone is a rich source of infection and diaphyseal fragments, regardless of their size, which are devoid of soft tissue attachments must be removed metaphyseal bones, which are purely cancellous, have a higher capacity for revascularization and integration and can be preserved if not grossly contaminated. Cancellous bone involving the articular surface is usually retained so that reconstruction of the joint surface is possible In sports and farmyard injuries, there can be considerable mud and dirt inside the medullary canal which should be carefully curetted and cleaned .

36. Skeletal Stabilization To reduce pain and prevent further soft tissue damage It is good practice to discard the instruments and table that are utilized during debridement and use a separate set of fresh instruments for skeletal stabilization so that contamination is avoided In cases of severe organic contamination, it is also advisable to redrape the limb and for the surgical team to rescrub before reconstruction is undertaken In high-energy injuries associated with contamination , preference is to use a temporary external fixator device followed by secondary internal fixation at a later operation. In situations where there is a good soft tissue envelope as in upper limb and femoral fractures or in situations where soft tissue cover could be achieved within 48 to 72 hours primary internal fixation can be considered. Plaster casts and are now rarely used in open injuries . Wound inspection and dressing is very difficult and cast contamination can be unpleasant and increase the risk of infection

37. External Skeletal Fixation Provides a swift versatile method of providing stability without the need for additional exposure or periosteal striping Whenever external fixation has to be maintained for a long period, pre-drilling should be done to minimize thermal necrosis as this may lead to pin loosening and Infection The pins must be judiciously placed to allow further soft tissue reconstruction Pins should be placed through intact soft tissues rather than through the open wound Whenever conversion to internal fixation is planned in advance, care must be taken to avoid placing the pins in the line of future surgical incisions. In fractures with articular surface involvement especially in fractures around the knee and elbow,joint congruity must be achieved on day 1 with appropriate internal fixation as late reconstruction of the joint surface is often not possible.

38. Pins must be placed with a thorough knowledge of the regional anatomy so that injuries to the neurovascular structures are avoided. Pins should avoid joints and the capsular reflections of joints as any infection will lead to septic arthritis. Muscle and tendon impalement must be avoided as entrapped musculotendinous units restrict movement The pin tracts must be cleaned with hydrogen peroxide and dressed every day with chlorhexidine solution or povidone iodine.

39. Primary Internal Fixation Primary internal fixation was considered unacceptable due to the fear of increased infection and damage to the blood supply during the process of fixation But primary bone stabilization by interlocking nails and plate fixations are being increasingly performed with good results. As a general rule, plate fixation is ideal for fractures of the upper limb . The choice between a locking nail and a plate for the lower limb bones is made depending on the fracture morphology,the instrumentation that is available and the surgeon’s preference.

40. Plate fixation is the method of choice in most open upper limb fractures, femoral fractures involving the periarticular and articular regions, all intra-articular and juxta articular fractures,and in open injuries with vascular involvement, If plate fixation is performed, a critical factor to maximizing the chances of success is achieving wound cover within 3 days.

41. Intramedullary nails are often the first choice for fixation of lower limb diaphyseal fractures as they provide superior biomechanical conditions and also maintain the length of the Limb They are ideally suited for Gustilo type I and II injuries and even in type III injuries where contamination is minimal and effective debridement has been performed.

42. Acute Management of Bone Loss Bone loss of varying degrees can occur due to primary bone loss at the time of accident or during primary or secondary debridement. There is no clear indication as to how much soft tissue attachment is required to maintain viability of the fragments . Although a low threshold is advised for retaining cortical fragments , metaphyseal fragments with cancellous bone and fragments containing articular margins are usually retained after adequate cleaning even when there is no soft tissue attachment. larger bone gap without infection is a preferable to a smaller gap with nonviable bone must also be remembered. Bone gaps in the upper limb can generally be managed by bone shortening followed by bone grafting. Whenever there is bone loss, the ends of the bone can be trimmed suitably so that there is a good contact for stable fixation. .

43. In the forearm, bone differential loss of up to 2 cm in one bone can be easily managed by bone grafting the defect. If there is a very severe loss of either the radius or the ulna, reconstruction to create a single bone forearm is a viable option

44. In the lower limb, the extent of bone loss determines reconstruction options. A loss of less than 2 cm is well tolerated and primary shortening can be safely done When the loss is due to the removal of a large comminuted fragment, or when the circumferential loss is less than 3 cm, iliac crest bone grafting will usually done When the loss exceeds 4 cm , a decision is made between primary bone shortening and subsequent lengthening or bridging the gap by bone transport

45. The patient was treated with Acute shortening with lengthening at the subtrochanteric region

46. Bridging the gap by bone transport

47. Wound Cover Primary Closure of Open Wounds Although controversial, good results are being increasingly reported after primary skin closure Indications Contraindications Type I and II open injuries and III A and B injuries of limbs without vascular deficit. • Wounds without primary skin loss or secondary skin loss after debridement. • Ganga Hospital skin score of 1 or 2 and a total score of 10 or less . • Injury to debridement interval less than 12 hours . • Presence of bleeding wound margins which can be apposed without tension. • Stable fixation achieved either by internal or external fixation. Type IIIC injuries . • Ganga Hospital skin score of 3 or more and a total score of >10. • Wounds in patients with severe polytrauma involving and an injury severity score >25. • Sewage or organic contamination/farmyard injuries. • Peripheral vascular diseases/thromboangiitis obliterans. • Drug-dependent diabetes mellitus.

48. Open tibial fracture with a GHIOS score of 6 (skin 2, bone 2, and MTS 2) which has been treated by primary closure and interlocking nail at the index procedure , Good functional outcome was achieved without any complications.

49. the assessment of skin loss and the ability to oppose the skin without tension should be done only after fracture Reduction A GHOIS of ≥10 denotes a high-energy injury possibly with a crushing component. The zone of injury may not be obvious on day 1 or during the index procedure. These limbs have a tendency to swell up in the next few days and therefore are not suitable for primary closure. Wounds treated with primary closure should have a deep drain inserted so that an underlying hematoma is avoided A useful policy is “whenever in doubt, do not close . GHOIS is >9, it is preferable to stage the soft tissue reconstruction High-energy blast injuries Severe contamination, farmyard, and sewage contamination Delayed presentation >12 hours Evidence of infection during debridement Initial debridement considered unsatisfactory Need for Second Look Debridement

50. Timing of wound closure Primary Closure: Wound closed by direct skin suturing during the index procedure. Immediate Cover: Soft tissue cover performed within 48 hours. Early Cover: Soft tissue cover performed within 1 week. Delayed Cover: Soft tissue cover performed within 3 weeks. Staged Reconstruction: Soft tissue reconstruction done after 3 weeks.

51. Lacerated wounds without skin loss, which can be opposed without tension, can be primarily sutured . In small linear vertical wounds, lying over bone, with minimal soft tissue loss cover can be achieved using a parallel releasing skin incision which will allow direct closure of the laceration. The releasing skin incision should be over a good muscle bed or fascia so that it will allow skin grafting of the defect. Wounds which are not directly over the bone and which have a healthy muscle bed can usually be treated by split skin grafting with good results. Small defects in the skin which are directly over bone and are exposing implants can be successfully covered with rotational fasciocutaneous flaps which may have either a proximal or a distal base.

52. The revised reconstructive ladder includes the newer methods of reconstruction such as NPWT and acute shortening/bone transport. The “ reconstructive elevator ” concept is more popular now where the most appropriate and effective method of cover is chosen as the primary choice, however complex it may be

53. Negative Pressure Wound Therapy A useful treatment option in all injuries where soft tissue cover is not immediately possible is Vacuum-assisted wound closure (VAC) using NPWT(Negative pressure wound therapy) Indications Contraindications Severely crushed injuries not amenable for immediate soft tissue cover. • Wounds which require dead space management • Exposed bone with degloved skin • Exposed Tendons and ligaments • Open joint injuries with soft tissue loss • Presence of necrotic skin with eschar. • Untreated osteomyelitis • Exposed neurovascular bundle. • Exposed vascular anastomosis when heavy bleeding is anticipated.

54. Circumferential application of the adhesive drapes must be avoided to prevent a tourniquet effect If patients complain of pain with the intermittent suction protocol continuous suction can be used. The VAC device is left in place for 2 or 3 days after which the wound can be inspected and suction continued. Beneficial Effects of VAC Therapy Promotes wound contraction and increases the chance of delayed primary closure. Continuously removes excess edematous fluid. Causes reactive increase in blood flow and promotes healing. Decreases bacterial burden. Causes cellular microdeformation and favorable which stimulate cell response and growth factors.

55. Although there are many encouraging reports, there is no conclusive evidence supporting the superiority of NPWT over standard wet dressings in avoiding wound infection and the requirement for flap cover. There are also no studies that have compared NPWT with other treatment methods such as the use of antibiotic bead pouches which have also been reported to be useful. The overall outcome is affected by the nature of the wound, the adequacy of debridement, the presence of comorbidities, and the health status and nutrition of the patient. NPWT is also contraindicated in patients taking anticoagulants and in those who have significant adhesions between the wound bed and dressings when dressings are removed. Loss of suction and failure of the VAC system to maintain a vacuum will increase the risk of wound infection.continuous monitoring NPWT system is essential

56. Fix and Primary Closure skin Score of 1 and 2 have no skin loss at injury or during debridement When contamination is low and there has been a satisfactory debridement The total score must be <9 as this indicates low-energy violence and the chances of postoperative swelling or compartment syndrome are low Stable skeletal fixation and bleeding skin margins which are opposed without tension are the prerequisites for primary closure. It should be noted that the length of the wound is not a criterion.

57. Fix and Delayed Closure Injuries with skin score of 1 or 2, but with either a total score of >9 or with moderate or severe contamination are not treated by primarily closure higher score of >9 indicates high-energy violence and a reassessment at 48 or 72 hours is necessary delayed closure is performed if the wound characteristics at a second look debridement allow closure If additional debridement is required at the time of the second look leading to further skin and soft tissue resection,the patient is managed by a staged flap protocol.

58. A severe open injury of leg with a GHIOS score of 13 managed by secondary debridement and a delayed free flap performed at 1 week

59. Fix and Skin Grafting A skin score of 3 indicates skin loss either at injury or during debridement. In skin score 3 the wound either does not expose the fracture site or there is adequate soft tissue cover. Here simple wound management by split skin grafting possible .

60. Fix and Early Flap A skin score of 3 or 4 indicates skin loss either at injury or during Debridement If the wound exposes bone, articular cartilage,tendons , or a vascular anastomosis site, a flap is necessary An early flap can be done if the total score is less than 9.

61. Fix and Delayed Flap whenever there is severe contamination or the total score is >10 If,during the relook procedure, the wound is not suitable for flap cover the use of NPWT following another debridement is an attractive option.

62. Staged Reconstructions A score of 5 in any of the tissue scores and a total score of >9 indicates a limb that is not suitable for immediate or even early Reconstruction immediate or early application of NPWT at the initial procedure must be seriously considered The expertise of a skilled plastic surgical team with microsurgical reconstruction capability and an orthopedic team capable of bone reconstruction and regeneration techniques is essential. If this is not available, patients must be expeditiously transferred to a center where such facilities are available.

63. Treatment algorithm for wound management derived from the Ganga Hospital Open Injury Score.

64. Open Fracture “Take-Home Points ” Modern medicosurgical management has improved outcomes for patients with open fractures Open fractures are a surgical urgency requiring thorough debridement/irrigation and skeletal stabilization. External and internal fixation, amputation, as well as innovative strategies are necessary for skeletal reconstruction of open fractures Orthoplastic reconstruction is often necessary for open fracture with soft tissue loss Complications are commonplace with open fracture including infection, chronic pain and nonunion as well as physical and psychosocial dysfunction Host, injury pattern, and treatment plan will influence outcome after open fracture Open fractures, however, are infamous for complications Increased risk with higher grade and compromised host Timely antibiotic administration, debridement, and fracture stabilization are of paramount importance Standard and innovative treatment strategies are required for limb salvage Amputation should be considered as part of the reconstructive technique.

65. THANK YOU

66. The Orthopaedic Trauma Association Classification of Open Fractures