Treatment of open fractures (compound)
Patient with open fractures have multiple injuries and severe shock. At the site accident the wound should be covered with sterile dressing or clean material and left undisturbed until the patient reach the accident department.Tetanus prophylaxis is administered. In hospital a rapid general assessment is the first step (clinical examinations).
We should study the nature of the wound. State the skin around . State of circulation. Neurological statement. Antibiotic cover.
Type I
Small woundclean ,little soft tissue damage, fracture not comminuted (low –energy fracture)Type II
Wound more than 1 cm no much soft tissue damage, moderate comminuted fracture.(low –energy fracture)
Type III
Extensive damage to skin ,Soft tissue & neurovascular structure, with considerable contamination of the wound. it is divided in to A,B,C. (High energy force )1.Antibiotic should be given as soon as possible
Benzylpencillin and flucloxacillin 2nd generation cephalosporin 6 hourly. Gram negative coverage by add gentamycin. And anaerobes by adding metronidazole.2.Debridment
Under general anaesthesia. The wound all around should be cleaned and shaved. The wound should be irrigated thourghly with copious amounts of physiological saline. Tourniquet should not be used.Wound exscion only enough to leave healthy skin. Wound cleansing from all debris and foreign materials with copious saline. (a common mistake is to inject syringefuls of fluid through small aperture so push contaminants further in).
Removal of devitalized tissue (no bleeding , not contractile, no change in color ). All doubtfully viable tissue ,whether soft or bony should be removed. Nerves and tendons is best to leave them by marking .
3.Wound closure
Either primary sutured. Delayed primary sutured. Split skin graft. Flap graft.4.Stabilization of fractures
The stability of the fracture is important in reducing infection and assist recovery of soft tissue. If no obvious contamination and the time less than 8 hours open fracture up to grade 3 A could be treated with as for closed .Or better in not expertise surgeons to do
External fixationsThe patient should be followed till healing developed . And physiotherapy.
Gunshot injuriesMissile wounds are special type of injuries. Tissue damage produced by direct through immediate path of the missile contusion of muscles around the track. contusion and congestion away from the track.
Either high velocity missiles as rifles (>600m/s).
Mechanism of injureWound results from absorption of energy imparted by the missile it strike and penetrate tissue. Kinetic energy is calculated by the formula (KE=MV2/2 )
1. Laceration and crushing by bullet passage in the tissues.
2.Shock wave
through forcing atract in the solid tissue the missile compresses the medium in front of it and this compression moves away as a shock wave of spherical form.3.Temporary cavitation only in high velocity missiles . 4.This cavity has sub atmospheric pressure, so bacteria and debris sucked into the depth of the wound.
5.and tissue destruction over wide area. 6.greater bone damage.
Low velocity (300-600 m/s)From civilian hand-guns . Smaller tissue damage confined to the bullet tract. In all gunshot injuries debris is sucked into the wound.
Emergency treatment.
A B C.Covering the wound with sterile dressing till general condition is well.Antibiotic. antitetenus…