Management of compound fractures
Patients with open fractures may have multiple injuries;a rapid general assessment is the first step and any life threatening conditions are addressed. The open fracture may draw attention away fromother more important conditions and it is essentialthat the step-by-step approach in advanced trauma life support not to be forgotten.When the fracture is ready to be dealt with, the wound is first carefully inspected; 1-arterial bleeding should be ligated 2- any gross contamination is removed . 3-the wound is photographed with aPolaroid or digital camera to record the injury 4-area then covered with a saline-soaked dressing to prevent desiccation. This is left undisturbed until the patient is in the operating theatre . 5-The patient is given antibiotics, usually co-amoxiclav or cefuroxime, but clindamycin if the patient is allergic to penicillin.6- Tetanus prophylaxis is administered: toxoid for those previously immunized, human antiserum if not.7- The limb is then splinted until surgery is undertaken.
The limb circulation and distal neurological status will need checking repeatedly, particularly after any fracture reduction maneuvers. Compartment syndrome is not prevented by there being an open fracture
CLASSIFYING THE INJURY
Treatment is determined by 1- the type of fracture, 2- thenature of the soft-tissue injury (including the woundsize) and 3- the degree of contamination. Gustilo’s classification of open fractures is widely usedType 1 – The wound is usually a small, clean puncturethrough which a bone spike has protruded. There islittle soft-tissue damage with no crushing and thefracture is not comminuted (i.e. a low-energyfracture).Type II – The wound is more than 1 cm long, butthere is no skin flap. There is no much soft-tissuedamage and no more than moderate crushing orcomminution of the fracture (also a low- tomoderate-energy fracture).Type III – There is a large laceration, extensivedamage to skin and underlying soft tissue and, in themost severe examples, vascular compromise. Theinjury is caused by high-energy transfer to the boneand soft tissues. Contamination can be significant.
There are three grades of severity. In type III A the fractured bone can be adequately covered by soft tissue despite the laceration. In type III B there is extensive periosteal stripping and fracture cover is not possible without use of local or distant flaps. The fracture is classified as type III C if there is an arterial injury that needs to be repaired, regardless of the amount of other soft-tissue damage. The incidence of wound infection correlates directly with the extent of soft-tissue damage, rising from less than 2 per cent in type I to more than 10 per cent in type III fractures.
PRINCIPLES OF TREATMENT
All open fractures, no matter how trivial they mayseem, must be assumed to be contaminated; it isimportant to try to prevent them from becominginfected. The four essentials are:• Antibiotic prophylaxis.• Urgent wound and fracture debridement.• Stabilization of the fracture.• Early definitive wound cover.
Debridement
The operation aims to render the wound free of foreignmaterial and of dead tissue, leaving a clean surgicalfield and tissues with a good blood supplythroughout. Under general anesthesia the patient’sclothing is removed, while an assistant maintains tractionon the injured limb and holds it still. The dressingpreviously applied to the wound is replaced by asterile pad and the surrounding skin is cleaned. Thepad is then taken off and the wound is irrigated thoroughlywith copious amounts of physiological saline.The wound is covered again and the patient’s limbthen prepped and draped for surgery.It is advisable not to use tourniquet in this condition unless if there is sever bleeding or arterial injury to deal with .Wound excision The wound margins are excised, but only enough to leave healthy skin edges. Removal of devitalized tissue: Devitalized tissue provides a nutrient medium for bacteria. Dead muscle can be recognized by a- its purplish colour, b-its mushy consistency, c-its failure to contract when stimulated and d-its failure to bleed when cut. All doubtfully viable tissue, whether soft or bony, should be removed. The fracture ends can be nibbled away until seen to bleed
Wound cleansing : All foreign material and tissue debrisis removed by excision or through a wash with copiousquantities of saline. A common mistake is to injectsyringefuls of fluid through a small aperture – this onlyserves to push contaminants further in; 6–12 L ofsaline may be needed to irrigate and clean an openfracture of a long bone. Adding antibiotics orantiseptics to the solution has no added benefit .
Nerves and tendons : as a general rule it is best to leavecut nerves and tendons alone at the time of the wound excision,to be sutured by delay primary suture ; though if the wound is absolutely clean and no dissection is required – and providedthe necessary expertise is available – they can beSutured at the time of wound excision .
Stabilization of the fracture : Stabilizing the fracture is important in reducing the likelihood of infection and assisting recovery of the soft tissues. The stabilization of the fracture is usually by external fixation Wound closure : A small, uncontaminated wound in a Grade I or II fracture may (after debridement) be sutured, provided this can be done without tension. In the more severe grades of injury, immediate fracture stabilization and wound cover using split-skin grafts, local or distant flaps is ideal, provided both orthopaedic and plastic surgeons are satisfied that a clean, viable wound has been achieved after debridement.
Aftercare : In the ward, the limb is elevated and its circulation carefully watched. Antibiotic cover is continued but only for a maximum of 72 hours in the more severe grades of injury.
GUNSHOT INJURIES
With high-velocity missiles (bullets, usually fromrifles, travelling at speeds above 600 m/s) there ismarked cavitation and tissue destruction over a widearea. The splintering of bone resulting from the transferof large quantities of energy creates secondary missiles,causing greater damage.With low-velocitymissiles (bullets from civilian hand-guns travelling atspeeds of 300–600 m/s) cavitation is much less, andwith smaller weapons tissue damage may be virtuallyconfined to the bullet track. However, with all gunshotinjuries debris is sucked into the wound, which istherefore contaminated from the outset.Emergency treatment : As always, the arrest of bleeding and general resuscitation take priority. The wounds should each be covered with a sterile dressing and the area examined for artery or nerve damage. Antibiotics should be given immediately . Definitive treatment : Traditionally, all missile injuries were treated as severe open injuries, by exploration of the missile track and formal debridement. However, it has been shown that low-velocity wounds with relatively clean entry and exit wounds can be treated as Gustilo type I injuries, by superficial debridement, splintage of the limb and antibiotic cover; the fracture is then treated as for
similar open fractures. If the injury is to soft tissues only with minimal bone splinters, the wound may be safely treated without surgery but with local wound care and antibiotics. High-velocity injuries demand thorough cleansing of the wound and debridement, with excision of deep damaged tissues and, if necessary, splitting of fascial compartments to prevent ischaemia; the fracture is stabilized and the wound is treated as for a Gustilo type III fracture. If there are comminuted fractures, these are best managed by external fixation.
The method of wound closure will depend on the state of tissues after several days; in some cases delayed primary suture is possible but, as with other open injuries, close collaboration between plastic and orthopaedic surgeons is needed . Close-range shotgun injuries, although the missiles may be technically low velocity, are treated as highvelocity wounds because the mass of shot transfers large quantities of energy to the tissues.