principle of fractures

بسم الله الرحمن الرحيم

Lectures 4

Orthopedics

Principle of Fractures
Dr. Ali Khairaldeen

Principles of Treatment of open fractures (compound)

All open fractures must be supposed to be contaminated; it is important to try to prevent it from becoming infected.
The four essentials roles in treatment of open fracture are:
Antibiotic prophylaxis.
Urgent wound debridement.
Stabilization of the fracture.
Early definitive wound cover.
Patient with open fractures may have multiple injuries and shock. The wound should be covered with sterile dressing and left undisturbed until the patient reach the accident department.
Any open fracture should classified according to Gustilo classification
(Gustilo classification of compound fractures)
Type I
Wound small
Little soft tissue damage with no crushing
Fracture not comminuted
(Low –energy fracture)
Type II
Wound more than 1 cm
No much soft tissue damage,
Moderate comminuted fracture.
(Low – moderate 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)
Type III A the fractured bone can be adequately covered by soft tissue.
Type III B the fracture cannot cover by soft tissue and there is periosteal striping as well as severe comminution of the fracture and\ or bone loss.
Type III C if there is vascular injury need to be repaired regardless of the amount of soft tissue damage and fracture.

After classification of compound fracture we must start Treatment

Antibiotic should be given
In most cases co-amoxiclave , cefuroxime or penicillin (clindamycin if the patient is allergy to penicillin) is given as soon as possible
At the time of debridement, gentamicin is added to a second dose of the first antibiotic
Both antibiotics provide prophylaxis against the majority of Gram-positive and Gram negative bacteria that may have entered the wound at the time of injury.
And for anaerobes by adding metronidazole.
Tetanus prophylaxis is administered: toxoid for those previously immunized, human antiserum if not.
Debridement
Under general anesthesia.
The wound all around should be cleaned and shaved.
The wound should be irrigated thoroughly with copious amounts of physiological saline.
6–12 L of saline may be needed to irrigate and clean an open fracture of a long bone.
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 material and bacteria further in).
Removal of devitalized tissue (dead muscles when cut it will not bleed, when touch it will not contract and it is brown color).
All doubtfully viable tissue, whether soft or bony should be removed.
Nerves and tendons is best to leave them by marking.
Stabilization of fractures
The stability of the fracture is important in dealing with the wound and assist recovery of soft tissue.
The method of fixation depends on the degree of contamination, length of time from injury to operation and amount of soft-tissue damage.
If there is no obvious contamination, definitive wound cover can be achieved at the time of debridement.
If the time is less than 8 hours from injury to operation, open fractures up to grade III A can be treated as for a closed injury.
For safety external fixation is the choice.


Wound closure
Either primary sutured.
Delayed primary sutured.
Partial thickness skin graft.
Skin Flap.
The patient should be followed till healing developed.
And don’t forget Physiotherapy.

Gunshot injuries

Missile wounds are looked upon as a special type of open injury.
Tissue damage is produced by:
Direct injury in the path of the missile.
Contusion of muscles around the missile track.
Bruising and congestion of soft tissues at a greater distance from the primary track.
The exit wound is usually larger than the entry wound.
Either high velocity missiles as rifles (>600m/s).
There is marked cavitation and tissue destruction over a wide area.
The splintering of bone resulting from the transfer of large quantities of energy creates secondary missiles, causing greater damage

Who the missile cause damage?

Wound results from absorption of energy of the missile that strike and penetrate tissue.
Laceration and crushing by bullet passage in the tissues.
Shock wave.
Temporary cavitation only in high velocity missiles.
This cavity has sub atmospheric pressure, so bacteria and debris sucked into the depth of the wound.
Tissue destruction over wide area.
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.
Antibiotic. Crystalline penicillin, Gentamicin, Metronidazole
Antitetenus…
Definitive treatment
Low velocity:
Debridement.
Splintage.
High velocity:
Thorough cleansing with exscion of the deep damaged tissues.
Wound kept open for dressing.
Bone immobilization by external fixation.

Wound closure either by:

Delayed primary suture ,
skin graft ,
Or skin flap.


Complications of fractures
General complications:
Bleeding.
Shock.
Fat embolism.
Bed sore
DVT, Cardio respiratory failure…..etc
Local complications
Urgent:
Local Visceral injury.
Vascular injury.
Nerve injury.
Compartment Syndrome.
Haemoarthrosis.
Infection.
Gas Gangrene.
Less urgent complication
Fracture blister.
Plaster sore.
Pressure sores.
Nerve entrapment.
Myositis ossifficans.
Joint stiffness.
Algodystrophy
Ligament injury
Tendon injury
Late complications
Delayed union.
Malunion.
Non-union.
Avascular necrosis.
Muscle contracture.
Joint instability.
Secondary Osteoarthritis.