48: Treatment of Open Fractures

PROCEDURE 48 Treatment of Open Fractures



Kostas P. Panagiotopoulos, Piotr Blachut, Pierre Guy



image



Controversies



• Antibiotic administration

• Timing of surgery

• Wound irrigation techniques and additives

• Stabilization techniques

• Adjunctive therapies


Indications



image Open fractures of Gustilo and Anderson types I–III


Examination/Imaging



image Emergency management
• Emergency treatment must be initiated as soon as possible. This includes intravenous antibiotic treatment, tetanus prophylaxis, sterile dressings, and splinting of the limb (Fig. 1).

• Any delays in definitive operative treatment of the injury must be minimized.

image Standard radiographs (anteroposterior, lateral) of affected limb(s) should be obtained to plan operative stabilization of the injury (Fig. 2).

image Computed tomography may also be required to plan surgical treatment.

image

FIGURE 1


image

FIGURE 2




PEARLS



• Ideally, the patient should be positioned only once to allow for both irrigation and débridement of the wound and stabilization procedures.

• Try to set up a separate sterile table to carry out the irrigation and débridement procedure, particularly when there is a great deal of contamination of the wound. This way, any contaminated instruments will not be used for the stabilization procedure.


Surgical Anatomy



image The important structures depend on the area that needs to be débrided and surgically stabilized.

image The surgeon needs to be familiar with the local anatomy in the fracture area in order to protect all neurovascular structures.

image Open fractures should be graded according to the Gustilo and Anderson classification:
• Type I fractures (Fig. 3A and 3B)

• Type II fractures (Fig. 4A and 4B)

• Type III fractures (Fig. 5A and 5B)

image

FIGURE 3


image

FIGURE 4


image

FIGURE 5




Equipment



• The surgeon needs to plan for use of a fracture table or radiolucent table as required. Any fluoroscopy equipment needs to be arranged appropriately in the room before the start of the procedure (see Fig. 6).

image

FIGURE 6




PITFALLS



• During débridement and exploration, be careful not to devascularize any bony fragments that may be supported only by a small amount of soft tissue.


Positioning



image Patient positioning should be determined by the location of the open wound and location of the fracture. Most patients can be positioned supine.

image The use of a fracture table or radiolucent table may be required, particularly when treating long-bone fractures in the lower extremity (Fig. 6).



Controversies



• Timing of surgical treatment
image Two studies have shown a decreased infection rate when the initial débridement is performed within 6 hours after injury.

image However, several studies have not shown any significant difference in infection rates when comparing early débridement (within 6 hours) to later débridement (after 6 hours). Ideally, the patient should be brought to the operating room as soon as possible.

image Ultimately, the use of systemic antibiotics, adequacy of débridement, and soft tissue coverage are probably more important variables.


Procedure



STEP 1: DÉBRIDEMENT



image Prior to formal prepping and draping of the limb, a “prescrub” can be useful to remove gross contamination from the wound and skin (Fig. 7).

image The open wound should be extended proximally and distally until healthy tissue is visualized (Fig. 8). An attempt should be made to incorporate the extension of the wound into the definitive approach for the ultimate surgical exposure.

image The full extent of the injury needs to be visualized to allow a thorough débridement.
• Damaged or devitalized skin edges must be sharply excised to leave a clean and viable skin edge (Fig. 9A).

• All devitalized tissue must be excised with sharp dissection (Fig. 9B).

• The surgeon should be able to visualize both ends of the bone to ensure that a proper débridement is done (Fig. 10).

image When performing the débridement, one should avoid distally based flaps and leave the smallest skin flaps whenever possible.

image The surgeon must be aware of the local surgical anatomy and neurovascular structures.
• For the patient shown in Figures 8–10, pertinent bony anatomy of the distal tibia and proximal ankle (Fig. 11A) and the local neurovascular structures (Fig. 11B) must be reviewed.

image Only the minimum skin required for a thorough débridement should be excised in order to plan for future definitive wound closure. However, when in doubt, any tissue that looks suspicious should be excised.

image

FIGURE 7

Related posts:

16: Perilunate Injuries 29: Proximal Tibia Fractures: Intramedullary Nailing 11: Open Reduction and Internal Fixation of Olecranon Fractures 18: Femoral Neck Fractures: Arthroplasty 8: Terrible Triad Injuries of the Elbow 5: Humeral Shaft Fractures

Stay updated, free articles. Join our Telegram channel
Tags:
Jun 7, 2016 | Posted by in ORTHOPEDIC | Comments Off on 48: Treatment of Open Fractures

Full access? Get Clinical Tree
Get Clinical Tree app for offline access