Open Fractures

Background

Definition: fracture of the bone and breach of the dermis in the same limb fragment

ALWAYS BEAR IN MIND INFECTION

Classification

Gustilo and Anderson classification commonly used:

  • Grade I – wound that is <1 cm in length
  • Grade II – wound that is >1 cm and <10 cm in length
  • Grade III – wound >10 cm in length or of any size associated with:
    • High-energy mechanism of injury or fracture comminution
    • Crushing of soft tissues
    • Extensive contamination or contamination that involves farmyard or marine material

Grade III is further subdivided into:

  • IIIA – no extensive loss of periosteum or soft tissue
  • IIIB – extensive periosteal stripping and/or inadequate soft tissues to allow closure of the wound (requiring skin flap or graft)
  • IIIC – presence of vascular compromise

Assessment of the Patient

Open fractures often result from high-energy trauma – initial management is with an ATLS survey and then secondary survey

History

Full history of the nature of the injury

Should include:

  • Mechanism of injury
  • Environment to which the bone was exposed – must check for exposure to farmyard waste or marine material

Examination

  • Inspect and assess wound
  • Cover with a simple, sterile, saline-soaked dressing
  • Must test movement of the joint involved
  • No need to test movement of adjacent joints unless as part of motor tests
  • Neurovascular assessment (VERY IMPORTANT)

Treatment

Medical treatment

  • IV antibiotics – as early as possible (see hospital guidelines for which antibiotics to use)
  • Consider tetanus vaccine if patient not fully immunised
  • Do not attempt to clean the wound further during initial non-surgical treatment – simply cover with sterile, saline-soaked dressing
  • The limb should be brought out to length and correct alignment, then splinted or casted unless going immediately to surgery

Surgical management

  • Debridement and fixation of fracture
  • Surgical management can either be emergency (straight away) or urgent (<24hrs)

Indications for emergency surgery:

  • Gross contamination of wound or contamination with farmyard or marine matter
  • Vascular compromise
  • Compartment syndrome
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