easy step wise methodology

1. MANAGEMENT OF
COMPOUND FRACTURES
DR.JAYANT SHARMA
M.S. D.N.B. M.N.A.M.S.
CONSULTING ORTHOPAEDIC SURGEON
ARIHANT HOSPITAL AND RESEARCH
CENTRE. INDORE

3. Nearly two centuries ago
Percival Pott was thrown from
his horse in the Old Kent Road
and sustained an open fracture
of tibia, he bought a backyard
door, to which he nailed two
poles to make a stretcher not
only did he survive the injury
but escaped an amputation.

4. High Velocity of vehicles
Competitive sports
Increased Terrorism.

5. PATHOPHYSIOLOGY
 The limb absorbs the energy on contact
 Releases the energy in an explosion
 Comminutes the bone
 Creates a soft tissue shock wave
 Strips the periosteum, tears apart the
skin causing a momentary vacuum
 Sucks the adjacent foreign material in
the depth of the limb

6. GUSTILO ANDERSON CLASSIFICTION
Grade I- Open fracture clean wound , less than 1
cm long.
Grade II- More than 1 cm long, extensive soft tissue
damage, skin flaps or avulsion includes
segmental, and comminuted fracture.
Grade III -
A - Extensive soft tissue damage, but
bone covered.
B - Bones periosteum also stripped and
bone exposed.
C - Open fractures with Arterial injuries.

7. DRAWBACKS OF GUSTILO
 Highly case dependent
 Needs experience of the Surgeon
 Changes with debridement
 Not an adequate basis for the treatment
decision.
 Not comparable.

8. A.O. CLASSIFICATION
IC1 - No skin lesion
IC2 - No laceration but contusion
IC3 - Circumscribed degloving
IC4 - Extensive closed degloving
IC5 - Necrosis from contusion
And with Fracture,
IO1 - Skin breakage from inside out
IO2 - Skin breakage from outside less than 5 cms.
IO3 - Skin breakage from outside more than 5 cms
with devitalized edges.
IO4 - Full thickness contusion with degloving.

9. DRAWBACKS OF A.O.CLASSIFICATION
Score is biased on the size and nature of
the wound.
Equal emphasis is not provided to the
damage of the functional structures, and
severity to the bony injury.
Poor predictor of the outcome.

10. M.E.S.S.– MANGLED EXTREMITY
SEVERITY SCORING
 It is good to decide the amputation but ,
 Does not provide the guidelines for the
treatment.
 Does not prognosticate the outcome.

11. GANGA HOSPITAL SCORE
COVERING STRUCTURES
1. WOUND- NOT OVER THE BONE 0
i. No skin loss 1
ii. With skin loss 2
2. WOUND OVER THE BONE
i. No skin loss 3
3. With skin loss/ friction burns/ degloving 4

12. GANGA HOSPITAL SCORE
FUNCTIONAL TISSUE
Exposed musculotendinous unit without injury 1
Reparable injury to MT unit 2
Crushing with loss of MT unit with reparable Nerve 3
Loss of one compartment with irreparable nerve 4
Loss of 2 or more compartment 5

13. GANGA HOSPITAL SCORE
SKELETAL TISSUE
Transverse/oblique # with periosteal stripping 1
Butterfly fragment/ unicortical injury
Comminution/ segmental/without bone loss 2
Periarticular comminution with joint disorganized 3
Circumferential comminution bone loss less than 4cm. 4
Comminuted with bone loss more than 4 cm 5

14. GANGA HOSPITAL SCORE
COMORBID CONDITION
(2 POINTS FOR EACH)
Open injuries more than 12 hrs.
Sewage contamination
More than 65 yrs. Of age
Debilitating disease
Fat embolism
Associated systemic injury
Other injury in the same limb/compartment syndrome.

15. TREATMENT OPTIONS
The philosophy of the treatment requires,
reduction of the risk of complication :
a) By urgent treatment,
b)
Removal of foreign body,
c) Sharp
debridement and

16. GOLDEN HOUR CONCEPT
, “Every person has right to the best
medical care, if you are critically injured,
you have less than 60 mins to survive.You
may not die right then, it may be 3 days to
2 weeks later, but something has
happened in your body that is
irreparable.”
R. Adams Cowley

17. SILVER DAY CONCEPT
The first day is of great significance. It involves ,
a) Quick reaction of the medical team
b) Documentation
c) Investigation
d) Transportation to an appropiate trauma
center.
e) Splintage - movements allow material
contamination to be buried deeper in the
wound and suction of infected material in
the joint

18. DEBRIDEMENT
 It is a term applied to the,
 Exploration of the wound
 Excision of devitalized tissue.
 Removal of the foreign material.

19. EXPLORATION
The greatest of all antiseptics is a living
tissue”- Sir, Alexander Fleming.
Superficial wound opening must be extended
sufficiently to expose all deep structures.

20. EXPLORATION
For the debridement of the Muscles we
should take under consideration of the 4-
C ,are,
COLOUR,
CONSISTENCY,
CONTRACTILITY,

21. EXPLORATION
Remove all nonviable bone fragments
without adequate soft tissue attachment.
 Clear the tract if wide excision of muscles
is not required, with a gauze.
Irrigation with the Normal saline should
be carried out using 10-14 lts. of Saline.
Installation of local antibiotics is no
remedy for incomplete wound toilet.

22. EXPLORATION
Jeffery Anglen — Irrigation with a detergent
solution is more effective then a solution
with antibiotic additives.
(JBJS Oct2005)

23. EXCISION
Beginning with skin,it includes excision of
devitalized structures, till the fresh
bleeding is seen.

24. REMOVAL OF FOREIGN BODY
Fragments of clothing, wood, grass, or mud should
be removed .
Shot gun pellets cause little devitalization and
quick healing occurs.
Metallic foreign bodies should be lifted from the
cavity, but there need not be exploration beyond
the tissue limits.
Bullets should be removed they donot get sterilized
by the heat, there is a suction effect which draws
outside environment inside.

25. PROPHYLACTIC ANTIBIOTIC
The ATLS protocol(Advanced trauma life
support), must be administered for
prophylactic Intravenous antibiotics,
preferably III generation Cephalosporins,
Aminoglycosides(Gentamicin),
Entroquinolones(Metronidazole) is given,
depending on the contamination.

26. PRIMARY CLOSURE
Depending on the adequacy of the
debridement, viability of the skin margins,
and ability to approximate the skin, without
tension, placed ¼ inch (6mm) apart,
sometimes skin closure is possible by making
releasing incisions.
Do not drag the tissue to approximate.

27. DELAYED PRIMARY CLOSURE V/S
FLAPS
The older concept of the delayed suture is still
practiced but has taken a back seat over the
flaps,due to decreased risk of –
Secondary infection
Wound dessication
Need for redebridement

28. Split Skin grafting is
considered most effective
means of delayed primary
closure
Instability of scar from split
skin grafting may not heal well
during reconstructive
procedures
This could be achieved by
full thickness pedicle flaps and
free flaps.

29. STABILIZATION OF BONE
Upto grade IIIA- Internal fixation after thorough
debridement is the standard followed practice.
IIIB - A primary stabilization using external
fixators followed by a definitive fixation and bone
grafting.

30. COMPLICATIONS
• INFECTION
• NON UNION & DELAYED UNION
• COMPLICATIONS OF WOUND
HEALING.

31. THANK YOU