1. October 19, 2013
Open Fractures
Mohammad Alsofyani
Teaching Assistant – Orthopedic Department
Surgery Block - 6th MBBS
1

2. 2
Syllabus
Open Fracture
Definition
Mechanism
General
Considerations
Diagnosis
Classification
Management
Compartment
Syndrome
Definition
Types
Pathophysiology
Diagnosis
Management
Surgery Block - 6th MBBS
October 19, 2013

3. 3
Open Fracture
Surgery Block - 6th MBBS
October 19, 2013

4. 4
Open Fracture
 Definition: as one in which a break in the skin and
underlying soft tissues leads directly into or
communicates with the fracture and the hematoma
Surgery Block - 6th MBBS
October 19, 2013

5. 5
Open Fracture
 Mechanism:
 Occurs most commonly after high-energy limb
injuries.
Surgery Block - 6th MBBS
October 19, 2013

6. 6
Open Fracture
 General Considerations:
 one of the true orthopedic emergencies.
 Such a fracture is suspect to contamination by the
environment at the time of injury.
 Can present as isolated injuries or in the context of a
multiply injured patient.
Surgery Block - 6th MBBS
October 19, 2013

7. 7
Open Fracture
 Diagnosis:
 Soft tissue injuries may be threatening to life or limb.
 Clinical examination is required BEFORE obtaining
the X-ray.
 it is essential to check for neurological and vascular
compromise.
 Diagnosed clinically and often difficult to appreciate
on X-rays.
 Soft tissue should be assessed on x-rays.
Surgery Block - 6th MBBS
October 19, 2013

8. 8
Open Fracture
 Diagnosis:
Surgery Block - 6th MBBS
October 19, 2013

9. 9
Open Fracture
 Classification:
 The classification of open fractures as described by
Gustilo and Anderson.
 Type I:
 Skin wound less than 1 cm.
 Clean.
 Simple fracture pattern.
Surgery Block - 6th MBBS
October 19, 2013

10. 10
Open Fracture
 Classification:
 Type II:
 Skin wound more than 1 cm.
 Soft-tissue damage not extensive.
 No avulsions.
 Simple fracture pattern.
Surgery Block - 6th MBBS
October 19, 2013

11. 11
Open Fracture
 Classification:
 Type III:
 High-energy injury involving extensive soft-tissue damage
 Or multifragmentary fracture, segmental fractures, or
bone loss irrespective of the size of skin wound
 Or severe crush injuries
 Or vascular injury requiring repair
 Or severe contamination including farmyard injuries
Surgery Block - 6th MBBS
October 19, 2013

12. 12
Open Fracture
 Classification:
 Type III:
 More than 10 cm.
 Is subdivided based on the degree of contamination, the
extent of periosteal stripping, and the presence of
vascular injury.
Surgery Block - 6th MBBS
October 19, 2013

13. 13
Open Fracture
 Classification:
 Type IIIA: Adequate soft-tissue cover of bone despite
extensive soft-tissue damage
Surgery Block - 6th MBBS
October 19, 2013

14. 14
Open Fracture
 Classification:
 Type IIIB:
 Extensive soft-tissue injury with periosteal stripping and
bone exposure.
 Major wound contamination.
Surgery Block - 6th MBBS
October 19, 2013

15. 15
Open Fracture
 Classification:
 Type IIIC:
 High-energy injury involving extensive soft-tissue damage.
 Major arterial injury.
Surgery Block - 6th MBBS
October 19, 2013

16. 16
Open Fracture
 Classification:
Classification
Size
Inadequate
Soft Tissue
Covering
I
<1cm
✗
✗
✗
✗
II
>1 cm
✗
✗
✗
✗
III
>10
cm
IIIA
✗
✓
✗
✗
IIIB
✓
✓
✓
✗
IIIC
✓
✓
✓
Surgery Block - 6th MBBS
Soft Tissue Contamination
Damage
Vascular
Injury
✓
October 19, 2013

17. 17
Open Fracture
 Management:
 The treatment aims of open fracture is to:
1. Prevention of infection.
2. Soft-tissue coverage.
3. Fracture stabilization.
Surgery Block - 6th MBBS
October 19, 2013

18. 18
Open Fracture
 Management:
1. Prevention of infection:
 In all open fracture injuries, the patient must receive anti-tetanus
prophylaxis and appropriate antibiotic coverage.
 Antibiotics should be given intravenously as soon as possible.
Classification
I
0–2%
II
2 – 10 %
III
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Infection Risks
10 – 50 %
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19. 19
Open Fracture
 Management:
1. Prevention of infection:
Classification
I
Likely
organisms
Coverage Antibiotics (I.V)
II
Gram + Cocci
1st Generation
Cephalosporin
III
Gram + Cocci
and Gram Rod
1st Generation
Cephalosporin +
Gentamicin
Surgery Block - 6th MBBS
October 19, 2013

20. 20
Open Fracture
 Management:
2. Soft tissue coverage:
 Debridement of open fractures is one of
the single most important principles in
management of open fractures.
 The recommended time for
debridement within 6 hours has for long
been considered critical in prevention
of infection.
 Irrigation is very important principle in
open fracture management with
amount around 6 liters.
Surgery Block - 6th MBBS
October 19, 2013

21. 21
Open Fracture
 Management:
2. Soft tissue coverage:
 Surgical incisions performed
during initial debridement can
be closed primarily and original
open fracture wound left open.
 Assisted wound closure using
antibiotic bead pouch or
vacuum assisted dressings are
useful methods.
Surgery Block - 6th MBBS
October 19, 2013

22. 22
Open Fracture
 Management:
3. Fracture stabilization:
 External fixation is the mainstay of treatment in severe
open fracture. Allowing easy access to management of
soft tissues injuries.
Surgery Block - 6th MBBS
October 19, 2013

23. 23
Open Fracture
 Management:
3. Fracture stabilization:
 Definitive fixation is considered, when:
1. The patients clinical status is optimized
2. The wounds are healthy and the soft-tissue envelope will
allow for chosen surgical approach
3. A good preoperative plan has been created.
Surgery Block - 6th MBBS
October 19, 2013

24. 24
Compartment Syndrome
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October 19, 2013

25. 25
Acute Compartment
Syndrome
 Definition:
 Is a true surgical emergency with increasing in tissue
pressure prevents capillary blood flow and produces
ischemia in muscle and nerve tissue.
Surgery Block - 6th MBBS
October 19, 2013

26. 26
Acute Compartment
Syndrome
 Types:
 Compartment of the leg:
 Anterior compartment.
 Posterior superficial compartment.
 Posterior deep compartment.
 Lateral compartment.
Surgery Block - 6th MBBS
October 19, 2013

27. 27
Acute Compartment
Syndrome
 Types:
 Compartment of the forearm:
 Anterior (Flexor).
 Posterior (Extensor).
 Mobile wad of henry (Medially).
Surgery Block - 6th MBBS
October 19, 2013

28. 28
Acute Compartment
Syndrome
 Pathophysiology:
Arterial Damage
Direct Injury
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Ischemia
Reduced Blood Flow
Edema
Compartment
Pressure
October 19, 2013

29. 29
Acute Compartment
Syndrome
 Diagnosis:
 Muscles:
 3-4 hours: reversible changes.
 6 hours: variable damage.
 8 hours: irreversible change.
 Nerves:
 2 hours: looses nerve conduction.
 4 hours: neuropraxia.
 8 hours: irreversible changes.
Surgery Block - 6th MBBS
October 19, 2013

30. 30
Acute Compartment
Syndrome
 Diagnosis:
 The key to successful treatment of
compartment syndrome is early diagnosis
and decompression.
 The hypoxic muscle will become necrotic
within hours.
 Any peripheral nerve passing through the
compartment is likely to suffer permanent
functional impairment.
Surgery Block - 6th MBBS
October 19, 2013

31. 31
Acute Compartment
Syndrome
 Diagnosis:
 Muscle, once infarcted, can
never recover and replaced by
inelastic fibrous tissue (Volkmann’s
ischemic contracture).
Surgery Block - 6th MBBS
October 19, 2013

32. 32
Acute Compartment
Syndrome
Surgery Block - 6th MBBS
October 19, 2013

33. 33
Acute Compartment
Syndrome
 Diagnosis:
Arterial Damage
Ischemia
Reduced Blood
Flow
•
Direct Injury
Surgery Block - 6th MBBS
Edema
Volkmann’s
ischemia
 Painful.
 Pale.
 Pulseless.
 Paresthesi
as.
 paralysis
Compartment
Pressure
October 19, 2013

34. 34
Acute Compartment
Syndrome
 Diagnosis:
 Clinical:
 The classical signs (5P)
 Pain. (out of proportion on passive stretch of the muscles
compartment).
 pallor.
 Parasthesia.
 Paralysis.
 Pulselessness.
 These signs and symptoms are subjective.
Surgery Block - 6th MBBS
October 19, 2013

35. 35
Acute Compartment
Syndrome
 Diagnosis:
 Intercompartmental pressure monitoring.
 Incase of disturbance of level of conscious,
impose the use of objective methods
Surgery Block - 6th MBBS
October 19, 2013

36. 36
Acute Compartment
Syndrome
 Management:
 Remove cast or dressing
 Place at level of heart
 decompress the affected compartment (
Fasciotomy )
Surgery Block - 6th MBBS
October 19, 2013

37. 37
Chronic Compartment
Syndrome
 Definition:
 Occurs in young active patients after intense
muscular activity.
Surgery Block - 6th MBBS
October 19, 2013

38. 38
References
Textbook of Orthopedics (John Ebnezar).
Aply’s System of Orthopedics and Fractures.
Essential of Orthopedics (RM Shenoy).
Essential Orthopedics (J.Maheshwari).
Field Guide to Fracture Management (Richard
B. Birrer).
 Current Diagnosis and Treatment of Orthopedic
(Harry B. Skinner).
 Essential Orthopedic and Trauma (David J.
Dandy)
 Pocket of Orthopedics and Fractures. (Ronald
McRae).
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Surgery Block - 6th MBBS
October 19, 2013