LOWER LIMB FRACTURES Identifying problems early

LOWER LIMB FRACTURES LOWER LIMB FRACTURES Identifying problems earlyIdentifying problems early

Professor Jegan KrishnanProfessor Jegan KrishnanFlinders UniversityFlinders University

Adelaide, South AustraliaAdelaide, South Australia

Specialists Without BordersSeminar in Surgery

Rwanda, September 2010

Specialists Without BordersSeminar in Surgery

Rwanda, September 2010

www.specialistswithoutborders.org

Learning ObjectivesLearning Objectives

Emergency care of traumatised patient Acute care of compound fractures Assessment and Management of Neurovascular

Injury Recognition and Management of Compartment

Syndrome


Emergency Care of Traumatised LimbEmergency Care of Traumatised Limb

General assessment of patient – Emergency Medical and Surgical Trauma (EMST)

Clinical assessment Neurovascular assessment Limb stabilisation Wound inspection dressings Preliminary radiology


Compound FracturesCompound Fractures

Goals of open fracture management include: Prevention of infection Achievement of bony union Restoration of function



Compound fractures according to Gustilo and Anderson: Grade I: skin wound < 1 cm, clean

no contamination Grade II: skin wound > 1 cm

no major soft tissue damage Grade III: high energy, major soft tissue injury or crush injury



Grade I compound #



Grade IIIc compound #



Grade III A: adequate soft tissue coverage of bone, although major soft

tissue damage B: major soft tissue damage with periostal stripping and no coverage of bone C: arterial damage requiring reconstruction


Management PrinciplesManagement Principles

Antibiotic utilisation Timing of initial surgery Type of wound closure Antibiotic delivery methods Tetanus coverage Wound irrigation Adjunctive therapies



Need immediately: Bandage and splint Antibiotics (Cephazolin 1gram IV) Immediate referralFollows: Arteriography? Surgery (<6 hrs) At least 5 days of IV antibiotics



Surgery Grade I and II: - no plates

- intramedullary nail possible Grade III: - external fixator - plastic surgeon – flap

- intramedullary nail possible


External FixationExternal Fixation All over ………………………All over ………………………



Standard treatment for open tibial fractures undergone changes over the last 20 years

Prompt assessment in emergency room required Early aggressive soft tissue and bone debridement High volume pulsatile lavage Administration of IV antibiotics


Compound Fractures – current conceptsCompound Fractures – current concepts

Delayed wound closure or soft tissue coverage with local or distant flaps proven highly effective

Minimise the risk of late deep infection, overall infection rate between 3 and 5% for all open fractures

Risk of infection related to severity of associated soft tissue injury; Gustilo-Anderson Grade II fractures reported incidence as high as 10%, with Grade III reporting as high as 20%



Heitmann et al and Faisham et al have both reported 60-64% of all open tibial fractures are contaminated on presentation in emergency room

Robson et al demonstrated nearly all open fractures are contaminated to some degree, introduced the concept of “Golden Period of Opportunity” – initial 4 to 12 hr period following injury.



Early soft tissue coverage generally believed to limit risk of subsequent deep infection after open fracture

Very early wound closure is not a radical or new concept in trauma surgery

No universal agreement regarding the potential advantages of primary wound closure


SUMMARYSUMMARY

Early EMST wound dressing and splintage Wound debridement Appropriate antibiotics Tetanus prophylaxis Wounds coverage Amputation

LOWER LIMB FRACTURES Identifying problems early

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