By Dr. Manal Nageeb

Objectives

Definition .

Causes .

.Classification

Diagnosis .

Management .

Complication .

Definition:

A fracture in which broken bone

fragments lacerate soft tissue and

protrude through an open wound in

the skin.

Also called “compound

fracture”.

This type of fracture is particularly

serious because once the skin is

broken, infection in both the wound

and the bone can occur

An open fracture can be defined as a

broken bone that is in communication

through the skin with the

environment

Causes

Open fractures are caused by high-

energy trauma, most commonly from a

direct blow, such as from a fall or motor

vehicle collision.

These fractures can also occur

indirectly, such as a high-energy

twisting type of injury.

Classification :

“ GRADING”

:Open fractures have been classified by

“Gustilo and Anderson

The classification of open fractures is based on the size of the wound and the amount of soft-tissue injury, and correlates with both infection and amputation rates as shown below.

Gustilo and Anderson classification of

open fractures

Type I: clean wound smaller than 1 cm in

diameter, appears clean, simple fracture

pattern, no skin crushing.

Type II: a laceration larger than 1 cm but

without significant soft-tissue crushing,

including no flaps, degloving, or contusion.

Fracture pattern may be more complex..

Type III: an open segmental fracture or a single

fracture with extensive soft-tissue injury. Also

included are injuries older than 8 hours. Type III

injuries are subdivided into three types:

o Type IIIA: adequate soft-tissue coverage of the fracture

despite high-energy trauma or extensive laceration or

skin flaps.

o Type IIIB: inadequate soft-tissue coverage with

periosteal stripping. Soft-tissue reconstruction is

necessary.

o Type IIIC: any open fracture that is associated with

vascular injury that requires repair.

Diagnosis :1-clinical features .

2-Radiology .

Clinically

* History :-

- Mechanism of injury “cause “-age

-General health & specific comorbidities

- pt.'s activity level , disability ambulatory status

Physical examination :

- Open wound ,deformity , swelling ,instability ,

crepitus

- Tests for Compartment syndrome

- Vascular assessment , distal pulses

- Nerves assessment

- Assessment & monitoring of soft tissue swelling &

injury .

Radiology(X-RAY) :

• PLAIN X-RAY should show JOINT above

&JOINT below in at least 2 views

• CT SCAN • MRI .. Non helpful in fractures

diag… other than association with injuries to

the CNS or SUBTROCHANTERIC (ST)

disruption .

Management :

General considerations

Assessment

Emergency management

Débridement and irrigation

Fracture stabilization

Wound management

Definitive treatment

1- General considerations

1-First :- ABCD …

2-Wound-severity classification

>>>> Gustilo and Anderson

The AO classification of fracture wound severity

provides a grading system for injuries of each of the

skin (I), muscles and tendons (MT), and

neurovascular (NV), each of which is divided into

five degrees of severity.

2- Assessment

1- Neurovascular assessment

- The dorsalis pedis and posterior tibial pulses should be palpated in the foot.

Reduced pulses require urgent further assessment.

- Motor function in each of the four leg compartments should be evaluated

- (toe flexion, toe extension, ankle eversion and

plantarflexion).

- Test sensation of the following nerves:

tibial (plantar surface of foot)

deep peroneal (dorsal webspace between 1st and 2nd toe)

superficial peroneal (dorsal lateral foot)

saphenous (medial foot)

2- Imaging to assess location and severity of fracture

3- Emergency management

-Iv fluid , or blood - analgesics

- A temporary splint may be applied to protect

the soft tissues while awaiting the availability of

an operating room .

- As in all open fracture injuries, the patient

must receive anti-tetanus prophylaxis and

appropriate antibiotic coverage ( co-amoxiclav ).

Antibiotics should be given intravenously as

soon as possible.

4- Débridement and irrigation

-- Wound excision >> wound margins

-- Wound extension :

>> Starting with the skin, each layer is debrided

systematically. One can imagine a clock face;

wound débridement starts at the 12 o’clock

position and continues in a clockwise manner

around the circumference of the wound. This is

repeated for each layer down to the level of the

bone.

- Delivery of the fracture >> bend the joint

-- Remove devitalized tissue >>

-The quality of the muscle tissue is assessed using

the classic 4 C’s:

- Color (red or brown)

- Consistency (how does the muscle feel)

- Capillary Circulation (does it bleed?)

- Contractility (responds to pinch or electro-

cautery)

Irrigation

After removing visible dirt and necrotic tissue, irrigation

with several liters of fluid is a key component of the

decontamination of the injury zone.

5- Fracture stabilization (temporary )

External fixation. Depending on your injury,

your doctor may use external fixation to hold you

bones in general alignment. In external fixation,

pins or screws are placed into the broken bone

above and below the fracture site. Then the

orthopaedic surgeon repositions the bone

fragments. The pins or screws are connected to a

metal bar or bars outside the skin. This device is

a stabilizing frame that holds the bones in the

proper position.

6- Wound management

1->> Systemic antibiotics are a critical part of open

fracture wound management. Their choice and duration

will depend upon several factors including severity of

the wound, patient comorbidities, contamination etc.

Antibiotics may also be applied locally to deliver

high concentrations directly to the wound site itself.

2->>Repeat débridement

every 2-3 days, until only healthy, viable tissue remains

and no further necrotic tissue is found on follow-up

débridements.

7- Definitive treatment 1-Internal fixation.

During the operation, the bone fragments are first repositioned

(reduced) into their normal alignment, and then held together with

special screws or by attaching metal plates to the outer surface of the

bone.

2- wound closure .

Definitive fixation is considered, when:

- the patients clinical status is optimized

- the wounds are healthy and the soft-tissue envelope

will allow for chosen surgical approach

- a good preoperative plan has been created.

According to severity of # & wound : >>>

1- minor # -> stabilized by external

fixation

2-sever # -> external fixation -> internal

fixation

3- COPLEX # -> as sever # + :

Local Flap OR Free Flap

Complications :

1- Infection .

2- Neurovascular injury .

3- Acute Compartment syndrome .

Compartment syndrome

Assessment - Firmness of compartment + 6P :

- Pain (out of proportion to what one would expect, especially

with passive stretch of the muscles)

- Paresthesia - Paralysis - Pallor (pale color)

- Poikilothermia (cold distal extremity compared to the

contralateral side) - Pulselessness

Treatment >>> surgical

Treatment for acute compartment syndrome is surgical

release of the involved compartment(s

‘GOOD LUCK ,