Introduction
• All open fractures, no matter how trivial they may seem, must be assumed to be
contaminated.
• Open fractures have a potential for serious bacterial wound infections, including gas
gangrene and tetanus, and these in turn may lead to long term disabilities, chronic wound or
bone infection, and death.
Wound infection is particularly of concern when:
A. Injured patients present late for definitive care, or
B. In disasters where large numbers of injured survivors exceedavailable trauma care capacity.
• Appropriate management of injuries is important to reduce the likelihood of wound
infections.
🔷TheINITIAL MANAGEMENT AT THE SCENE OF THE ACCIDENT:
usual combination:
• Multiple injuries • Severe shock • Open Fracture
Introduction
• Trauma and fracture are not the same thing. When a limb isbroken every tissue in it is
damaged and the fact that thebony injury is the only one visible on the radiograph does
notmake it the most serious.
• Radiographs does not show severed nerves, crushedmuscles, ruptured blood vessels or
torn ligaments any morethan they tell whether a wound is contaminated how the injury
occurred or how it should be treated
Treat the patient, not only the fracture
• General treatment and resuscitation
• No undue delay in attending to the fracture Antibiotics:
• swelling of the soft parts during the first 12 hours makes reduction increasingly difficult Do not use topical antibiotics Do not use Washing with antibiotic solutions
Antibiotics are necessary but not sufficient, you need to do appropriate wound debridement
Initial Management Antibiotics do not reach the source of the wound infectionWhat is it?
The advanced trauma life support programme supervised by the American college of
surgeons has become the standard of emergency care consisting of 4 inter-related stages
• A rapid primary survey with simultaneous resuscitation
• Constant re-evaluation
• A detailed secondary survey
• Initiation of definitive care Tetanus Prophylaxis
Tetanus Prophylaxis is initiated in emergency room or trauma bay Guidelines for
tetanus prophylaxis depend on 3 factors:
A Airway and Cervical spine •complete or incomplete vaccination history (3 doses)
support •date of most recent vaccination
• Is the airway Intact? •severity of wound
• Do you need to apply cervical collar
Two forms of prophylaxis
• toxoid dose 0.5 mL, regardless of age
B Breathing and Chest Injuries • immune globulin dosing
• <5-years-old receives 75U
• Is chest expansion symmetrical?
• Is the breathing depth normal? • 5-10-years-old receives 125U
• Is the rate of breathing normal? • >10-years-old receives 250U
• Toxoid and immunoglobulin should be given intramuscularly with two different
Problems
syringes in two different locations
• Pneumothorax (Simple, tension or open)
• Massive haemothorax
• Cardiac tamponade Wound Debridement
• Flail chest
• Disruption of tracheobronchial tree Treatment of Open Fractures • Wound debridement is the surgical procedure aims to render the wound free of foreign material
Constant Re-evaluation
The Primary Survey at Hospital Core Principles and dead tissue, leaving a clean surgical field with a good blood supply throughout.
A simple pneumonic for remembering the elements of • Because open fractures are often associated with severe tissue damage, the operation should be
• The patient must be re-evaluated frequently to assess the Four questions need to be answered performed by someone skilled in dealing with both skeletal and soft tissues; ideally this should be
response to resuscitation and to detect any deterioration at C Circulation primary surveys based on the first five letters of the
alphabet
(1) What is the nature of the wound? a joint effort by orthopaedic and plastic surgeons.
the earliest movement Are the vital signs normal? (2) What is the state of the skin around the wound?
ABCDE (3) Is the circulation satisfactory?
• Nasogastric tube There are five types of shock: The steps for wound debridement:
• Airway maintenance with cervical spine support (4) Are the nerves intact?
• Urethral catheter • Vasoconstrictive: 1. GA
• Breathing and oxygenation (Care to chest injuries
• ECG • Hypovolaemic.• Cardiogenic.
• Circulation and control of bleeding Hospital Management 2. No tourniquet (unless severe bleeding is out of control)
• Blood pressure, arterial blood gases, oxygen saturation… • Vasodilative: 1. General rapid assessment “ABCDE” 3. Wound cleaning
• Disability
etc • Septic. • Neurogenic. • 2. Warm the patient 4. Wound extension
• Exposure and avoidance of hypothermia
Anaphylactic. 3. Wound inspection • The site and size • Tidy or ragged • Clean or dirty • 5. Remove foreign bodies
Open Fractures Communication with the fracture or not 6. Excise devitalized soft and bony tissues.
4. Wound photographing 7. Take swabs for culture
D Disability
Principles of
5. Immediate wound cover
6. Tetanus prophylaxis
8. Identify the vital structures
9. Leave the wound open
How is the mental status of the patient? 7. Systemic antibiotics
What is the GCS?Is there any deficit in
motor and sensory modalities?Problems:
• Head Injury
Treatment 8. Under appropriate aseptic technique in OR
a) Cleansing and irrigationb) Early wound debridement (within 8 hours if possible)
Characteristics of devitalized tissues:
• Dusky or black muscle tissue.
c) Stabilization of fracture • Muscles do not bleed on cutting
• Spinal Injury
Closed Fractures • Muscles do not contract on stimulation
• Disintegrated muscle tissue or very dirty that can not be cleaned
E Exposure
Have you explored other parts of the Blood Vessels, Nerves & Tendons
body? • Major vascular injuries:
• All body parts• Region by region The circulation is initially established with bypassing tubes. Definitive repair should follow thorough
• Avoid hypothermia debridement and stabilization of the fracture
• As a general rule it is best to leave cut nerves and tendons alone, though if the wound is absolutely
Clinical Assessment clean and no dissection is required – and provided the necessary expertise is available – they can be
Assist the patient for the following: sutured.
• Any evidence of visceral injury.
• Any evidence of vascular injury. Fracture Stabilization
• Any evidence of neurological injury. • External fixation is a useful method of holding the fracture while the wound remains
• Whether there is wound communicating with accessible.
the fracture. • Severe wounds as crushed and gunshot wounds require secured stabilization with external
• Resuscitation if necessary before definitive fixators
treatment • Type I and Type II small wounded and relatively stable fractures are supported with complete
split plaster or traction on splint as in open femoral fractures
Reduction - Aim
(1) adequate apposition and normal alignment of the bone fragments. Wound Closure
(2) The greater the contact surface area between fragments the more likely is healing to occur • Never close infected wounds (e.g gunshot wounds).
(3) a gap between the fragments is a common cause of delayed union or non-union. • Do not close contaminated wounds and clean wounds that are more than six hours old.
(4) However, so long as the fragments are in contact and properly aligned, some overlap at the • Systematically perform wound toilet and surgical debridement.
fracture surfaces is permissible; the exception is a fracture involving an articular surface, which • Copious irrigation with normal saline.
should be reduced as near to perfection as possible. • In war time or mass casualties use thoroughly boiled water for wound irrigation after cooling to
(5) Reduction may be ‘closed’ or ‘open’. preserve normal saline.
🔷
• Continue the cycle of surgical debridement and irrigation until the wound is completely clean.
Closed reduction:
🔺
• Manage these with surgical toilet, leave open and then close 48 hours later. This is known as
Is Reduction Unnecessary? delayed primary closure.
There are some situations in which reduction is unnecessary:
🔷
🔹 Open reduction
Indications:
(1) Little or no displacement.
(2) Displacement does not initially matter
• e.g. in some fractures of the clavicle.
🔹
• Recall the Classification of open fractures
• Gustilo Classification is based on the following:
1. Wound size 2. Pattern of fracture 3. Periosteal stripping 4. Skin and soft tissue coverage 5. Neurovascular injury
Operative reduction under direct vision is (3) Reduction is unlikely to succeed
indicated in the following situations: • e.g. with compression fractures of the vertebrae
(1) The closed reduction fails.
(2) Difficulty in holding the bony fragments
together.
🔹Indication
• All partially displaced fractures
(3) Soft tissues are interposed between bony • Most fractures in children
fragments • Fractures are likely to be stable after closed reduction
(4) There is a large articular fragment that • Unstable fractures are sometimes reduced ‘closed’ prior to mechanical fixation.
needs accurate positioning.
(5) Avulsion fractures in which the fragments
are held apart by muscle pull
🔹 Manipulative Manoeuvre
Under anesthesia and muscle relaxation, the fracture is reduced by a three fold manoeuvre:
Secondary Survey
• Once the patient has been resuscitated, he or she is
(6) An operation is needed for associated (1)the distal part of the limb is pulled in the line of the bone examined thoroughly from head to toe.
injuries (e.g. arterial damage). (2) as the fragments disengage, they are repositioned (by reversing the original direction of force if • Advice necessary imaging: X-ray, CT scan, MRI, US… etc.
Generally open reduction is the first step to this can be deduced) • However the patient should not leave the emergency
internal fixation. (3) alignment is adjusted in each plane . It is most effective, department for these investigations unless his or her
When? …The periosteum and muscles on one side of the fracture remain intact. condition is absolutely stable.
Why? …The soft-tissue strap prevents over-reduction and stabilizes the fracture after it has been
reduced.
▪️
What about femoral shaft fracture?
▪️Is manipulative reduction effective in a femoral shaft fracture? No
Why?
▪️
Persisting instability Counterforces exerted on bony fragments by powerful muscles
What is the alternativeSolution?
Past: Mechanical Traction
Current: ORIF
🔷Hold / Maintain /Immobilize ?
🔹 Functional Bracing 🔹 Objective Treat the patient, not only the fracture
🔹
• Functional bracing Functional bracing, using either • To maintain the reduced position of the bony fragments. The principles of Treatment of closed fractures, consists of:
• To prevent them from redisplacement Methods
plaster of Paris or one of the lighter materials, is one way
of preventing joint stiffness while still permitting fracture 🔹 Nonivasive methods:
• Slabs, gutters and casts
Reduce
. By close reduction:
-By manipulate
splintage and loading.
• It is usually applied only when the fracture is beginning • Functional bracing -By mechanical traction
to unite, i.e. after 3–6 weeks of traction or restrictive • Other splints and slings
🔹
• By open reduction
Hold / Maintain / Immobilize
🔹
splintage. • sustained traction
Invasive methods • By external splintage
• Internal fixation
• External fixation 🔹
• By internal fixation
Exercise / Use / Rehabilitation
🔹 Complications of the cast
🔹 Internal Fixation
Bone fragments may be fixed with one or a
• Tight cast
• Ischemia
by fatema okoff
• Compartment syndrome
combination of the following methods: • Pressure sores
1. Plate held by screws • Skin abrasion or laceration
2. Bone graft held by screws • Blisters
3. Intramedullary nail • Loose cast
4. Compression plate and screws • Broken cast
5. Nail and Plate Prevention of Complications
6. Trans-fixation screws You will never ever apply a cast around a limb which has
🔹
7. Circumferential wires
Complications
• Infection
an acute injury and liable to be swollen
• Use a slap, gutter or splint.
• Ensure no further swelling.
• Non-union • Apply a cast if necessary.
• Implant failure
• Refracture If a window is opened on a cast the cover should be
returned on place and secured by bandage … why?
EXERCISE – Restore Function
Not only to the injured parts but also to the patient as a
🔹
whole
The objectives are to:
• Reduce oedema
• Preserve joint movement
• Restore muscle power
• Guide the patient back to normal activity
• All open fractures, no matter how trivial they may seem, must be assumed to be
contaminated.
• Open fractures have a potential for serious bacterial wound infections, including gas
gangrene and tetanus, and these in turn may lead to long term disabilities, chronic wound or
bone infection, and death.
Wound infection is particularly of concern when:
A. Injured patients present late for definitive care, or
B. In disasters where large numbers of injured survivors exceedavailable trauma care capacity.
• Appropriate management of injuries is important to reduce the likelihood of wound
infections.
🔷TheINITIAL MANAGEMENT AT THE SCENE OF THE ACCIDENT:
usual combination:
• Multiple injuries • Severe shock • Open Fracture
Introduction
• Trauma and fracture are not the same thing. When a limb isbroken every tissue in it is
damaged and the fact that thebony injury is the only one visible on the radiograph does
notmake it the most serious.
• Radiographs does not show severed nerves, crushedmuscles, ruptured blood vessels or
torn ligaments any morethan they tell whether a wound is contaminated how the injury
occurred or how it should be treated
Treat the patient, not only the fracture
• General treatment and resuscitation
• No undue delay in attending to the fracture Antibiotics:
• swelling of the soft parts during the first 12 hours makes reduction increasingly difficult Do not use topical antibiotics Do not use Washing with antibiotic solutions
Antibiotics are necessary but not sufficient, you need to do appropriate wound debridement
Initial Management Antibiotics do not reach the source of the wound infectionWhat is it?
The advanced trauma life support programme supervised by the American college of
surgeons has become the standard of emergency care consisting of 4 inter-related stages
• A rapid primary survey with simultaneous resuscitation
• Constant re-evaluation
• A detailed secondary survey
• Initiation of definitive care Tetanus Prophylaxis
Tetanus Prophylaxis is initiated in emergency room or trauma bay Guidelines for
tetanus prophylaxis depend on 3 factors:
A Airway and Cervical spine •complete or incomplete vaccination history (3 doses)
support •date of most recent vaccination
• Is the airway Intact? •severity of wound
• Do you need to apply cervical collar
Two forms of prophylaxis
• toxoid dose 0.5 mL, regardless of age
B Breathing and Chest Injuries • immune globulin dosing
• <5-years-old receives 75U
• Is chest expansion symmetrical?
• Is the breathing depth normal? • 5-10-years-old receives 125U
• Is the rate of breathing normal? • >10-years-old receives 250U
• Toxoid and immunoglobulin should be given intramuscularly with two different
Problems
syringes in two different locations
• Pneumothorax (Simple, tension or open)
• Massive haemothorax
• Cardiac tamponade Wound Debridement
• Flail chest
• Disruption of tracheobronchial tree Treatment of Open Fractures • Wound debridement is the surgical procedure aims to render the wound free of foreign material
Constant Re-evaluation
The Primary Survey at Hospital Core Principles and dead tissue, leaving a clean surgical field with a good blood supply throughout.
A simple pneumonic for remembering the elements of • Because open fractures are often associated with severe tissue damage, the operation should be
• The patient must be re-evaluated frequently to assess the Four questions need to be answered performed by someone skilled in dealing with both skeletal and soft tissues; ideally this should be
response to resuscitation and to detect any deterioration at C Circulation primary surveys based on the first five letters of the
alphabet
(1) What is the nature of the wound? a joint effort by orthopaedic and plastic surgeons.
the earliest movement Are the vital signs normal? (2) What is the state of the skin around the wound?
ABCDE (3) Is the circulation satisfactory?
• Nasogastric tube There are five types of shock: The steps for wound debridement:
• Airway maintenance with cervical spine support (4) Are the nerves intact?
• Urethral catheter • Vasoconstrictive: 1. GA
• Breathing and oxygenation (Care to chest injuries
• ECG • Hypovolaemic.• Cardiogenic.
• Circulation and control of bleeding Hospital Management 2. No tourniquet (unless severe bleeding is out of control)
• Blood pressure, arterial blood gases, oxygen saturation… • Vasodilative: 1. General rapid assessment “ABCDE” 3. Wound cleaning
• Disability
etc • Septic. • Neurogenic. • 2. Warm the patient 4. Wound extension
• Exposure and avoidance of hypothermia
Anaphylactic. 3. Wound inspection • The site and size • Tidy or ragged • Clean or dirty • 5. Remove foreign bodies
Open Fractures Communication with the fracture or not 6. Excise devitalized soft and bony tissues.
4. Wound photographing 7. Take swabs for culture
D Disability
Principles of
5. Immediate wound cover
6. Tetanus prophylaxis
8. Identify the vital structures
9. Leave the wound open
How is the mental status of the patient? 7. Systemic antibiotics
What is the GCS?Is there any deficit in
motor and sensory modalities?Problems:
• Head Injury
Treatment 8. Under appropriate aseptic technique in OR
a) Cleansing and irrigationb) Early wound debridement (within 8 hours if possible)
Characteristics of devitalized tissues:
• Dusky or black muscle tissue.
c) Stabilization of fracture • Muscles do not bleed on cutting
• Spinal Injury
Closed Fractures • Muscles do not contract on stimulation
• Disintegrated muscle tissue or very dirty that can not be cleaned
E Exposure
Have you explored other parts of the Blood Vessels, Nerves & Tendons
body? • Major vascular injuries:
• All body parts• Region by region The circulation is initially established with bypassing tubes. Definitive repair should follow thorough
• Avoid hypothermia debridement and stabilization of the fracture
• As a general rule it is best to leave cut nerves and tendons alone, though if the wound is absolutely
Clinical Assessment clean and no dissection is required – and provided the necessary expertise is available – they can be
Assist the patient for the following: sutured.
• Any evidence of visceral injury.
• Any evidence of vascular injury. Fracture Stabilization
• Any evidence of neurological injury. • External fixation is a useful method of holding the fracture while the wound remains
• Whether there is wound communicating with accessible.
the fracture. • Severe wounds as crushed and gunshot wounds require secured stabilization with external
• Resuscitation if necessary before definitive fixators
treatment • Type I and Type II small wounded and relatively stable fractures are supported with complete
split plaster or traction on splint as in open femoral fractures
Reduction - Aim
(1) adequate apposition and normal alignment of the bone fragments. Wound Closure
(2) The greater the contact surface area between fragments the more likely is healing to occur • Never close infected wounds (e.g gunshot wounds).
(3) a gap between the fragments is a common cause of delayed union or non-union. • Do not close contaminated wounds and clean wounds that are more than six hours old.
(4) However, so long as the fragments are in contact and properly aligned, some overlap at the • Systematically perform wound toilet and surgical debridement.
fracture surfaces is permissible; the exception is a fracture involving an articular surface, which • Copious irrigation with normal saline.
should be reduced as near to perfection as possible. • In war time or mass casualties use thoroughly boiled water for wound irrigation after cooling to
(5) Reduction may be ‘closed’ or ‘open’. preserve normal saline.
🔷
• Continue the cycle of surgical debridement and irrigation until the wound is completely clean.
Closed reduction:
🔺
• Manage these with surgical toilet, leave open and then close 48 hours later. This is known as
Is Reduction Unnecessary? delayed primary closure.
There are some situations in which reduction is unnecessary:
🔷
🔹 Open reduction
Indications:
(1) Little or no displacement.
(2) Displacement does not initially matter
• e.g. in some fractures of the clavicle.
🔹
• Recall the Classification of open fractures
• Gustilo Classification is based on the following:
1. Wound size 2. Pattern of fracture 3. Periosteal stripping 4. Skin and soft tissue coverage 5. Neurovascular injury
Operative reduction under direct vision is (3) Reduction is unlikely to succeed
indicated in the following situations: • e.g. with compression fractures of the vertebrae
(1) The closed reduction fails.
(2) Difficulty in holding the bony fragments
together.
🔹Indication
• All partially displaced fractures
(3) Soft tissues are interposed between bony • Most fractures in children
fragments • Fractures are likely to be stable after closed reduction
(4) There is a large articular fragment that • Unstable fractures are sometimes reduced ‘closed’ prior to mechanical fixation.
needs accurate positioning.
(5) Avulsion fractures in which the fragments
are held apart by muscle pull
🔹 Manipulative Manoeuvre
Under anesthesia and muscle relaxation, the fracture is reduced by a three fold manoeuvre:
Secondary Survey
• Once the patient has been resuscitated, he or she is
(6) An operation is needed for associated (1)the distal part of the limb is pulled in the line of the bone examined thoroughly from head to toe.
injuries (e.g. arterial damage). (2) as the fragments disengage, they are repositioned (by reversing the original direction of force if • Advice necessary imaging: X-ray, CT scan, MRI, US… etc.
Generally open reduction is the first step to this can be deduced) • However the patient should not leave the emergency
internal fixation. (3) alignment is adjusted in each plane . It is most effective, department for these investigations unless his or her
When? …The periosteum and muscles on one side of the fracture remain intact. condition is absolutely stable.
Why? …The soft-tissue strap prevents over-reduction and stabilizes the fracture after it has been
reduced.
▪️
What about femoral shaft fracture?
▪️Is manipulative reduction effective in a femoral shaft fracture? No
Why?
▪️
Persisting instability Counterforces exerted on bony fragments by powerful muscles
What is the alternativeSolution?
Past: Mechanical Traction
Current: ORIF
🔷Hold / Maintain /Immobilize ?
🔹 Functional Bracing 🔹 Objective Treat the patient, not only the fracture
🔹
• Functional bracing Functional bracing, using either • To maintain the reduced position of the bony fragments. The principles of Treatment of closed fractures, consists of:
• To prevent them from redisplacement Methods
plaster of Paris or one of the lighter materials, is one way
of preventing joint stiffness while still permitting fracture 🔹 Nonivasive methods:
• Slabs, gutters and casts
Reduce
. By close reduction:
-By manipulate
splintage and loading.
• It is usually applied only when the fracture is beginning • Functional bracing -By mechanical traction
to unite, i.e. after 3–6 weeks of traction or restrictive • Other splints and slings
🔹
• By open reduction
Hold / Maintain / Immobilize
🔹
splintage. • sustained traction
Invasive methods • By external splintage
• Internal fixation
• External fixation 🔹
• By internal fixation
Exercise / Use / Rehabilitation
🔹 Complications of the cast
🔹 Internal Fixation
Bone fragments may be fixed with one or a
• Tight cast
• Ischemia
by fatema okoff
• Compartment syndrome
combination of the following methods: • Pressure sores
1. Plate held by screws • Skin abrasion or laceration
2. Bone graft held by screws • Blisters
3. Intramedullary nail • Loose cast
4. Compression plate and screws • Broken cast
5. Nail and Plate Prevention of Complications
6. Trans-fixation screws You will never ever apply a cast around a limb which has
🔹
7. Circumferential wires
Complications
• Infection
an acute injury and liable to be swollen
• Use a slap, gutter or splint.
• Ensure no further swelling.
• Non-union • Apply a cast if necessary.
• Implant failure
• Refracture If a window is opened on a cast the cover should be
returned on place and secured by bandage … why?
EXERCISE – Restore Function
Not only to the injured parts but also to the patient as a
🔹
whole
The objectives are to:
• Reduce oedema
• Preserve joint movement
• Restore muscle power
• Guide the patient back to normal activity
