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Fractures

Open

Definition

  • Fracture with a break in the skin communicating with fracture haematoma or fracture

Classification

Gustilo and Anderson Classification of Open Fractures

Described 1976: treatment of 1025 open fractures

Modified 1984

Modified Gustilo & Anderson Classification of Open Fractures
Grade Wound Description
I < 1cm
  • Low Energy
  • Low contamination, Clean wound
  • Minimal tissue injury
II 1-10cm
  • Moderate Energy
  • Moderate contamination
  • Moderate tissue injury
IIIa > 10cm
  • High Energy Trauma regardless of size of wound
  • Contaminated
  • Extensive soft tissue laceratiosn or flaps, but maintain adequate soft tissue coverage of bone
IIIb  
  • Needs flap/ graft for closure
IIIc  
  • Needs vascular repair to save limb
    Automatic Grade III
  • Shotgun wound
  • High-velocity gunshot wound
  • Segmental fracture with displacement
  • Diaphyseal segmental loss
  • Wound occurring in a farmyard/ highly contaminated environment
  • Crushing force from a fast-moving vehicle

Management

  • General Principles Trauma Management
    • Resuscitation & Assessment
    • Appropriate antibiotics
    • Debridement/ Irrigation
    • Bony stabilization
    • Soft tissue envelope
    • Definitive bony procedure
    • Bone grafting as needed

  • Gustilo JBJSA 1987
    • Infection higher if < 10L washout
  • Anglen 1984
    • Pulse lavage 100x more effective than bulb

Antibiotics

Patzakis 1974

  • Controlled, randomized, prospective trial
  • Infection with pre-operative Cephalothin was 2.3% cf. 13.9% with no AB
  • Finding initial swab correlating with infecting organism has been discredited

Gustilo

  • Gram negative infection in Grade II ↑
  • Hence add aminoglycoside if Grade II
  • Tetanus
  • Rationale of not swabbing open wounds
  • No real correlation between road-side organisms & subsequent infection
  • Which is typically hospital acquired

Tetanus Prophylaxis

Patient previously fully immunised

Wound not Tetanus-prone

  • If < 10 years since TT: nothing
  • If > 10 years since TT: single TT

Wound Tetanus-prone

  • If < 5 years since TT: nothing
  • If > 5 years since TT: single TT

Patient not adequately immunised or unknown

  • Wound not Tetanus-prone
    • Give 0.5ml TT
  • Wound Tetanus-prone
    • Give 250-500 units TIG
    • + 0.5ml TT in other arm
    • ± penicillin

Principles of Open/ Infected Fractures

  • Management 5 fold
    • Appropriate antibiotics
    • Adequate debridement
    • Soft tissue envelope preserved
    • Skeletal stabilization
    • Bone graft as needed
  • Note can expand this as needed to TJR loose/ Infected/ Osteomyelitis