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Flashcards in Open Fractures Deck (20)
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1

Open fractures

There is a direct communication between the external environment and the fracture usually through a break in the skin (but not always)

2

Why are open fractures important?

-Higher energy injury
-Increased infection rate
-Soft tissue -Complications
-Long term morbidity

3

What is the epidemiology of open fractures?

-23 per 100,000 popu. per year
-Fingers + tibial shaft account for >50%
-Probably about 3,500 open tibial shaft fractures in UK per year
-1/3 of polytraumatised patients have open fractures- distracting injuries

4

How are open fractures classified?

Gustilo classification of open fractures
-Type 1
-Type 2
-Type 3

5

What is a type 1 open fracture?

Wound <1cm, clean, simple fracture pattern

6

What is a type 2 open fracture?

Wound >1cm, moderate soft tissue damage, adequate skin coverage, simple fracture pattern

7

What is a type 3 open fracture

Extensive soft-tissue damage, complex fracture pattern
-3A: adequate periosteal coverage
-3B: Tissue loss requiring soft-tissue coverage procedure (such as a flap or a graft)
-3C: Vascular injury requiring repair

8

What is the epidemiology of open tibial shaft fractures?

-Type I: 24%
-Type II: 22%
-Type IIIA: 22%
-Type III B: 30%
-Type IIIC: 4%

9

What is the historical treatment principles of open fractures?

-Preservation of life
-Preservation of limb
-Avoidance of infection
-Rehabilitation of function

10

What are the principles recommendations for modern open fracture treatment?

-MDT approach
-Hospitals lacking staff or equipment have a contingency plan
-Primary surgical treatment takes place at specialist centre
-Specialist centres organised on a regional basis

11

Give examples of fracture patterns.

-Transverse or short oblique tibial fractures with fibular fractures at a similar level
-Tibial fractures with comminution/butterfly fragments with fibular fractures at a similar level
-Segmental tibial fractures
-Fractures with bone loss, either from extrusion at the time of injury or after debridement

12

Give examples of soft tissue injury patterns.

-Skin loss such that direct tension-free closure is not possible following wound excision
-Degloving
-Injury to the muscles which requires excision of devitalised muscle via wound extensions
-Injury to one or more of the major arteries of the leg

13

How are open fractures managed before treatment?

-Full ATLS assessment and treatment
-Tetanus and antibiotic prophylaxis
-Cefuroxime / Augmentin / Clindamycin- Gent at time of fixation
-Repeated examination neurovascular status
-Wounds only handled to remove gross contamination,
photograph, cover (saline swabs) and stabilise limb
-No provisional irrigation / exploration
-Radiographs- orthogonal views including joint above and below

14

Who is the 6 hour surgical rule pertinent for?

-Polytraumatised patient
-Marine or Farmyard environment
-Gross contamination
-Neurovascular compromise
-Compartment syndrome

15

Who does the 6 hour rule not apply to?

Solitary open fractures

16

What are the 4Cs of surgical debridement?

-Colour
-Contraction
-Consistency
-Capacity t bleed

17

What is multiple debridements associated with?

Poorer outcomes

18

What techniques can be used for definitive skin coverage?

-SSG
-Myofasciocutanoeus
-Fasciocutaneous
-Rotational
-Free flaps

19

The decision to amputate is based on...

-Limb ischaemia?
-Patient age
-Shock?
-Injury mechanism

20

When is amputation considered?

-Insensate limb or foot
-Irretrievable soft tissue or bony damage
-Other life threatening injuries