Good afternoon

the topics to be presented are ​Soft tissue injuries, open fractures, biomaterials,
Pediatric fractures
the exhibitors are ​Yeraldin cruz, Angie Velasquez and jonathan quiroga

The effective treatment of fractures depends on good soft-tissue management.

The energy transfer required to fracture bone also results in damage to the
neighboring soft tissue, with a “zone of ​injury” surrounding any fractured bone.

The condition of the wound after injury is determined by several factors, including:

• Type of insult and area of contact (blunt, penetrating,

crushed, ballistic, etc)
• Magnitude of the force applied
• Direction of force
• Area(s) of body affected
• Wound contamination
• General physical condition of the patient

A combination of these factors will produce different types of wounds.

in this table we can observe that depending on the type of force the type of injury is
formed
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leer algo de la tabla
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Segunda diapositiva
Problems of diagnosis and assessment
The degree of ​injury and ischemic tissue may not be apparent and this can ​make
diagnosis and therapeutic decisions difficult Many
modern imaging techniques permit qualitative assessment
of closed soft-tissue injuries but clinically useful quantitative
assessment of damage is lacking.​ ​There are no diagnostic
criteria that allow definitive, preoperative differentiation
between reversibly (living) and irreversibly (dead or dying)
damaged tissue

Secondary damage
Edema may reduce the microvascular blood supply in adjacent areas and
this can result in progressive necrosis of skeletal muscle or skin in
marginal areas that were not directly affected by trauma.​ ​Thus, secondary
tissue loss may occur.
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Tercer diapositiva

Evaluation of soft-tissue injury

Most important is the knowledge of the amount and direction

of force or energy causing the injury.​ ​This determines
both the extent of the injury and the necessary steps in
treatment. ​The greater the force, the more serious the damage
and sequelae

Systematic examination
Their evaluation can be much more difficult than open injuries and their severity is
easily underestimated.​ ​Simple abrasions represent an injury of the physiological skin
barrier and can allow the development of deep infection.
“Closed skin degloving” occurs when there is shear force.
so
“Fracture blisters” are formed when there is significant acute swelling of a limb, with
resultant shearing at the epidermal level.Fracture blisters are sterile and best
treated by antiedema measures alone.​ ​However, blood-filled fracture blisters are
“more serious” blisters, as they are indicative of significant deeper tissue damage
and potential healing delay

It is mandatory to determine the vascular status of all injured

limbs.​ ​The peripheral pulses, temperature, and capillary
refill must be checked and compared with the uninjured
side

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Cuarta diapositiva
Compartment syndrome
Compartment syndrome is due to raised pressure in a closed
fascial or osteofascial space that results in local tissue ischemia.
This will compromise neuromuscular function and
may result in muscle necrosis with loss of function, infection,
and possible amputation.

The cause may be exogenous pressure (eg, restrictive plaster casts) or

endogenous pressure due to an increase in volume within
the compartment.​ ​The latter results from hemorrhage, perivascular
infusions, or edema that is caused by abnormal
capillary permeability, which in turn is due to prolonged
ischemia or reperfusion

Advances in diagnostic modalities include magnetic resonance imaging,

near-infrared spectroscopy and color Doppler ultrasound;​ ​however, these are more
appropriate
for the diagnosis of CECS

Quinta diapositiva
Management of compartment syndrome
The initial treatment should include release of all circumferential
dressings and elevation of the limb to the level of
the heart.
Compartment syndrome is a surgical emergency and the
treatment of choice is immediate dermatofasciotomy.
In trauma, percutaneous fasciotomy is not indicated
since the skin, as long as it remains intact, acts as a
limiting membrane and may sustain compartment
syndrome.

All four compartments must be released using

either the Mubarak double-incision technique or the parafibular
dermatofasciotomy described by Matsen et al
The likelihood of requiring a split skin graft for tension free
final closure is high.

We can see Clinical images after the release of the compartment. on the left, live
muscles. on the right Death of all compartment muscles.
Sexta Diapositiva

Open soft-tissue injuries

Any fracture associated with an open soft-tissue injury is
more susceptible to infection due to the breach in skin integrity,
and the likelihood of microorganism impregnation
or contamination exists.

must have knowledge of advanced bandaging techniques,

including silver nanocrystal dressings and negative pressure
wound dressings is mandatory for the appropriate trauma patient
care.

sectima Diapositiva
Tscherne classification of open soft-tissue injuries

Open fracture grade I : The skin is lacerated by

a bone fragment from the inside.​ ​There is no or minimal
contusion of the skin and these simple fractures are the
result of indirect trauma

Open fracture grade II : There is a skin laceration

with circumferential skin or soft-tissue contusion and
moderate contamination.​ ​All open fractures resulting
from direct trauma
Open fracture grade III : There is extensive softtissue
damage, often with an additional major vessel
and nerve injury

Open fracture grade IV (Fr. O 4): These are subtotal and

total amputations

octava Diapositiva

Tscherne classification of closed fractures

Closed fracture grade 0 (Fr. C 0): There is no or minor

soft-tissue injury with a simple fracture from indirect
trauma.

Closed fracture grade I (Fr. C 1): There is superficial

abrasion or skin contusion, simple or medium fracture
types
Closed fracture grade II (Fr. C 2): There are deeply contaminated
abrasions and localized skin or muscle contusions
resulting from direct trauma. Imminent compartment
syndrome also belongs to this group

Closed fracture grade III (Fr. C 3): There is extensive skin

contusion, destruction of muscle or subcutaneous tissue
avulsion (closed degloving). Manifest compartment syndrome
and vascular injuries are included. The fracture
types are complex

novena Diapositiva

AO soft-tissue classification: closed skin lesions

The first picture shows no evident skin lesion (IC 1).

on the images ​below no skin laceration but contusion (IC 2)​.

The image on the right​ Circumscribed degloving IC 3

Décima Diapositiva

IC 4 Extensive, closed degloving

and
IC 5 Necrosis from contusion
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Por si pregunta las fases
it is also important to remember, The sequential healing process starts immediately
after trauma and can be divided into three phases:
• Exudative or inflammatory phase
• Proliferative phase
• Reparative phase