PRINCIPLE OF DEBRIDEMENT

1. Wound excision : The wound margins are excised, but only enough to leave healthy skin
edges.
2. Wound extension : Thorough cleansing necessitates adequate exposure; poking around
in a small wound to remove debris can be dangerous. If extensions are needed they
should not jeopardize the creation of skin flaps for wound cover if this should be needed.
The safest extensions are to follow the line of fasciotomy incisions; these avoid damaging
important perforator vessels that can be used to raise skin flaps for eventual fracture
cover.
3. Delivery of the fracture: Examination of the fracture sur- faces cannot be adequately
performed without extract ing the bone from within the wound. The simplest (and
gentlest) method is to bend the limb in the manner in which it was forced at the moment
of injury; the fracture surfaces will be exposed through the wound without any additional
damage to the soft tissues. Large bone levers and retractors should not be used.
4. Removal devitalized tissue: Devitalized tissue provides a nutrient medium for bacteria.
Dead muscle can be recognized by its purplish colour, its mushy consistency, its failure
to contract when stimulated and its failure to bleed when cut. All doubtfully viable tissue,
whether soft or bony, should be removed. The fracture ends can be nibbled away until
seen to bleed.
 5. Wound cleansing: All foreign material and tissue debris is removed by excision or
through a wash with copious quantities of saline. A common mistake is to inject
syringefuls of fluid through a small aperture – this only serves to push contaminants
further in; 6–12 L of saline may be needed to irrigate and clean an open fracture of a long
bone. Adding antibiotics or antiseptics to the solution has no added benefit.
6. Nerves and tendon : As a general rule it is best to leave cut nerves and tendons alone,
though if the wound is absolutely clean and no dissection is required – and pro- vided the
necessary expertise is available – they can be sutured.

PRINCIPLE OF OPEN FRACTURE

 Antibiotic prophylaxis.
 Urgent wound and fracture debridement.
 Stabilization of the fracture.
 Early definitive wound cover.
ANATOMI TIBIA FIBULA (CRURIS)
TIBIA FRACTURE ADULT (HANDBOOK OF FRACTURE 6TH EDITION)

BLOOD SUPLY
PRINCIPLE EXTERNAL FIXATION

The stiffness of the frame depends upon the following factors

 Distance of the pins/Schanz screws from the fracture focus: closer means stiffer
 Distance between the pins/Schanz screws inserted in each main fragment: further apart
means stiffer
 Distance of the longitudinal connecting tube/bar from the bone: closer means stiffer
 Number of bars/tubes: two are stiffer than one
 Configuration (low to high stiffness): uniplanar/A-frame/biplanar
  Combination of limited internal fixation (lag screw) with external fixation: only rarely
indicated as mixing elastic with stable fixation is for temporary use only
 Thickness of Schanz screws or Steinmann pins—6 mm vs 5 mm pins (double bending
stiffness)

EXTERNAL FIXATION

 Indications
 External fixation is particularly useful for:
 1. Fractures associated with severe soft-tissue damage (including open fractures) or those
that are contaminated, where internal fixation is risky and repeated access is needed for
wound inspection, dressing or plastic surgery.
 2. Fractures around joints that are potentially suitable for internal fixation but the soft
tissues are too swollen to allow safe surgery; here, a spanning external fixator provides
stability until soft-tissue conditions improve.
 3. Patients with severe multiple injuries, especially if there are bilateral femoral fractures,
pelvic fractures with severe bleeding, and those with limb and associated chest or head
injuries.
 4. Ununited fractures, which can be excised and compressed; sometimes this is combined
with bone lengthening to replace the excised segment.
 5. Infected fractures, for which internal fixation might not be suitable.

OPEN FRACTURE CLASSIFICATION GUSTILO ANDERSON

MESS SCORE
EXTERNAL FIXATION FOR TIBIA
APPROACH TIBIA
APPROACH FIBULA
Hemorrhagic Shock
Trias of death
Indication ETC
Indication DCO
MESS Score
Respond to Initial Fluid Resuscitation

HANNOVER CRITERIA
ANATOMY OF FOOT