Easy Orthopedics

Open Fractures and ATLS Management of Polytrauma

By : Karim Hisham
 Open Fracture
Definition

Types

Classification

Complications

Management
 Definition
Connect
Fracture
Wound at Open
Hematoma
Fracture site fracture
to Exterior
environment

Note : a fracture of the tibia with a wound in the knee, is NOT an open fracture

Note : Secondary open suspected in Subcutaneous bone fractures with 100%

Displacement as tibia If wound not at fracture site → Considered as Technically
open
Types
Primary Secondary

Wound by Trauma itself Wound by Bone Fragment

From outside From inside

Classification
• The modified Gustillo-Anderson classification
This divides open fractures into 3 grades. Grade 1, 2 and 3
This is according to:
-Size of the wound
-Velocity of the injury
-Soft tissue injury
- Contamination of the wound
Classification Description

Grade I •Wound < 1 cm → Mostly Secondary open Fracture

•Low velocity injury - Low soft tissue damage - Low contamination

Grade II •Wound 1 – 10 cm
•Moderate velocity injury - Moderate soft tissue damage - Moderate contamination

Grade III •Any size of wound + 1 of:

•High Velocity injury - Gun shot injury – High Contamination - severe Segmental or comminuted
fracture – Bone Loss – NV injury

•IIIA : Adequate •Adequate periosteal covering → no need for Graft or Flap

•IIIB : Bad •Extensive periosteal loss → need Graft or Flap

•IIIC : Circulation •Arterial injury → Need repair for limb salvage

The modified Gustillo-Anderson classification
 Complications
• Infection
• Bleeding
• All types of shock
Hemorrhagic shock due to blood loss
Neurogenic shock due to the pain
Septic shock due to the infection
• Delayed union ,Non-union due to loss of fracture Hematoma
Management
Management

Emergency Operating Evaluation for Post TTT

room room infection evaluation

Skin and
Examination Wound
muscle

Lab ( infection
Fracture Fracture
Profile )

N.V repair
 Emergency Room
• culture and sensitivity
Take swab • (90% of cases of osteomyelitis are caused by the first offending organism)

• Normal saline washing ( can even reach 15 liters ) for:

Copious irrigation Remove foreign body - Dilution of Bacteria – Hemostasis

Dressing • Sterile Betadine soaked dressing

Splint fracture • Immobilization

• Early as possible + for 72 h Post-operative

IV antibiotics • Triple antibiotic (G+ve, -ve, anaerobe)

Tetanus booster vaccine • In highly contaminated accident scene, extensive wound

 Operating Room
1- Debridement and Remove any necrosis

Why ? … To Avoid Colonization

Skin and Fascia • Remove Necrotic edges

Muscle • Necrotic if 4 C

Healthy Necrotic
Color Pink Blue
Consistency Firm Mush or Dowry
Contractility Contracted if pinched Not contracted

Capillary filling Bleeding with Cut No Bleeding

2- Early fixation by External Fixator
Why ? ..
1. Prevent bacterial colonization by Internal fixation

2. Access to wound: Wound care + Further operations

3- Delayed N.V. ( Ligate ,Repair or Graft )

Why delayed ? …
To avoid affection by manipulation
 Evaluation for Infection
Examination Lab ( Infection Profile )

1. General:
• General Ex – Vital
signs – Consciousness
ESR • ↑ by Trauma
• then ↓ gradually by 2-3 weeks

• ↑ by Trauma
CRP • then ↓ Dramatically.
If ↑ → Infection

• Hotness – Redness –
2. Local: • WBCs.
Edema – Discharge
CBC If ↑ Polymorphic cells →
Infection
 Post Treatment Evaluation
Wound Fracture

If evidence of • Secondary look If Evidence of

• Keep External fixator
infection debridement infection

If no Infection • closure without If no infection

• Internal Fixation
after 8 h tension. after 5-7 days
ATLS Management of Polytrauma
Polytrauma • 2 or more Trauma at same or different site

Injury severity score ( ISS )

Each injury has score from 1-5

Calculate it power 2

Score is the sum of the highest 3 scores

Minor Moderate Serious Severe Critical Max

1-8 9-15 16-24 25-49 50-74 75
Primary Survey
A Airway Assessment: Ability to speak free
Action:
1. Clear from any foreign body – Aspiration – No tongue retraction
2. Protect: Intubation
3. Cervical spine control

B Breathing Assessment: Chest examination

Action: TTT of cause e.g. e.g. Chest tube for tension pneumothorax.

C Circulation Assessment: Shock → cardiogenic (Pulse – heart sounds) or

Neurogenic
Action: IV fluids – Control source of bleeding – Replacement – CVP

D Disability Assessment by GCS or Neurological examination

E Extremities / Exposure
/Environment
T Transfer Hard neck collar + Hard back board.
If not available → Log Roll
R Radiology U/S : Internal hemorrhage
X-ray: cervical (Lateral) – Chest (P/A) – Pelvis (A/P)
CT brain: Head trauma
Secondary survey

• From patient If conscious or From Relatives if Unconscious → AMPLE

History Allergy – Medication – Pregnancy / Past menstruation – Last meal – Events
(operations)

General examination • More Detailed from Head to Heal

Neurological • AVPU
Alert – Verbal – Pain – Unresponsiveness
examination

Investigations • More Detailed