CASE 46 open fractures
A 49-year-old male is brought to the emergency department after a high-speed motor vehicle collision. There is a significant soft tissue defect about the proximal left leg with gross contamination. The dorsalis pedis and posterior tibial arterial pulses are palpable. A single AP radiograph of the knee is shown in Figure 6–48. The patient is indicated for application of a knee-spanning external fixator. Figure 6–49 shows the left leg after debridement and irrigation.
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Figure 6–48
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Figure 6–49
Based upon the appearance of this wound, this open fracture is most
appropriately described according to the Gustilo–Anderson classification as:
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II
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IIIA
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IIIB
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IIIC
Discussion
The correct answer is (C). Type II injuries are relatively low energy and have soft tissue wounds greater than 1 cm but are not associated with significant soft tissue damage or periosteal stripping. Type IIIA injuries are associated with high-energy mechanisms with more significant soft tissue damage and periosteal stripping, although these injuries have adequate soft tissue for primary coverage. Type IIIB injuries are associated with more severe soft tissue damage and periosteal stripping. The extent of soft tissue damage necessitates soft tissue coverage procedure. Type IIIC injuries are open fractures that require a vascular repair. The patient is indicated for debridement and irrigation with application of a knee-spanning external fixator, which is appropriate given the extensive soft tissue damage and gross contamination.
Postoperatively, the patient is interested in discussing the prognosis of his left lower extremity. He inquires as to whether or not below-the-knee amputation would offer more of a clinical benefit versus a limb salvage approach.
Which of the following statements regarding amputation and limb salvage is correct?
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When controlling for injury severity, patients undergoing primary amputation exhibit superior functional outcomes at 2- and 7-year follow-up.
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The extent of soft tissue damage is most important factor in determining the viability of severely injured lower extremity.
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The fact that the patient’s plantar sensation was intact at the time of his presentation portends a favorable outcome with limb salvage.
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The patient’s socioeconomic status has been shown to play a significant role in predicting the success of limb salvage.
Discussion
The correct answer is (B). The most important determinant of whether or not a severely injured lower extremity should be amputated or salvaged is the extent of the associated soft tissue injuries. The LEAP study group demonstrated that patients
who underwent amputation had functional outcomes similar to those patients treated with limb salvage. Neither the status of a patient’s plantar sensation nor their socioeconomic status were predictors of limb salvage success.
Which of the following statements regarding the management of large soft tissue defects associated with open tibia fractures is correct?
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The use of negative pressure wound dressings have not been shown to influence the need for free flap coverage.
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The use of negative pressure wound dressings have been shown to lower infection rates in Type IIIB tibia fractures.
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Deep infection rates significantly decrease when soft tissue coverage is delayed for at least 72 hours.
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Initial debridement of large soft tissue wounds is best accomplished by high-flow, pulsatile lavage.
Discussion
The correct answer is (B). Bhattacharyya et al. demonstrated that the use of negative pressure wound dressings does not significantly allow for coverage delay for open tibia fractures. The use of negative pressure wound dressings have been shown to decrease the need for free flap coverage of large soft tissue defects. In a series of 84 Type IIIB and IIIC tibia fractures, a single-stage procedure involving fixation with immediate flap coverage demonstrated significantly lower infection rates compared to the group in which coverage was undertaken more than 72 hours after injury. There is concern that pulsatile lavage damages healthy tissues and has the potential to increase the deep penetration of gross and microscopic contamination when used in the management of contaminated open fractures, which has been corroborated in an animal model.
Objectives: Did you learn...?
The Gustilo–Anderson classification system for open fractures?
Prognostic factors associated with severe lower extremity injuries and the LEAP Study Group findings pertaining to functional outcomes amongst amputees and those treated with limb salvage?
The infection rates for open fractures and strategies to manage large soft tissue defects?