OPEN FRACTURES: Comprehensive Guide for Diagnosis and Treatment

Clinical Evaluation for Traumatic Injuries

Patient assessment involves ABCDE: airway, breathing, circulation, disability, and exposure. Resuscitate and address life-threatening injuries first. Evaluate injuries to the head, chest, abdomen, pelvis, and spine. Identify all injuries to the extremities and assess the neurovascular status of the injured limb(s). Assess skin and soft tissue damage, but exploration of the wound in the emergency setting is not indicated if operative intervention is planned because it risks further contamination with limited capacity to provide useful information and may precipitate further hemorrhage. Irrigation of wounds with sterile normal saline may be performed in the emergency room if surgery is delayed.

Compartment Syndrome

An open fracture does not preclude the development of compartment syndrome, particularly with severe blunt trauma or crush injuries. Severe pain, decreased sensation, pain with passive stretch of fingers or toes, and a tense extremity are all clues to the diagnosis. If there is a strong suspicion or an unconscious patient in the appropriate clinical setting, monitoring of compartment pressures is warranted. Compartment pressures greater than 30mm Hg or within 30mm Hg of the diastolic blood pressure indicate compartment syndrome and immediate fasciotomies should be performed.

Vascular Injury

Ankle brachial indices (ABIs) should be obtained if signs of vascular compromise exist. ABIs measure the systolic pressure at the ankle and arm, and a normal ratio is greater than 0.9. A vascular consultation and an angiogram should be obtained if a vascular injury is suspected. Indications for angiogram include knee dislocation with ABI less than 0.9 following reduction, cool pale foot with poor distal capillary refill, high-energy injury in an area of compromise, or documented ABI less than 0.9 associated with a lower extremity injury.

Radiographic Evaluation

Extremity radiographs are obtained as indicated by the clinical setting, injury pattern, and patient complaints. Every attempt should be made to obtain at least two views of the extremity at 90 degrees to one another. It is important to include the joint above and below an apparent limb injury. Additional studies may include a CT if there is intra-articular involvement.

Classification

Gustilo and Anderson (Open Fractures) is a quantitative classification system that is useful for communicative purposes despite variability in interobserver reproducibility. It includes size of skin wound and the subcutaneous soft tissue injury that is directly related to the energy imparted to the extremity. Final typing of the wound is reserved until after operative debridement. The system includes:

For more information on classification, see Gustilo and Anderson (Open Fractures) tables 3.2 and 3.3.

• Type I: Clean skin opening of less than 1cm, usually a “poke hole,” minimal muscle contusion, low-energy simple spiral or short oblique fractures
• Type II: Laceration greater than 1cm long with more extensive soft tissue damage, minimal-to-moderate crushing component, simple transverse or short oblique fractures with minimal comminution
• Type III: Extensive soft tissue damage, including muscles, skin, and neurovascular structures; often a high-energy injury with a severe crushing component
  • IIIA: Extensive soft tissue laceration, adequate bone coverage, segmental fractures, gunshot injuries, minimal periosteal stripping
  • IIIB: Extensivesoft tissue injury with periosteal stripping and bone exposure requiring soft tissue flap closure, usually associated with massive contamination
  • IIIC: Vascular injury requiring repair
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  Clinical Evaluation for Orthopedic Injuries

  1. Assessing the patient

     Patient assessment involves ABCDE: airway, breathing, circulation, disability, and exposure. Address life-threatening injuries.

  2. Evaluating injuries

     Evaluate injuries to the head, chest, abdomen, pelvis, and spine. Identify injuries to the extremities and assess the neurovascular status of injured limb(s).

  3. Skin and soft tissue damage

     Assess skin and soft tissue damage, but exploration of the wound in the emergency setting is not indicated if operative intervention is planned because it risks further contamination. Wounds can be irrigated with sterile saline in emergencies, and foreign bodies can be removed

  4. Identifying skeletal injury

     Identify skeletal injury and obtain necessary radiographs at 90 degrees to one another, as well as the joint above and below the apparent limb injury. Additional studies may include a CT if there is intra-articular involvement.

     Compartment Syndrome and Vascular Injury

     • Monitor compartment pressures if compartment syndrome is suspected and perform immediate fasciotomies if the pressure is above 30 mm HG or within 30 mm HG of the diastolic blood pressure (ΔP).

     • Obtain ankle-brachial indices (ABIs) if signs of vascular compromise exist. A vascular consultation and an angiogram should be obtained if a vascular injury is suspected.

  5. Classification of Open Fractures

     For open fractures, use the Gustilo and Anderson classification system, which classifies soft tissue injuries associated with open fractures based on the size of skin wound, soft tissue damage, and energy imparted to the extremity. It is useful for communicative purposes despite variability in interobserver reproducibility. Final typing of the wound is reserved until after operative debridement.

  Clinical Evaluation

  Patient assessment involves ABCDE: airway, breathing, circulation, disability, and exposure.

  Triage

  Triage is the process of prioritizing patients based on the severity of their injuries. The goal of triage is to ensure that the most critical patients are treated first.

  The following criteria are used to triage orthopaedic trauma patients:

  • Airway compromise
  • Respiratory distress
  • Shock
  • Open fractures
  • Neurological deficits

  Primary Assessment

  Once the patient has been triaged, the primary assessment is performed. The primary assessment is a rapid evaluation of the patient's vital signs and airway, breathing, and circulation.

  If the patient has any life-threatening injuries, these are addressed immediately.

  Secondary Assessment

  Once the patient's life-threatening injuries have been addressed, the secondary assessment is performed. The secondary assessment is a more detailed evaluation of the patient's injuries.

  The following areas are assessed during the secondary assessment:

  • Head and neck
  • Chest
  • Abdomen and pelvis
  • Extremities
  • Neurovascular status

  Imaging

  Imaging studies, such as X-rays, CT scans, and MRI scans, may be ordered to help assess the patient's injuries.

  Treatment

  Treatment for orthopaedic trauma patients is based on the specific injuries that the patient has sustained.

  Treatment may include:

  • Surgery
  • Splints and casts
  • Physical therapy
  • Medication

  Links

  • Patient Assessment
  • Triage
  • Imaging
  • Treatment
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  Tscherne Classification of Open and Closed Fractures

  When dealing with bone fractures, it's important to understand the degree of injury in order to plan the best course of treatment. For open fractures, the Tscherne Classification system takes into account wound size, contamination level, and the fracture mechanism, while for closed fractures, it classifies soft tissue damage based on the injury mechanism.

  Open Fractures: Tscherne Classification

  • Grade I:

    Small puncture wound without contusion, low-energy mechanism of fracture, and negligible bacterial contamination

  • Grade II:

    Small laceration, soft tissue contusion, moderate bacterial contamination, variable injury mechanisms

  • Grade III:

    Large laceration with heavy bacterial contamination, substantial soft tissue damage, frequently with associated arterial or neural injury

  • Grade IV:

    Incomplete or complete amputation, with the injury location and nature determining the prognosis

  Closed Fractures: Tscherne Classification

  This system classifies soft tissue injury and takes into account indirect versus direct injury mechanisms.

  • Grade 0:

    Injury from indirect forces with negligible soft tissue damage

  • Grade I:

    Closed fracture caused by low-to-moderate energy mechanisms, with superficial abrasions or contusions of soft tissues overlying the fracture

  • Grade II:

    Closed fracture with significant muscle contusion, deep and contaminated skin abrasions, moderate-to-severe energy mechanisms and skeletal injury; high risk for compartment syndrome

  • Grade III:

    Extensive crushing of soft tissues, with arterial disruption, subcutaneous degloving or avulsion, and established compartment syndrome

  TREATMENT

  After an initial trauma survey and resuscitation for life-threatening injuries, patients should be evaluated for skin and soft tissue damage, wound hemorrhage, and fracture location and severity. Antibiotics should be administered promptly, followed by reduction of the fracture and placement in a splint, brace, or traction. For open fractures, early surgical intervention is key, and the wound should be explored, irrigated, and debrided before definitive fracture fixation. Tetanus prophylaxis should also be given in the emergency room.

  Tscherne Classification of Open Fractures

  The Tscherne Classification system takes into account wound size, level of contamination, and fracture mechanism to determine the severity of an open fracture. Grade I is a small puncture wound without associated contusion or bacterial contamination, caused by a low-energy mechanism of fracture. Grade II is a small laceration with soft tissue contusions and moderate bacterial contamination from variable mechanisms of injury. Grade III is a large laceration with heavy bacterial contamination, extensive soft tissue damage, and frequent associated arterial or neural injury. Grade IV is an incomplete or complete amputation with a variable prognosis based on the location and nature of the injury.

  Tscherne Classification of Closed Fractures

  The Tscherne Classification system classifies soft tissue injury in closed fractures and takes into account indirect versus direct injury mechanisms. Grade 0 injuries result from indirect forces with negligible soft tissue damage. Grade I closed fractures are caused by low-to-moderate energy mechanisms and have superficial abrasions or contusions of soft tissues overlying the fracture. Grade II closed fractures have significant muscle contusion and possible deep, contaminated skin abrasions associated with moderate-to-severe energy mechanisms and skeletal injury, with a high risk for compartment syndrome. Grade III injuries involve extensive crushing of soft tissues, with subcutaneous degloving or avulsion, and arterial disruption or established compartment syndrome.

  Treatment

  In the emergency room, after initial trauma survey and resuscitation for life-threatening injuries:

  1. Perform a careful clinical and radiographic evaluation as outlined earlier.
  2. Address wound hemorrhage with direct pressure rather than limb tourniquets or blind clamping.
  3. Initiate parenteral antibiosis.
  4. Assess skin and soft tissue damage and place a moist sterile dressing on the wound.
  5. Perform provisional reduction of fracture and place in a splint, brace, or traction.
  6. Operative intervention for open fractures should be done after formal wound exploration, irrigation, and debridement before definitive fracture fixation, with the understanding that the wound may require multiple debridements. Do not irrigate, debride, or probe the wound in the emergency room if immediate operative intervention is planned, as this may further contaminate the tissues and force debris deeper into the wound. Only remove obvious foreign bodies that are easily accessible.

  Antibiotic Coverage for Open Fractures includes a first-generation cephalosporin for Type I and II and adding an aminoglycoside for Type III and farm injuries.

  Tetanus prophylaxis should also be given in the emergency room. The current dose of toxoid is 0.5mL regardless of age. For immune globulin, the dose is 75 U for patients less than 5 years old, 125 U for those 5 to 10 years old, and 250 U for those over 10 years old. Both shots are administered intramuscularly, each from a different syringe and into a different site.

  Tscherne Classification of Open Fractures

  Classify Soft Tissue Damage in Open Fractures Based on Wound Size, Contamination Level, and Fracture Mechanism:

  • Grade I: Small Puncture Wound with Negligible Bacterial Contamination and Low-Energy Fracture Mechanism

  • Grade II: Small Laceration with Moderate Bacterial Contamination, Soft Tissue Contusions, and Variable Fracture Mechanism

  • Grade III: Large Laceration with Heavy Bacterial Contamination, Extensive Soft Tissue Damage, and Frequent Arterial or Neural Injury

  • Grade IV: Incomplete or Complete Amputation with Variable Prognosis Based on Location and Nature of Injury

  Tscherne Classification of Closed Fractures

  Classify Soft Tissue Injury in Closed Fractures Based on Direct or Indirect Injury Mechanisms:

  • Grade 0: Injury from Indirect Forces with Negligible Soft Tissue Damage

  • Grade I: Closed Fracture Caused by Low-to-Moderate Energy Mechanisms

  • Grade II: Closed Fracture with Significant Muscle Contusion and Possible Deep, Contaminated Skin Abrasions

  • Grade III: Extensive Crushing of Soft Tissues with Subcutaneous Degloving or Avulsion, and Arterial Disruption or Established Compartment Syndrome

  Treatment: Emergency Room Management

  After Initial Trauma Survey and Resuscitation for Life-Threatening Injuries:

  1. Perform a Careful Clinical and Radiographic Evaluation

  2. Address Wound Hemorrhage with Direct Pressure

  3. Initiate Parenteral Antibiosis

  4. Assess Skin and Soft Tissue Damage and Place a Moist Sterile Dressing on the Wound

  5. Perform Provisional Reduction of Fracture and Place in a Splint, Brace, or Traction

  6. Operative Intervention for Open Fractures:

     Administer Intravenous Antibiotics Early

     Undergo Formal Wound Exploration, Irrigation, and Debridement Before Definitive Fracture Fixation

  7. Do Not Irrigate, Debride, or Probe the Wound in Emergency Room if Immediate Operative Intervention is Planned

  8. Antibiotic Coverage for Open Fractures:

     • Type I, II: First-Generation Cephalosporin

     • Type III: Add an Aminoglycoside

     • Farm Injuries: Add Penicillin and an Aminoglycoside

  9. Requirements for Tetanus Prophylaxis:

     Administer Toxoid and Immune Globulin Intramuscularly Based on Age and Dose

  Operative Treatment:

  Irrigation and Debridement

  The Most Important Steps in Open Fracture Treatment:

  • Extend the Wound Proximally and Distally to Examine the Zone of Injury

  • Clinical Utility of Intraoperative Cultures is Highly Debated and Controversial

  • Meticulous Debridement Should Be Performed Starting with the Skin Subcutaneous Fat and Muscle

    • Large Skin Flaps Should Not Be Developed to Avoid Tissue Devitalization

    • Tendons Should Be Preserved Unless Severely Damaged or Contaminated

    • Devoid Osseous Fragments May Be Discarded

    • Extension into Adjacent Joints Requires Exploration, Irrigation, and Debridement

    • The Fracture Surfaces Should Be Fully Exposed by Recreation of the Injury Mechanism

    • Pulsatile Lavage May Produce Less Damage, While Antibiotic Addition Shows No Efficacy

    • Meticulous Hemostasis Should Be Maintained

    • Fasciotomy Should Be Considered for Compartment Syndrome

  • Some Centers Close the Traumatic Open Wound Over a Drain or Vacuum-Assisted Closure (VAC) System After Debridement

  Operative Treatment for Open Fractures

  Adequate irrigation and debridement are essential steps in the treatment of open fractures. The wound should be extended proximally and distally in line with the affected extremity to examine the zone of injury. Intraoperative cultures remain controversial and are not currently recommended.

  Meticulous debridement should be performed, starting with the skin subcutaneous fat and muscle, according to Table 3.4. Large skin flaps should not be developed because they further devitalize tissues receiving vascular contributions from vessels arising vertically from fascial attachments. Traumatic skin flaps with a base-to-length ratio of 1:2 will frequently have a devitalized tip, particularly if distally based. Tendons, unless severely damaged or contaminated, should be preserved, while osseous fragments devoid of soft tissue may be discarded.

  The extension of open fractures into adjacent joints mandates exploration, irrigation, and debridement. Fracture surfaces should be exposed fully by recreating the injury mechanism. Lavage irrigation should be performed, with some authors favoring pulsatile lavage, but low-flow, high-volume irrigation may produce less damage to the surrounding tissues with the same effect. The addition of antibiotics to the solution has not been shown to be efficacious. Meticulous hemostasis should be maintained because blood loss may already be significant, and clot generation may contribute to dead space and nonviable tissue.

  If concern for compartment syndrome exists, fasciotomy should be considered, especially in obtunded patients.

  Historically, traumatic wounds were not closed, and only the surgically extended part of the wound was closed. More recently, some centers have been closing traumatic open wounds over a drain or vacuum-assisted closure (VAC) system after debridement with close observation for signs or symptoms of sepsis.

  If you have an open fracture, the most important step in treatment is adequate irrigation and debridement. To maximize your chances of recovery, the wound should be fully examined, including the zone of injury. At https://hutaif-orthopedic.com/, we offer high-quality content covering various aspects of orthopedic health, such as diagnosis, treatment, recovery, prevention and lifestyle.

  Irrigation and debridement should be performed meticulously, starting with the skin, subcutaneous fat, and muscle. Large skin flaps should not be developed because this further devitalizes tissues that receive vascular contributions from vessels arising vertically from fascial attachments. Tendons should be preserved unless severely damaged or contaminated. Osseous fragments devoid of soft tissue may be discarded.

  The fracture surfaces should be exposed fully by recreation of the injury mechanism. Lavage irrigation should be performed, and some authors favor pulsatile lavage. Meticulous hemostasis should be maintained because blood loss may already be significant and the generation of clot may contribute to dead space and nonviable tissue. Fasciotomy should be considered if concern for compartment syndrome exists, especially in the obtunded patient.

  Closure of traumatic wounds has long been debated. Historically, it has been advocated that such wounds should not be closed. One should close only the surgically extended part of the wound. More recently, some centers have been closing the traumatic open wound over a drain or vacuum-assisted closure (VAC) system after debridement with close observation for signs or symptoms of sepsis.

  Our website provides detailed information on operative treatment for orthopedic injuries. We have included a variety of helpful resources such as tables, figures, and reader testimonials for you to explore. Trust https://hutaif-orthopedic.com/ for reliable and comprehensive guidance on orthopedic health and injury treatment.

• Extension into adjacent joints mandates exploration, irrigation, and debridement.

• The fracture surfaces should be exposed fully by recreation of the injury mechanism.

• Lavage irrigation should be performed. Some authors favor pulsatile lavage. There is growing evidence that low-flow, high-volume irrigation may produce less damage to the surrounding tissues with the same effect. The addition of antibiotic to the solution has not been shown to be efficacious.

• Meticulous hemostasis should be maintained because blood loss may already be significant and the generation of clot may contribute to dead space and nonviable tissue.

• Fasciotomy should be considered if concern for compartment syndrome exists, especially in the obtunded patient.

• Historically, it has been advocated that traumatic wounds should not be closed. One should close the surgically extended part of the wound only. More recently, some centers have been closing the traumatic open wound over a drain or vacuum-assisted closure (VAC) system ( Fig.3.1) after debridement with close observation for signs or symptoms of sepsis.