5. 04/22/13
Type IIType II ::
greater than 1cm in lengthgreater than 1cm in length
moderate amount of soft tissue damagemoderate amount of soft tissue damage
higher energy trauma.higher energy trauma.
(Usually confined to one compartment(Usually confined to one compartment
and amount of debridement required is minimal)and amount of debridement required is minimal)
ClassificationClassification
[Gustillo & Anderson][Gustillo & Anderson]
6. 04/22/13
¤ Type III¤ Type III ::
Wound longer than 10cmWound longer than 10cm
with extensive muscle devitalisationwith extensive muscle devitalisation
7. 04/22/13
Type IIIaType IIIa ::
Limited stripping of periosteum and softLimited stripping of periosteum and soft
tissues from bone.tissues from bone.
adequate soft tissue coverage for bone,adequate soft tissue coverage for bone,
tendons and neurovascular bundle.tendons and neurovascular bundle.
8. 04/22/13
¤¤ Type IIIbType IIIb : Extensive stripping of soft: Extensive stripping of soft
tissue and periosteum from bone.tissue and periosteum from bone.
Requires a local flap or free tissue transferRequires a local flap or free tissue transfer
9. 04/22/13
¤¤ Type IIIcType IIIc : A major vascular: A major vascular
injury requiring repairinjury requiring repair
((AA tibia # with disruption of ant. tibialtibia # with disruption of ant. tibial
arteryartery
but preservation of post. tibial artey isbut preservation of post. tibial artey is
not Type IIIc)not Type IIIc)
ClassificationClassification
[Gustillo & Anderson[Gustillo & Anderson
11. 04/22/13
MANAGEMENT
EMERGENCY
GOLDEN HOUR CONCEPT
AIM:-
To convert contaminated wound into clean woundTo convert contaminated wound into clean wound
To convert the open # into a closed one.To convert the open # into a closed one.
To establish a union in a good positionTo establish a union in a good position
To prevent pyogenic and clostridial infection.To prevent pyogenic and clostridial infection.
18. 04/22/13
MUSCLEMUSCLE
Mechanism of injuryMechanism of injury
Necrotic muscle : pabulum of infectionNecrotic muscle : pabulum of infection
““When in doubt,take it out” is approachWhen in doubt,take it out” is approach
10 % muscle belly is enough10 % muscle belly is enough
21. 04/22/13
TENDONSTENDONS
Not a pabulum of infectionNot a pabulum of infection
Adequate coverageAdequate coverage
RepairRepair
Usually preservedUsually preserved
22. 04/22/13
BONEBONE
Retain bones with soft tissueRetain bones with soft tissue
attachmentattachment
DebridementDebridement
ViabilityViability
Adequate coverageAdequate coverage
24. 04/22/13
NERVES AND VESSELSNERVES AND VESSELS
Layer by layer hemostasisLayer by layer hemostasis
Delayed repair if contaminatedDelayed repair if contaminated
Total loss of blood supply-moreTotal loss of blood supply-more
than 8 hrs:AMPUTATIONthan 8 hrs:AMPUTATION
Emergency repairEmergency repair
43. 04/22/13
STABILIATION OF OPEN FRACTURESTABILIATION OF OPEN FRACTURE
METHODSMETHODS
1.1. PLASTER IMMOBILISATIONPLASTER IMMOBILISATION
2.2. PINS &PLASTERPINS &PLASTER
3.3. SKELETAL TRACTIONSKELETAL TRACTION
4.4. EXTERNAL FIXATIONEXTERNAL FIXATION
5.5. INTERNAL FIXATIONINTERNAL FIXATION
6.6. HYBRID FIXATIONHYBRID FIXATION
trade-off between bony stability
and foreign body response
44. 04/22/13
External fixatorsExternal fixators
Method of choice in most open fracturesMethod of choice in most open fractures
ADVATAGESADVATAGES
•Easily appliedEasily applied
•Good skeletal & soft tissue stabilityGood skeletal & soft tissue stability
• Anatomical reduction.Anatomical reduction.
• No additional traumaNo additional trauma
45. 04/22/13
ADVATAGES of EX.FIXADVATAGES of EX.FIX
•Risk of infection is comparatively less.Risk of infection is comparatively less.
•Allows wound inspection & wound dressing.Allows wound inspection & wound dressing.
•Temporarizing frame ,restoring the limb to lengthTemporarizing frame ,restoring the limb to length
until definitive fixation.until definitive fixation.
•Allows transportationAllows transportation
•Better nursing careBetter nursing care
46. 04/22/13
INTERNAL FIXATIONINTERNAL FIXATION
CONTROVERSIALCONTROVERSIAL
IndicationIndication
1.1. Type- I #Type- I #
2.2. Type-II # - 5-8% infectionType-II # - 5-8% infection
3.3. Type III # - 26-43 % infectionType III # - 26-43 % infection
4.4. Intra articular #Intra articular #
5.5. Reimplantation surgeryReimplantation surgery
6.6. Vascular repairsVascular repairs
7.7. Old patientsOld patients
8.8. Polytrauma patientsPolytrauma patients
47. BONE GRAFTINGBONE GRAFTING
INDICATIONSINDICATIONS
1.1. Bone lossBone loss
2.2. High velocity traumaHigh velocity trauma
3.3. Severe comminutionSevere comminution
TimingTiming
type-I immediatetype-I immediate
type II &III 6-12 weekstype II &III 6-12 weeks
48. 04/22/13
AMPUTATIONAMPUTATION
IndicationsIndications
1.1.vascular injury – norepair possiblevascular injury – norepair possible
2.functional outcome better with prosthesis2.functional outcome better with prosthesis
3. Life saving to arrest bleeding3. Life saving to arrest bleeding
4. Associated diseases OVD- DM etc.4. Associated diseases OVD- DM etc.
49. 04/22/13
COMPLICATIONSCOMPLICATIONS
EARLYEARLY
1. Gas gangrene1. Gas gangrene
2. Tetanus 2. Tetanus
3. Crush syndrome 3. Crush syndrome
1.1.Chronic osteomyelitisChronic osteomyelitis
2.Delayed union & Non union2.Delayed union & Non union
3.Joint stiffness3.Joint stiffness
LATELATE
50. 04/22/13
OPEN FRACTURES IN CHILDRENOPEN FRACTURES IN CHILDREN
differ from those in adultsdiffer from those in adults
1.1. healing capacity of the soft tissues & bonehealing capacity of the soft tissues & bone
excellentexcellent
2.2. No bone grafting neededNo bone grafting needed
3.3. Infection rareInfection rare
4.4. External fixation left in place until unionExternal fixation left in place until union
5.5. social and psychological impactsocial and psychological impact