OPen fractures management

1. Open Fractures and BOAST
Guidelines
“Most open tibial/ femoral fractures are caused
by high impact trauma, so the potential for
concomitant life-threatening injury should be
ruled out before addressing traumatic limb
injury”

2. The classification of such soft-
tissue wounding is according
to two systems, namely that
of Gustilo, Mendoza &
Williams (See: Gustilo RB,
Mendoza RM, Williams DN
(1984) Problems in the
management of type III
(severe) open fractures
In 1895, Stanley Boyd said
“The most important
divisions of fractures -
simple, compound and
complicated - are based
upon the condition of the
soft parts.”

5. Open fracture simplified

6. Gustillo Classification I
wound contamina
tion
Soft
tissue
injury
BONE
INJURY
TIME
(week
s)
risk of
infecti
on in
%
<1cm minimal Minimal Simple
minimal
comminut
ion
15 0-2
Court-Brown et al. 1990
Patzakis MJ et al. 1989 77/1104 – early ABx

7. Gustillo Classification II
wound contaminat
ion
Soft
tissue
injury
BONE
INJURY
TIME
(week
s)
risk of
infecti
on in
%
1-10cms Moderate Moderat
e to
some
muscle
damage
Moderate
comminuti
on
24 2-5
Court-Brown et al. 1990
Patzakis MJ et al. 1989 77/1104 – early ABx

8. Gustillo Classification IIIA wound contamina
tion
Soft
tissue
injury
BONE
INJURY
TIME
(week
s)
risk of
infecti
on in
%
>10cms High Moderat
e to
some
muscle
damage
Usually
comminut
ed
Soft tissue
coverage
may be
possible
27 5-10
Patzakis MJ et al. 1989 77/1104 – early ABx

9. Gustillo Classification IIIB
wound contaminati
on
Soft tissue
injury
BONE
INJURY
TIME
(weeks
)
risk of
infectio
n in %
>10cms High Very
severe,
Loss of
coverage
Requires
reconstruc
tive
surgery
Poor bone
cover
Moderate to
severe
comminutio
n
38 10-50

10. Gustillo Classification IIIc
wound contaminati
on
Soft
tissue
injury
BONE
INJURY
TIME
(weeks
)
risk of
infecti
on in
%
>10cms High Very
severe
Loss of
coverage
Vascular
injury
Soft tissue
reconstru
ctive
surgery
Poor bone
cover
Moderate
to severe
comminutio
n
74 25-50

11. OTA classification
Parameter Score
Injury to skin Small injury
Large/Immeasurable injury
Degloving injury
1
2
3
Muscular injury No/Minimal injury
Moderate/functional injury
Extensive muscle injury
1
2
3
Arterial injury No injury
Non-ischaemic injury
Ischaemia
1
2
4
Degree of contamination No/minimal contamination
Surface
Deep
1
2
3
Amount of bone loss No loss
Minimal bone loss
Significant bone loss
1
2
3

12. Ganga hospital scoring
Parameter Score
Skin losses No loss
Some loss/degloved
(+2 to above if over bone)
Extensive loss/exposed bone
1
2
5
Soft tissue injury No injury
Repairable
Irreparable
Loss of <2 compartments
Loss of ⩾2 compartments
1
2
3
4
5
Bony injury Fracture, no bone loss
Joint involvement
Bone losses: < 4cm
> 4cm
1 - 2
3
4
5
Additional risk factors Age >65
Contamination
Chronic illness
Systemic injury
Other trauma
+2 for each

13. Epidemiology
Diaphyseal fractures are more common than metaphyseal
fractures
Highest rates of diaphyseal fractures were seen in:
• Tibia 21.6%
• Femur 12.1%
• Radius and Ulna 9.3%
• Humerus 5.7%
EFORT Open ReviewsVolume 3, Issue 5, May 2018, Pages 316-325
https://doi.org/10.1302/2058-5241.3.170072
Annual incidence of 3.4 per 100 000
The mean age of those who sustain open tibial fractures is 43.3
years, most frequently occurring in young adult males and
elderly females.
High energy trauma is the primary mechanism of injury, with
over 50% of cases being attributed to road traffic accidents or
falls from a great height

14. Microbiology
• Poor tissue oxygenation & devitalisation of the surrounding tissues
including the bone provide a perfect medium for infection and
bacterial multiplication
• When left open >2 weeks – Wound is prone to nosocomial infection
such as pseudomonas species and gram negative species
• This phenomenon of hospital acquired infection emphasizes the
importance of a strict protocol for in-hospital management and early
wound coverage

17. Choice of antibiotics
• BOAST guidelines
• Start within 3 hours and continue until debridement
• Co-Amoxiclav 1.2g TDS IV
• OR Cefuroxime 1.5g TDS IV
• OR Clindamycin 600mg QDS IV if penicillin allergic
• Stat dose at wound excision and continue for 72
hours or until wound closure whichever is sooner
• Co-amoxiclav 1.2g TDS IV and Gentamicin
1.5mg/Kg

18. Management in theatre
1. Aggressive debridement and irrigation
• Low pressure lavage using NaCl 0.9%. 3L, 6L or 9L
• Remove bone fragments without soft tissue
attachments
2. Fracture stabilisation – Internal or external
3. Staged debridement – every 24 to 48 hours
as needed
4. Early soft tissue coverage or wound closure
• Aim for less than 7 days to decrease risk of infection
5. Place antibiotic bead pouch in dirty wounds

20. Case-1

22. Case 2

23. Type 2 open fractures both radius and ulna

24. Case 3

25. Type 3 A

26. Case- 4

27. Gustilo Anderson –Type 3 B

28. Case -5

29. Grade IIIC open Tibial shaft fracture clinical photo

30. External fixators

32. Case 6

34. “Mangled” refers to a
limb in which three of
the four functional
components (bone,
vessels, nerves, and soft
tissue) are injured

35. Take home message
• IV Antibiotics within 3 hours of injury and continue for 72 hours or
until closure
• Serial neurovascular examinations
• Vascular repair ≤6 hours
• Multidisciplinary team (Plastics and Orthopaedics) to treat complex
open fractures
• Wound is handled to remove gross contamination and allow
photography  cover with saline soaked gauze and impermeable film
• Early transfer of patients to specialised centres
• Definitive stabilisation and wound clover within 72 hours and not
exceed 7 days

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37. THANK
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