Specialists Without Borders
Seminar in Surgery
Rwanda, September 2010
LOWER LIMB FRACTURES
Identifying problems early
Professor Jegan Krishnan
Flinders University
Adelaide, South Australia
Specialists Without Borders
Seminar in Surgery
Rwanda, September 2010
www.specialistswithoutborders.org
Learning Objectives
 Emergency care of traumatised patient
 Acute care of compound fractures
 Assessment and Management of Neurovascular
Injury
 Recognition and Management of Compartment
Syndrome
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Emergency Care of Traumatised Limb
 General assessment of patient – Emergency
Medical and Surgical Trauma (EMST)
 Clinical assessment
 Neurovascular assessment
 Limb stabilisation
 Wound inspection dressings
 Preliminary radiology
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Compound Fractures
Goals of open fracture management include:
 Prevention of infection
 Achievement of bony union
 Restoration of function
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Compound Fractures
Compound fractures according to Gustilo and
Anderson:
 Grade I: skin wound < 1 cm, clean
no contamination
 Grade II: skin wound > 1 cm
no major soft tissue damage
 Grade III: high energy, major soft tissue injury
or crush injury
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Compound Fractures
Grade I compound #
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Compound Fractures
Grade IIIc compound #
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Compound Fractures
 Grade III A: adequate soft tissue coverage
of bone, although major soft
tissue damage
B: major soft tissue damage with
periostal stripping and no
coverage of bone
C: arterial damage requiring
reconstruction
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Management Principles
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Antibiotic utilisation
Timing of initial surgery
Type of wound closure
Antibiotic delivery methods
Tetanus coverage
Wound irrigation
Adjunctive therapies
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Compound Fractures
Need immediately:
 Bandage and splint
 Antibiotics (Cephazolin 1gram IV)
 Immediate referral
Follows:
 Arteriography?
 Surgery (<6 hrs)
 At least 5 days of IV antibiotics
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Compound Fractures
Surgery
Grade I and II: - no plates
- intramedullary nail possible
Grade III:
- external fixator
- plastic surgeon – flap
- intramedullary nail possible
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External Fixation
All over ………………………
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Compound Fractures
 Standard treatment for open tibial fractures
undergone changes over the last 20 years
 Prompt assessment in emergency room
required
 Early aggressive soft tissue and bone
debridement
 High volume pulsatile lavage
 Administration of IV antibiotics
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Compound Fractures – current concepts
 Delayed wound closure or soft tissue coverage with
local or distant flaps proven highly effective
 Minimise the risk of late deep infection, overall
infection rate between 3 and 5% for all open
fractures
 Risk of infection related to severity of associated
soft tissue injury; Gustilo-Anderson Grade II
fractures reported incidence as high as 10%, with
Grade III reporting as high as 20%
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Compound Fractures – current concepts
 Heitmann et al and Faisham et al have both
reported 60-64% of all open tibial fractures are
contaminated on presentation in emergency room
 Robson et al demonstrated nearly all open fractures
are contaminated to some degree, introduced the
concept of “Golden Period of Opportunity” – initial
4 to 12 hr period following injury.
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Compound Fractures – current concepts
 Early soft tissue coverage generally believed
to limit risk of subsequent deep infection
after open fracture
 Very early wound closure is not a radical or
new concept in trauma surgery
 No universal agreement regarding the
potential advantages of primary wound
closure
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SUMMARY
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Early EMST wound dressing and splintage
Wound debridement
Appropriate antibiotics
Tetanus prophylaxis
Wounds coverage
Amputation