Open Fractures
Management and
Classification
Presented by Dr Atif Labban
Supervised by Dr M.Abbas
DEFINITION:
An open fracture is one in which a break in the
skin and underlying soft tissues leads directly
into or communicates with the fracture and its
hematoma.
Gustilo Open Fx Class
JBJS, 72A: 299-303, 1990
2%
7%
7%
10-50%
25-50%
Open Fractures
Type II
Type IIIB
Type IIIA
Type IIIB
Negative Biology of Open Fx
Contamination
Crushing
Stripping
Devascularization
Comminution
Type I wound
is caused by a low-energy
injury that is usually less
than 1 cm long . It is
usually caused by the
bone piercing from the
inside outward rather
than by a penetrating
injury.
Type II wound
is greater than 1 cm in
length and has a
moderate amount of
soft tissue damage
owing to a higherenergy injury . These
are usually outside-toinside injuries.
Type III wound
a high-energy, outside-to-inside injury and is usually
longer than 10 cm with extensive muscle
devitalization.
Extensive wound contamination also increases the
likelihood of infection and subsequent complications.
A type IIIA open fracture
There is limited stripping
of the periosteum and
soft tissues from bone.
There may be loss of skin,
There is adequate
muscle and soft tissue
coverage over bone
A type IIIB open fracture
there is extensive
stripping of soft tissues
and periosteum from
bone. Devitalization or
loss of soft tissues
usually requires a local
flap or free tissue
transfer for coverage of
exposed bone.
A type IIIC open fracture
is one in which there is a
major vascular injury
requiring repair for
salvage of the
extremity. A tibia
fracture with disruption
of the anterior tibial
artery but preservation
of the posterior tibial
artery is not a type IIIC
injury.
MANAGEMENT OF OPEN FRACTURES
Goals of management:
Early return to the function
ER management:
Assesment
Reduction&splinting
Wound care
Tetanous prophylaxis
Antibiotics
avoid complications
OR management:
I&D
SK. Stabilization
Wound managment
EXAMINATION OF THE WOUND AND INITIAL
EMERGENCY MANAGEMENT
START BY APPLYING THE
PRINCIPLES OF ATLS
Tetanus Toxoid
Tetanus Toxoid 2.5 cc to all poly-trauma patients, otherwise:
IMMUNIZATION NON-TETANUS
HISTORY
PRONE
TETANUS
PRONE*
UNKNOWN
YES
YES
>3 IMMUNIZATIONS
(<5 YEARS)
NO
NO
*Tetanus Prone: >6 hours old, complex soft tissue injury, wound >1 cm deep, missile,
crush, burn, frostbite, devitalized tissues, soil contaminants, denervated, ischemic,
early infection.
Tetanus Immune Globulin
250-500 units IM:
IMMUNIZATION
HISTORY
NONTETANUS
PRONE
TETANUS
PRONE*
UNKNOWN
NO
YES
>3 IMMUNIZATIONS
(<5 YEARS)
NO
NO
ANTIBIOTICS
Is therapeutic not prophylactic.
role :kill residual organisms ,inhibit their growth to the
point where host protective mechanisms can eradicate
them .
Irrigation and debridement :most important measures in
preventing infection in open #,antibiotics certainly
cannot be relied on to prevent infection in an
inadequately debrided wound .
Early administration of antibiotics during initial phases of
within 3 hrs of injury decreases incidence of infection in
open fractures
common organism :Staphylococcus aureus
Duration :48 to 72 hours after initial and any subsequent
debridements, & after wound closure, bone graft &
major surgical procedure
Recommended Antibiotic Treatment
1 Gen Ceph
Gent
PCN
Grade I
(G+ve)

Grade II
(G+ve

Grade III
(G+ve& ve)


+/-
Farm &
Ischemic
Wounds
(anaerobic)



Local Antibiotics
• Numerous antibiotics can be
incorporated in polymethylmethacrylate
(PMMA) without losing their bactericidal
activity.
• Should prepared by surgeon
• Useful for type II & III
1)Decrease infection rates
2)High local antibiotic levels(1020times)
3)Useful for dead space
management
4)Decrease systemic effect of IV
antibiotics
PREPARATION FOR SURGICAL
DEBRIDEMENT
All open fractures need to be
formally treated in operating
room on an urgent basis with
meticulous
irrigation&debridement.
A 2-phase surgical preparation
of the limb may be advisable for
severely contaminated
wounds
IRRIGATION AND DEBRIDEMENT
“The solution to pollution is
dilution.”
The more important is
copious irrigation of the
wound
advantages of irrigation
1) Clear blood and other debris for inspection.
2)Lavage floats contaminated blood clots ,
loose tissue , debris from unseen places.
3)Lavage of tissue restores its normal color
and facilitates determination of viability.
4) reduces the bacterial population.