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Compound Fractures

Definition

- Fracture with break in skin communicating with fracture haematoma or fracture- Contamination with micro-organisms- Coupled with damage to ST and vascular supply- Leads to increased risk in infection and healing problems

Gustillo Classification

Grade I- low velocity / wound < 1cm- minimal contamination & minimal tissue injuryGrade II

- wound > 1cm- moderate contamination / moderate tissue InjuryGrade IIIA

High velocity injury

- segmental- comminuted- suggests extensive injury or loss of soft tissue- damage to periosteum- Delayed Primary Closure possibleAutomatic Grade III

- shotgun wound- high velocity gunshot wound- segmental fracture with displacement- diaphyseal segmental loss- wound occurring in a farmyard / highly contaminated environment- crushing force from a fast-moving vehicleGrade IIIB

- High velocity injury- After debridement needs skin flap / graftGrade IIIC

- Needed vascular repair to save limbInfection Rate

I: 0-2%

II: 2-7%

IIIA: 7%

IIIB: 10-50%

IIIC: 25-50% with 50% or more amputation

Management

Goals

Prevent infectionManage the wound

Stabilise the fracture

Enable healing

Immediate

EMST / ATLS Principles

Assess Limb

- Vascular- Neurology- skin defect / contamination- photosTreatment- irrigate wound- apply betadine dressing- stabilise with POP if possible- appropriate antibiotics / tetanus

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- early OT for irrigation / debridement / stabilisationAntibiotics

Guidelines

- grade 1: first generation cephalosporin- grade 2: add gentamicin- farmyard / heavily contaminate add penicillin (clostridium / gas gangrene)- infection with preoperative cephalothin was 2.3%- infection 13.9% without antibiotic- studies finding of initial swab correlating with infecting organism has been discredited- no real correlation between road-side organisms & subsequent infection- subsequent infection are typically hospital acquiredTiming

- delay > 3 hours increases infection risk- continue for 48 - 72 hours post injury- continue for 48 - 72 hours post each procedure

Wound Management

Irrigation

- infection higher if < 10L washout- pulse lavage 100 x effective than bulbDebridement- Must remove all non viable tissue- Remove cortical bone with no ST coveringTiming of wound closure

- Do so when wound is clean- No evidence of increased infection with primary closure

o may prevent secondary contaminationo risk of clostridial myonecrosis

- DPC (delayed primary closure)o prevent anaerobic conditions in woundo facilitates drainageo allows second debridemento

can seal the wound via vacuum dressing

Fracture Stabilisation

Advantage

- prevent soft tissue from further injury- facilitates host response to bacteria despite presence of implants- allows mobilisation and functional rehabFemur

- IMN best for I, II, IIIA and B- 10% deep infection in type III B- best to plate in type IIIC before revascularisationTibia

- Reamed v unreamedo no difference in infection rate- IMN v External fixatoro reduced risk of revision surgery, malunion and superficial infection with IM nailo no difference in infection rate or union

- External fixatoro heavily contaminated woundo non amenable to nail (i.e. very distal)o vascular injury

Soft Tissue Reconstruction

Options

- Proximal tibia - local pedicle gastrocnemius flap- Middle third - soleus flap- Distal third - free muscle flap (rectus / gracilis / lat dorsi)Timing

- early < 72 hours v late > 72 hours- 6% v 29% deep infection- did not use antibiotic beads