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Distal Femoral Fractures

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Open fractures ARS 31 yr old man Ped ... Bony Stabilization Diaphyseal Fractures Humerus Forearm Femur Tibia ORIF IM nail Bony ... Distal Femoral Fractures ... – PowerPoint PPT presentation

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Title: Distal Femoral Fractures


1
Open Fracture Management
P. Blachut Division of Ortho Trauma Vancouver
General Hospital University of British Columbia
2
  • Introduction
  • Assessment
  • Classification
  • Management

Open fractures
3
Goals of Fracture Management
  • Fracture healing with satisfactory length and
    alignment
  • Avoidance of complications
  • infection
  • nonunion
  • malunion
  • stiffness
  • Early restoration of function

4
Fracture Healing
  • Biologic factors
  • Biomechanical factor

5
Avoidance of Complications (Infection)
  • No necrotic tissue
  • No dead space
  • No contamination
  • Well vascularized tissue

6
Early Restoration of Function
  • Early mobilization
  • Stable fixation
  • Early wound healing
  • Avoid excessive scarring
  • Early wound coverage with quality tissue
  • Preservation of critical tissues
  • Nerves
  • Tendons

7
Therefore
  • The soft tissues are paramount to the successful
    management of fractures

8
  • A bone healing complication with good soft
    tissues is easier to deal with than a
    complication with poor soft tissues

9
Consequences of an Associated Soft Tissue Injury
  • healing potential
  • resistance to infection
  • contamination

10
Assessment
  • Look for associated life threatening injuries!!!
  • Carefully assess and document neurovascular status

11
ATLS (Advanced Trauma Life Support)
  • Primary Survey
  • A irway
  • B reathing
  • C irculation
  • D isability
  • E xposure
  • Secondary Survey

12
Compartment Syndrome
  • Always look for in fractures with soft tissue
    injuries
  • Open fractures - up to 10 have compartment
    syndrome

13
Amputation vs. Salvage
  • Multidisciplinary decision
  • Based on the assessment of likely ultimate
    function of limb compared to function with
    amputation

14
Factors Favoring Amputation
  • Warm ischemia time gt 8 hrs
  • Severe crush
  • minimal remaining functional tissue
  • Chronic debilitating disease
  • Severe polytrauma
  • Mass casualty
  • complexity of reconstruction

15
Classification
16
Classification - Open Fractures
  • Reflection of amount of energy imparted and
    consequently, the prognosis
  • Skin wound size
  • Level of contamination
  • Extent of soft tissue injury/ periosteal
    stripping
  • Fracture configuration

17
Classification - Open Fractures
  • Classification can really only be done at the
    completion of debridement

18
Classification - Open Fractures
  • Open injuries
  • Gustilo Anderson
  • AO

19
Open Fracture - Gustilo Classification
  • Type I
  • Small wound
  • Inside out
  • No/minimal contamination
  • Minimal soft tissue trauma
  • Low energy fracture pattern

20
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21
Open Fracture - Gustilo Classification
  • Type II
  • Moderate wound
  • Some contamination
  • Some muscle damage
  • Moderate energy fracture pattern

22
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23
Open Fracture - Gustilo Classification
  • Type III
  • Large wound
  • Significant comtamination
  • Major soft tissue trauma
  • crushing
  • periosteal stripping
  • High energy fracture pattern

24
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25
Open Fracture - Gustilo Classification
  • IIIA
  • enough soft tissue to cover bone
  • IIIB
  • insufficient soft tissue
  • need flap (local, free)
  • IIIC
  • vascular injury requiring repair

26
Open Fracture - Gustilo Classification
  • Type III - Additional Factors
  • Barnyard
  • Shotgun
  • High velocity gunshot
  • Displaced segmental fracture
  • Neglected open fracture (gt 8 hrs)
  • Bone loss

27
Management
  • First aid
  • Emergency Room
  • Definitive
  • Rehabilitation

28
First Aid
  • Control bleeding
  • direct pressure
  • Realign
  • further soft tissue damage/ compromise
  • Splint
  • comfort
  • further damage

29
Emergency
  • First aid if not already given
  • Remove gross debris/irrigate/dress/ splint
  • Tetanus prophylaxis - if necessary
  • Antibiotics

30
Emergency
  • The open wound should be assessed and documented
    only once

31
Antibiotics
  • ? Prophylactic vs. treatment
  • Closed with operative Rx Cephalosporin
  • Grade I
  • Grade II / III Add aminoglycoside
  • High Risk Add penicillin

32
Antibiotics
  • Antibiotics can not compensate for an inadequate
    surgical management

33
Timing of Administration of Antibiotics
  • The Prevention of Infection in Open Fractures An
    Experimental Study of the Effect of Antibiotic
    Therapy
  • Worlock, et al JBJS 1988

No antibiotics 1-4 hrs post-inoculation 1 hr.
pre-inoculation
91 infection 51 infection 30 infection
34
Antibiotics
  • The Role of Antibiotics in the Management of Open
    Fractures
  • Patzakis, et al JBJS, 1974

Control Pen./Streptomycin Cephalothin
13.9 infection 9.7 infection 2.3 infection
35
Definitive Treatment
  • Wound excision
  • Wound extension
  • Debridement
  • Irrigation
  • Bone stabilization
  • Wound dressing
  • /- re-debridement
  • Early wound closure/coverage

36
Timing of Operative Intervention
  • General standard - within 6-8 hours
  • Not evidence based!!

37
Operating Room
  • Scrub/remove gross debris/ irrigate
  • Double setup
  • debridement/irrigation
  • bone stabilization if internal fixation planned
  • Tourniquet
  • apply/not inflated
  • in case of bleeding

38
Wound Excision
  • Excise crushed/ contaminated skin edge

39
Wound Extension
  • Sufficient extension to fully evaluate and treat
    soft tissue injury (approximately 1 diameter of
    limb)
  • Anticipate incisions for bony stablization/soft
    tissue reconstruction
  • Avoid incision that will compromise skin further

40
Wound Extension
41
Debridement
  • Layer by layer
  • Remove all devitalized and contaminated tissue
    (including bone)

42
Debridement - Objective
  • To leave a wound with
  • No/minimal contamination
  • Well vascularized tissue for healing and to
    resist infection

43
Debridement
  • When in doubt, take it out

44
Irrigation
  • 10 litres for significant wounds
  • saline
  • ? antibiotics
  • ? pulsed lavage
  • ? detergent

45
Irrigation
  • Improves visualization
  • Float out necrotic tissue
  • Flush out debris
  • Reduce bacterial population

46
Irrigation
  • The solution to pollution is dilution

47
Stabilization
The Prevention of Infection in Open Fractures
An Experimental Study of the Effect of Fracture
Stability Worlock, et al Injury 1994
48
Bony Stabilization
  • Second prep if internal fixation
  • Principles
  • Minimize further trauma
  • Sufficient stability to allow early rehab
  • Should not impede subsequent soft tissue
    management
  • Restoration of anatomy

49
Bony Stabilization
  • Diaphyseal Fractures
  • Humerus
  • Forearm
  • Femur
  • Tibia

ORIF IM nail
50
Bony Stabilization
  • Articular Fractures
  • primary ORIF
  • spanning external fixator
  • / - articular ORIF
  • ? delayed ORIF
  • external fixation

51
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52
Open Wound Management
  • Can close extensions
  • Occasionally close open wound primarily
  • No crush
  • No contamination
  • Small wound
  • No dead space
  • Closure without tension
  • Keep wound moist - ? bead pouch

53
Open Wound Management
Price of Primary Open Wound Closure Gas
Gangrene Limb Loss Death
? leave open
54
Open Wound Management
  • Antibiotic beads
  • Depo of local
  • antibiotics
  • ? efficacy
  • ? toxicity

55
Antibiotic Bead Pouch VGH Experience
  • 85 open tibial shaft fractures
  • 59 antibiotic bead pouch
  • 26 no bead pouch
  • No statistical difference in
  • age, sex, ISS, time to wound coverage

Keating, et al
56
Antibiotic Bead Pouch VGH Experience
  • Infection

Type II Type III TOTAL
No Bead Pouch Bead Pouch p value
16 0 lt0.03
11 3 0.35
15 2 lt0.06
Keating, et al
57
Redebridement
  • High grade injury
  • Severe contamination
  • Questionable tissue viability
  • ? adequacy of debridement
  • Q 24-48 hours until wound is viable

58
Wound Closure/Coverage
  • ? Immediate
  • Optimally by 3-7 days
  • Principles
  • Durable coverage
  • Well vascularized
  • soft tissue envelope
  • for bone
  • Fill dead space

59
Wound Closure/Coverage
  • Secondary intent
  • Delayed primary closure
  • Skin graft
  • Flap
  • local
  • distant - free

60
Wound Closure/Coverage
Role of VAC yet to be delineated
61
Rehabilitation
  • Splint joints in functional position pending soft
    tissue healing
  • Swelling control
  • ROM/Muscle rehabilitation as soon as wound
    healing permits
  • Wound management to minimize scarring

62
Summary
  • The soft tissues are critical to the successful
    management of all fractures

63
Summary
  • Aggressive, systematic management is required for
    fractures with significant soft tissue injuries

64
THANK YOU !!
65
ARS
  • 31 yr old man
  • Ped struck
  • Isolated injury
  • The most critical component
  • of this mans treatment is
  • Antibiotics
  • Tibial fixation
  • Avoidance of reaming
  • Soft tissue management
  • Early fracture stabilization

Open fractures
66
ARS
  • 31 yr old man
  • Ped struck
  • Isolated injury
  • After management of the soft
  • tissues the bone is best
  • stabilized by
  • Cast
  • External fixator
  • Plate
  • Reamed IM nail
  • Unreamed IM nail

Open fractures
67
ARS
  • 31 yr old man
  • Ped struck
  • Isolated injury
  • How would you grade this
  • injury?
  • I
  • II
  • III A
  • III B
  • III C

Open fractures
68
ARS
  • 31 yr old man
  • Ped struck
  • Isolated injury
  • The most critical component
  • of this mans treatment is
  • Antibiotics
  • Tibial fixation
  • Avoidance of reaming
  • Soft tissue management
  • Early fracture stabilization

Open fractures
69
ARS
  • 31 yr old man
  • Ped struck
  • Isolated injury
  • After management of the soft
  • tissues the bone is best
  • stabilized by
  • Cast
  • External fixator
  • Plate
  • Reamed IM nail
  • Unreamed IM nail

Open fractures
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