Vous êtes sur la page 1sur 21

THE MANAGEMENT OF

OPEN FRACTURE

Gustillo RB
Richard F Kyle
David C Templeman
in Fracture and Dislocation, 1993
CONTENT
1. INTRODUCTION
2. CLASSIFICATION
3. PRINCIPLES PF TREATMENT
4. ANTIBIOTICS THERAPY
5. IMMEDIATE DEBRIDEMANT
AND IRRIGATION
6. TYPES OF IMMOBILIZATION
7. FIXATION DEVICES
8. SECURE FRACTURE STABILITY
9. WOUND COVERAGE
10. EARLY CANCELLOUS BONE GRAFTING
11. TREAT COMPARTMENT SYNDROME
12. AMPUTATION
13. DECIDE ON EARLY AMPUTATION
14. REHABILITATION
INTRODUCTION
1. Definition :
Fractures, communicated with the
environment with accompanying injury of
varying severity to underlying soft tissue

2. The Goals of Treatment :


1. Prevention of sepsis
2. Healing of fracture
3. Restoration of function
INTRODUCTION
3. The Initial treatment ~ the ultimate outcome
4. The operative aspects of management
1. Debridemant : immediate, meticulous,
repeated
2. Stabilization
3. Coverage of the wound
4. Early bone grafting
5. The effective antibiotic therapy is essential
6. Recognized life threatening problems
CLASSIFICATION
OF OPEN FRACTURE
Type I II III
Mechanism of low degree moderate high velocity
injury
Degree of soft little damage, moderate extensive
tissue crushing (-) wound : > 1 cm
wound < 1 cm
Configuration of simple, moderate segmental
fracture transverse comminution severe
little comminution
comminution
Level of low moderate high
contamination
SUBTYPE OF TYPE III
A : - Adequate soft tissue coverage
- segmental / severe comminutif regardless
the size of wound
B : - Exposed bone after debridemant,
- Extensive injury, loss of soft tissue
- Penosteal stripping, expose of bone
C : - Any open fracture with an arterial
injury that must be repaired
PRINCIPLES OF TREATMENT
1. Treat as an Emergency
2. Evaluation other life threatening injurris
3. Appropriate / adequate antibiotic
4. Adequately debride and irrigate the wund
5. Stabilize the fracture
6. Bonegrafting 1 6 weeks
7. Decide on early amputation
8. Treat compartment syndrome
9. Rehabilitation
ANTIBIOTIC THERAPY
A. Type I : cephalosporin
B. Type II and III open fracture : cephalosporin 2 g, plus
C. Aminoglycosides ; add penicillin, 10 to 12 million units
for farm injuries
D. Continue double antibiotic therapy for 3 days only for
type II and III open fracture
E. Repeat antibiotics during wound closure, internal
fixation, and bone grafting
IMMEDIATE DEBRIDEMANT
AND IRRIGATION
A. Adequate and meticulous removal
of devitalized tissues and copious irrigation
(NS solution 5.000 10.000)
B. Remove small and large free cortical fragments
C. Antibiotic solution
D. Repeat debridement and irrigation for type III
open fracture in 24 to 48 hours and as often as
need
TYPES OF IMMOBILIZATION

1. Plester Immobilization
2. Pin and Plester Immobilization
3. Skeletal Traction
4. Internal fixation with implant
FIXATION DEVICES

1. External Fixation

2. Internal Fixation
1. Intramedullarry nailing
2. Plate and screw
SECURE FRACTURE STABILITY
A. External fixation for all type III open tibia
fracture
B. Screws and plates for articular and
metaphyseal fracture
C. Primary nailing without reaming for type I and
II open fractures : undreamed nailing,
including locking nails, for open femoral shaft
fractures of all types
D. Casts and splints for stable type I and type II
open fracture
WOUND COVERAGE
A. Objective : soft tissue coverage in 3 to 7 days
if a clean, stable wound is obtained
B. Delayed primary closure for type I and type II
open fracture
C. Delayed primary closure with skin graft for
type IIIA or type IIIC without soft-tissue loss
D. Local flaps, or free muscle vascular transfer
for type IIIB or IIIC with soft-tissue loss
EARLY CANCELLOUS BONE GRAFTING

A. During delayed wound closure for


comminution or bone loss (type I and type II)
B. Delayed bone grafting in 4 to 6 weeks
following complete wound healing after
coverage by local flaps or free muscles
vascular transfer
C. Repeat bone grafting in 3 months in two
instance : absence of callus on x-ray films or
gross motion clinically
TREAT COMPARTMENT SYNDROME

Should not be overlooked


Type III : 7,1 %
Fasciotomy
2,7 % open tibial fracture need fasciotomy
Becareful in multiple trauma
AMPUTATION
INDICATION :
1. Absolute :
- IIIC injury + disruption posterior tibial
nerve
- IIIC injury : loss of soft tissue, masive
contamination, severe comminuted segmental
fractures, masive bone loss
2. Relative :
- IIIC type over 8 hours
DECIDE ON EARLY AMPUTATION
A. Type IIIC injury with posterior tibia nerve loss
B. Massive soft-tissue injury with poor
functional results likely
C. Combined soft-tissue and bone loss, implying
prolonged hospitalization, when below-knee
amputation can be performed
D. Relative indication : type IIIC injury over 8
hours old
REHABILITATION
Objective
Ultimate : restoration to the gratest degree
of function of which it is capable
Immediate : - prevent muscle atrophy
- prevent joint stiffnest
- improve circulation

Length of stay : type I : 5 7 days


type II : 12 14 days
type III : 67 days
Pasca Operasi