G13 mangled extremity

Fractures with Soft Tissue Injuries

Gary E. Benedetti, MD

Introduction• All fractures have some degree of soft tissue

injury– Prognosis determined by:

• Amount of energy transferred to the soft tissue and bone

• Degree of contamination and type of bacteria

• Patient factors

Introduction

• Energy Transfer– Fall from curb

• 100 ft-lbs

– Skiing• 300-500 ft-lbs

– High-Velocity GSW• 2000 ft-lbs

– Automobile Bumper @ 20 MPH

• 100,000 ft-lbs

Classification of Soft Tissue Injuries-Closed Fractures

• Tscherne Type 0: – Minimal soft tissue injury– Indirect injury mechanisms– Simple fracture patterns.

Classification of Soft Tissue Injuries-Closed Fractures

• Tscherne Type I: – Superficial abrasion

or contusion (pressure from within)

– Mild to moderate severe bony injury

Classification of Soft Tissue Injuries-Closed Fractures

• Tscherne Type II:– Deep,

contaminated abrasions or muscle contusion

– Impending compartment syndrome

– Severe fracture pattern

Classification of Soft Tissue Injuries-Closed Fractures

• Tscherne Type III: – Extensive skin contusion or

crush– Severe underlying muscle

damage– Subcutaneous avulsion

(degloving)– Associated major vascular injury– Severe, comminuted fracture

pattern

Skin Lesions• Blisters

– Clear– Sanguineous

• Abrasions• Degloving

– Morel-Lavalle

Treatment of Closed Fractures with Soft Tissue Injury

• Control swelling– Provisional reduction– Stabilize: splint/traction/brace– Elevate– Consider foot pump in lower extremity

• Serial evaluation for compartment syndrome

Treatment of Closed Fractures with Soft Tissue Injury

• Treat fracture operatively or non operatively as appropriate

• Timing– In tenuous areas (such as the ankle) await for skin lines

to reappear prior to surgical intervention-- “wrinkle sign”

– With skin lesions await for adequate resolution• Healing of abrasions, blisters or use alternate approach

Open Fracture

• Definition– A break in the skin and

soft tissues communicating with a fracture or its hematoma.

Classification of Open Fractures

Gustilo & Anderson

Gustilo-AndersonGrade I

Gustilo-AndersonGrade II

Gustilo-AndersonGrade IIIA

Gustilo-AndersonGrade IIIA

IIIA Includes severe comminution despite size of skin wound.

Gustilo-AndersonGrade IIIB

Gustilo-AndersonGrade IIIC

Limitations of Gustilo-Anderson Classification

• Tibia model• Emphasis on size of

skin lesion• Reproducibility • Does not differentiate

degree of vascular insult

Prognosis & Gustilo-AndersonClassification

INFECTION & AMPUTATION: Correlates with degree of soft tissue injury

GRADE I II IIIA IIIB IIIC

INFECTION 0-2% 2-7% 10-25% 10-50% 25-50%AMPUTATION 50%

*Tibia Fractures

Prognosis & Gustilo-AndersonClassification

IM NAIL TIBIA GRADE I GRADE II GRADE IIIA

GRADE IIIB

HEALING 21-28 WKS

26-28 WKS 30-35 WKS 30-35 WKS

FRACTURE HEALING: Correlates with degree of soft tissue injury

Assessment

• History– Mechanism

• High or low energy?

– Time since injury– Pre-morbid

conditions– Other injuries

Assessment

• Physical Exam– One look soft tissue

exam– Neurological status– Vascular status– Compartments

Assessment

• X-rays– Standard two 90°

views– Joint above and

below fracture

Emergent Treatment

• Stabilize the Patient– ATLS

SPLEEN

Emergent Treatment

• One Look Exam• Sterile Dressing• No ER Cultures

– Poor indicator of probability of infection and organism

– expensive• Realign and Splint

Tetanus Toxoid

IMMUNIZATION HISTORY NON-TETANUS PRONE

TETANUS PRONE*

UNKNOWN YES YES

>3 IMMUNIZATIONS(<5 YEARS)

NO NO

Tetanus Toxoid 2.5 cc to all poly-trauma patients, otherwise:

*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

IMMUNIZATION HISTORY

NON-TETANUS PRONE

TETANUS PRONE*

UNKNOWN NO YES

>3 IMMUNIZATIONS(<5 YEARS)

NO NO

250-500 units IM:

Bacteriology of Open Fractures

Blunt Trauma, Low Energy GSW Staph, Strept

Farm Wounds Clostridia

Fresh Water Pseudomonas, Aeromonas

Sea Water Aeromonas, Vibrios

War Wounds, High Energy GSW Gram Negative

Recommended Antibiotic Treatment

1 Gen Ceph Gent PCN

Grade I

Grade II +/-

Grade III +/-

Farm/War Wounds

(Gustilo, et al; JBJS 72A 1990)

Duration of Antibiotic Treatment

• Initial 72 hours

• 48 hours after each subsequent procedure

Treatment

• Principles– Decrease

contamination and remove devitalized tissues

Treatment

• Principles– Limb Salvage?– Vascular Injury?

Principles of I&D

• Longitudinal incisions-extensile exposures

• Excise non viable tissue– Systematic and detailed

approach• Irrigation• Stabilize fracture

I&D

• Systematic– Skin– Fascia and fat– Muscle: 4 C’s of

muscle viability• Contractility• Capacity to bleed• Consistency• Color

I&D

– Bone• Deliver, inspect

and cleanse bone ends

• Remove fragments without soft tissue attachment

• Cleanse and retain all major articular fragments

I&D• Pulsatile Irrigation

– Copious volume– Pulsatile action

reduces bacteria counts

– Antibiotics in solution controversial

– May impair bone healing

Stable Fixation

• Reduces infection– Options:

• External fixation– +/- delayed

internal fixation

• IM Nail• ORIF

IM Nailing of Open Fractures

• Immediate IM Nail• After External Fixation

– Generally safe if < 2-3 wks of placement– Avoid if evidence of pin tract infection

• Reamed vs. Unreamed?– No difference in infection rate

Treatment

• No routine intraoperative cultures– Unless clinically

suspect infection

Treatment

• Antibiotic Beads– Decrease infection

rates– High local

antibiotic levels– Useful for dead

space management– Bead pouch

Antibiotic Beads

• Pros– Very high levels of

antibiotics locally– Dead space

management

• Cons– Requires removal– Limited to heat

stable antibiotics– Increased drainage

from wound

Wound Closure

– Primary Closure?– Delayed

closure/coverage• DPC• STSG• Flaps• VAC

Temporary vessel loops, awaiting DPC

Early Soft Tissue Coverage

• Early <7 days decrease secondary infection rate.

• Requires Clean Defect

Gastrocnemius Flap

Questions?

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