1. Presented by:-DR.RANAT VISHNOI

2. INTRODUCTION An open fracture is one in which a break in the skin allows for direct communication of the fracture site or fracture hematoma with the elements external to the usual protection of the skin.The prognosis in open fractures is determined by :- the amount of devitalized soft tissue. the level and type of bacterial contamination. geometry of fracture. 3. Incidence Open fractures of the tibiaare more common than inany other long bone Rate of tibial diaphysisfractures reported 2 per1000 population and ofthese approximately onefourth are open tibiafractures. 4. PRINCIPLES OF MANAGEMENT ABCS AssocInjuries Tetanus Antibiotics Soft TissueManagement Fixation Long term issues 5. DIAGNOSISThe diagnosis of an open fracture is straight forward inmost cases. An injured patient usually has:- bleeding deep laceration overlying or near a fracture of theunderlying bone. In some cases, the fractured bone may be exposed.However, not all open fractures are obvious, and theirtimely and proper diagnosis and treatment depend on acareful examination of the patient, delineating salientfeatures from the patients history, a critical reading of x-rays, and good clinical judgment. 6. Examine the neurologic function and vascular function ofeach extremity. Note the state of circulation to the limb as indicated by capillary blush, the filling of veins, and the status of peripheral pulses. Examine meticulously for peripheral nerve function. Initial sensory examination by pressure and light touch gives a gross evaluation of limb sensation. Examination for motor function is difficult in the injured limb owing to pain and muscle spasm. The normal side should be compared with the abnormal side. 7. Mechanism of Injury Can occur in low energy, torsional type injury.(e.g. skiing) More common with high energy, direct force. (e.g. car bumper) 8. ENVIROMENTAL FACTORThe location where the injury occurred is essential to delineate. People exposed to feces or dirt may occur in a farm setting havepossibility of clostridial infection and need additional antibiotics(penicillin) and more aggressive surgical debridement. In automobile collisions there is less risk for development of aclostridial infection. Unusual environments, such as a barnyards or gardens, streams orlakes, will likely be contaminated by unusual organisms, such as soilanaerobes and Aeromonas hydrophilia, respectively. Injuries caused by lawn-mowers and other motorized gardenequipment are high-energy injuries with severe contamination. Animal Bite or presence of oral flora. 9. HISTORY The patients tetanus immunity must be determined. The surgeon must also inquire about medical illnesses:- diabetes mellitus, peripheral vascular disease, liver disease, and any immune deficiency syndromes. Any previous injuries and their treatments. Finally, a history of smoking or chronic use of steroids. 10. Physical Examination Due to subcutaneous nature oftibia, deformity and open woundusually readily apparent. Circumferential inspection of softtissue envelope, noting anylacerations, ecchymosis, swelling,and tissue turgidity necessary. 11. Neurologic and vascular exam of extremity must be done. Wounds should be assessed and then covered with sterile gauze dressing until treated or through digital camera / cell phone. True classification of wound best done after surgical debridement completed. 12. IMAGING EVALUATION Full length AP and lateral viewsfrom knee to ankle required for alltibia fractures. Ankle views suggested to examinemortise. Arteriography indicated if vascularcompromise present afterreduction . 13. Associated Injuries Approximately 30% of patientshave multiple injuries. Fibula commonly fracturedand its degree of comminutioncorrelates with severity ofinjury. Proximal or distal tib-fib jointsmay be disrupted. Ligamentous knee injuryand/or ipsilateral femur(floating knee) morecommon in high energyfractures. 14. Neurovascular structuresrequire repeated assessment. Foot fractures also common. Compartment syndromemust be looked. 15. CLASSIFICATIONOFOPENFRACTURES 16. HELPFUL FOR Communication between health care professionals Formulating a treatment plan Decision on limb salvage Detailed audit of care to ensure optimal management 17. METHODS OF CLASSIFICATION GRADING SYSTEM focus on severity of limb injury onlyEg: Gustilo Anderson , Tscherne and Gotzen, Byrd and Spicer etc SCORING SYSTEM focuses on limb injury and general health; also give amputation score. Eg: MESS , NISSSA ,LSI,etc COMPREHENSIVE SYSTEM combines the above two systems Eg: AO system , Ganga hospital score 18. GRADING SYSTEMS 19. Gustilo Anderson System In 1976 , Gustilo and Anderson treated 1025 open fracturesbased on his grading system that offered prognosis aboutoutcome of infected fractures In 1984, it was modified and was based ona. Size of woundb. Soft tissue damagec. Periosteal strippingd. Vascular injurySegmental fractures, farmyard injuries, fractures occurring in a highly contaminated environment, shotgun wounds, or high-velocity gunshot wounds automatically result in classification as type III open fracture. 20. Type Wound Level of Soft Tissue InjuryBone Injury Contaminatio n I 1 cm long ModerateModerate, some muscleModerate comminutiondamage III Usually >10 cm longHigh Severe with crushingUsually comminuted;A soft tissue coverage ofbone possible Usually >10 cm longHigh Loss of coverage; periostealBone coverage poor;B stripping & usually requiresvariable, may besoft tissue reconstructivemoderate to severesurgery comminution Usually >10 cm longHigh Very severe loss of coverageBone coverage poor;C plus vascular injury requiringvariable, may berepair; may require soft tissue moderate to severereconstructive surgerycomminution 21. Tscherne SystemGRADEDESCRIPTION 1Skin laceration mostly inside out injury with little or no contusion of skin 2Skin laceration with circumscribed skin or soft tissue contusion with moderate contamination 3Fractures with severe soft tissue injury often with NV injury , severebone comminution or compartment syndrome 4 Sub total (remaining soft tissue not exceeding of limbcircumference) or total amputation This system includes compartment syndrome which is notincluded in other grading systems 22. Byrd and SpicerTYPE DESCRIPTION I Both endosteal and periosteal supply intact and surrounding soft tissue is healthy IIEndosteal supply interrupted but periosteal supply maintained bysurrounding soft tissues IIIDevascularised bone fragment and requires flap coverage This system lacks sophistication and hence not widely used 23. SCORING SYSTEMS 24. Mangled Extremity Severity Score(MESS)TYPE CHARACTERISTICSINJURIES POINTSSKELETAL/ SOFT-TISSUE GROUP 1Low energy Simple closed #, small calibre gun shot 1 2 Medium energyOpen # , D/L , mulltiple level # 2 3High energyShot gun blast , high velocity gun shot 3 4 Massive crush Rail road, oil rig accidents4SHOCK GROUP 1Normotensive BP stable in field and OT 0 2 Transiently BP unstable in field but responds to IV 1 hypotensivefluids 3Prolonged SBP 50 yrs 2* If ischemia time > 6 hrs, add 2 points. 26. MESS Contd It was developed to identify those patients who will bebenefited by primary amputation In retrospective analysis, the outcome of injured limbwas either salvage or amputation A score of 7 or greater is predictive of amputation. MESS is found to be specific but lacks some sensitivitywhich infers that score predicting limb salvage( or =7) (Bosse MJ JBJS 83A:412,2001) 27. Injury Severity Score (ISS) More recently, Rajasekaran et al. proposed a newscoring system for Gustilo type IIIA and IIIB openfractures of the tibia that evaluated skin coverage,skeletal structures, tendon and nerve injury, andcomorbid conditions . The high specificity of this new scoring system maymake it a much better predictor of amputation. 28. Injury Severity Score for Gustilo Type IIIA and IIIB Open Tibial FracturesCovering Structures: Skin and FasciaWounds without skin lossNot over the fracture: 1Exposing the fracture: 2Wounds with skin lossNot over the fracture: 3Over the fracture: 4Circumferential wound with skin loss: 5Skeletal Structures: Bone and Joints Transverse or oblique fracture or butterfly fragment 50% circumference: 2 Comminution or segmental fractures without bone loss: 3 Bone loss 4 cm: 5 29. Functional Tissues: Musculotendinous and Nerve Units Partial injury to musculotendinous unit: 1 Complete but repairable injury to musculotendinous units: 2 Irreparable injury to musculotendinous units, partial loss of a compartment, or complete injury to posterior tibial nerve: 3 Loss of one compartment of musculotendinous units: 4 Loss of two or more compartments or subtotal amputation: 5Comorbid Conditions: Add 2 Points for Each Condition Present Injury leading to dbridement interval >12 h Sewage or organic contamination or farmyard injuries Age >65 y Drug-dependent diabetes mellitus or cardiorespirator diseases leading to increased anesthetic risk Polytrauma involving chest or abdomen with injury severity score >25 or fat embolism Hypotension with systolic blood pressure 65 , DM , cardio-respiratory disease , trauma chest/abdomen,farmyard/sewage contaminations, delay in debridement>12h 34. ANTIBIOTIC A short course of first-generation cephalosporins, begun assoon as possible after injury, significantly lowers the risk ofinfection when used in combination with prompt, modernorthopaedic fracture wound management. A broad-spectrum antibiotic, first-generation cephalosporin+ aminoglycoside, such as tobramycin or gentamicin, for highlycontaminated wounds in which there is a risk of gram-negativecontamination (Gustilo type III). If possibility of anaerobic organisms, such as Clostridium, high-dose penicillin is recommended. The duration of antibiotic treatment should be limited becausein most series the infecting organisms are hospital acquired. 35. Gustilo recommended Type I and II - 2 g of cefamandole on admission and 1 g every 8 hours for 3 days. In type III - an aminoglycoside in dosages of 3 to 5 mg/kg daily. Farm injuries - add penicillin, 10 to 12 million U daily. Gustilo continued double antibiotic therapy for 3 days only andrepeated the antibiotic regimen during wound closure, internalfixation, and bone grafting. Okike and Bhattacharyya recommended the administration ofcefazolin, 1 g intravenously, every 8 hours until 24 hours after thewound is closed, with intravenous gentamicin (with weight-adjusted dosing) or levofloxacin (500 mg every 24 hours) addedfor type III fractures. Campbell recommend obtaining cultures when obvious clinicalfindings of infection are present at the second dbridement. 36. MANAGEMENT 37. Initial Management ABC of initial management is addressed first. Compressive dressings for extremity hemorrhage.. Rule out cervical injuries , chest , abdominal injuries ,head injuries in polytrauma patients . As soon as possible careful examination of wound iscarried out and serial photographs of wound taken. 38. Initial wound managementIn emergency room : Dont do digital exploration (to avoid infection andbleeding). Obvious Foreign Body are removed with forceps. If patient will undergo formal debridement in12hr 2.Delayed administration of antibiotic >12hr 3.Deep seated contamination 4.Immunocompromised 5.NV injury 6.Inability to achieve tension free suture 7.High risk of anaerobic contamination like farm yard injuries 60. Wounds with skin loss:Type 3b fractures require either local advancementor rotation flap, split-thickness skin graft, or freeflap. 61. Soft Tissue Coverage Proximal third tibiafractures can be coveredwith gastrocnemiusrotation flap. Middle third tibiafractures can be coveredwith soleus rotationflap. Distal third fracturesusually require free flapfor coverage 62. Negative Pressure Would Therapy(NPWT)/ Vacuum Dressing Can lower need for free flaps Dedmond BT, The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissueinjuries associated with high-energy open tibial shaft fractures. J OrthopTrauma 2007 Cannot lower infection rates for Type IIIB openfractures Bhattacharyya T, Routine use of wound vacuum-assisted closuredoes not allow coverage delay for open tibia fractures. Plast Reconstr Surg2008 63. BMPs BMP-2 (Infuse) FDA approval in subset of open tibiafractures BESTT study group JBJS 84, 2002 Significant reduction in the incidence of secondaryprocedures Accelerated healing Lower infections 64. COMPLICATIONS 65. Complications1. Nonunion.2. Malunion.3. Infection- deep and superficial.4. Compartment syndrome.5. Fatigue fractures.6. Hardware failure.7. Chronic Osteomyelitis. 66. Nonunion Time limits vary from 6months to one year Fracture shows no radiologicprogress toward union over 3month period Important to rule out infection Treatment options foruninfected nonunions includeonlay bone grafts, freevascularized bonegrafts, reamednailing, compressionplating, or ring fixator 67. Malunion In general varus malunionmore of a problem thanvalgus In one study deformity up to15 degrees did not produceankle complications* For symptomatic patientswith significant deformitytreatment is osteotomy. 68. Deep Infection Often presents withincreasing pain, wounddrainage, or sinus formation. Treatment involvesdebridement, stabilization(often with ex-fix), coveragewith healthy tissue includingmuscle flap if needed, IVantibiotics, delayed bone graftof defect if needed. Staged reconstruction withthe used of PMMA +antibiotics. 69. Superficial Infection Most superficial infections respond to elevation ofextremity and appropriate antibiotics (typicallygram + cocci coverage) If uncertain whether infection extends deeperand/or it fails to respond to antibiotic treatment, then surgical debridement with tissue cultures necessary 70. Compartment Syndrome Diagnosis same asin closed tibialfractures Common with highenergy tibiafractures Release ALL 4compartments 71. Hardware Failure Usually due to delayed unionor nonunion Important to rule outinfection as cause of delayedhealing Treatment depends on type offailure- plate or nail breakagerequires revision, whereasbreakage of locking screw innail may not require operativeintervention 72. Chronic Osteomyelitis Osteomyelitis is a common complication of compoundfracture of long bones which is difficult to treat. Fever, Pain, swelling are seen in acute exacerbation ofchronic osteomyelitis. Sequestrectomy and saucerization. Open Bone Grafting (Papineau Technique). 73. Management of sequelae of chronic osteomyelitis by Illizarovs techniqueGroup A acute onset but ends up as chronic osteomyelitis withpersistent infection A 1- no alteration in bone lengthbifocal osteosynthesis resection andbone transport A 2 with limb length monofocal osteosynthesis and discrepancylenthgning. A 3 with deformities monofocal osteosynthesis anddeformities correction A 4- with both length discrepancymonofocal or bifocal osteosynthesisand deformity with simultaneously lengtheningand deformity correction A 5 infective pseudoarthosis and bifocal osteosynthesis compression non uniondistraction or distraction compression osteosynthesis 74. Outcomes 75. Outcomes Outcome most affected by severity of soft tissueand neurovascular injury Most studies show major change in results between type 3a and 3b/c fractures In one study of reamed nailing, the deep infectionrate was 3.5% for type 2 and 3a fractures, but 23%for type 3b fractures**Court-Brown JBJS 1991 76. Outcomes For type 3b and 3c fractures early soft tissuecoverage gives best results In one study of 84 type 3b and 3c fractures, resultswith single stage procedure involving fixation withimmediate flap coverage better than whencoverage delayed more than 72 hours (deepinfection 3% vs. 19%)**Gopal et al. JBJS[Br] 2000 77. SuggestedtreatmentalgorithmMelvin JS, Open TibialShaft Fractures: I andII, JAAOS, Jan-Feb 2010 78. THANK YOU.!!