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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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